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I&M II > II. CVP Monitoring > Flashcards

II. CVP Monitoring Flashcards

1
Q

Location of CV catheter tip

A

junction of SVC & RA

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2
Q

What is the CV catheter attached to?

A

pressure tubing & transducer

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3
Q

CV catheters measure CVP. CVP is akin to what other two pressures?

A

Right Atrial Pressure & Jugular Venous Pressure

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4
Q

What law explains the changes in venous compliance and their subsequent effects on cardiac output?

A

Frank-Starling Law

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5
Q

In healthy individuals, venous return is correlated to ____.

A

cardiac output

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6
Q

8 indications for CVC

A
  1. IV access (pts with poor peripheral access)
  2. Infusion of caustic substances
  3. CVP monitoring
  4. Venous blood sampling
  5. Aspiration of VAE
  6. Advanced hemodynamic monitoring
  7. Extracorporeal Therapies (ECMO, CRRT)
  8. Access point for other modalities

HINT: CHASEE

Caustic Substances, Hemodynamic Monitoring, Access Point, Sampling (blood), Embolism aspiration, ECMO

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7
Q

Examples of caustic infusion substances:

A
  • NE, Dopamine
  • IV nutrition (TPN)
  • Chemo
  • Prolonged antibiotics
  • Renal replacement therapy, plasmapheresis, or apheresis
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8
Q

Examples of advanced hemodynamic monitoring

A
  1. PICCO(Pulse index Continuous Cardiac Output)
  2. CVO2
  3. PA Catheter
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9
Q

Other modalities that may use CVC as access point (3)

A
  1. IVC filter replacement
  2. Venous Stenting
  3. Transvenous Pacing
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10
Q

C/I for CVC placement

A
  1. Infection
  2. SVC syndrome
  3. Thrombus of target vessel
  4. Patient intolerance
  5. Coagulopathy
  6. New Pacemaker wires
  7. Some providers avoid on side of previous CEA

HINT:TWIICS

Thrombus, Wires (pacemaker), Intolerance, Infection, Coagulopathy, SVC Syndrome

CHASE TWIICS

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11
Q

Thresholds for coagulopathy C/I for CVC placement

A

INR > 1.5

PLT<50,000

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12
Q

Complications of CVC

A
  1. Erroneous Data, Misinterpretation, or Misuse of equipment
  2. Arrhythmia (PVCs)
    3..Other
    - Thrombophlebitis
    - Pericardial effusion / Cardiac tamponade
    - Chylothorax (more common with Left IJ & SCV approaches)
    - Tracheal injury
    - Direct nerve injury
    • Brachial plexus,
    • stellate ganglion,
    • phrenic nerves all close to IJ

HINT: MATTT

Misuse/Misinterpretation, Arrhythmia, Thrombophlebitis, Tamponade, Tracheal Injury

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13
Q

____ ga or smaller “finder needle”
Not problematic with normal coagulation

A

22

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14
Q

____ ga or larger introducer needle
Risk for hematoma, hold pressure 5+ min

A

18

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15
Q

Large bore introducer
If accidentally dilated, hold pressure for ____ min!

A

30

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16
Q

If CVC placed in artery, what should we do?

A

leave it in & get vascular consult

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17
Q

Localized hematoma may expand → ____

A

airway compression

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18
Q

Sights of CVC placement

A
  1. Right & Left IJ
  2. Subclavian
  3. EJ
  4. Femoral
  5. Antecubital
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19
Q

Can be easily visualized with ultrasound
Most direct route to heart
Straight in-line course to right atrium

A

RIGHT Internal jugular vein

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20
Q

CVC placement site

Angled course through brachiocephalic vein
Increased risk of chylothorax (thoracic duct injury) → lymphatic fluid (chyle) accumulates in the pleural cavity

A

Left IJ

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21
Q

Subclavian has a ____ success rate compared to IJV

A

lower

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22
Q

Subclavian has what advantages compared to IJ

A

Better tolerated by patient
↓risk of infection
Can be performed on pt. in cervical collar

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23
Q

Subclavian has what complications compared to IJ?

A

-Greatest risk of pneumothorax
-Also Hemothorax / Mediastinal hematoma
(Chylothorax risk similar to LIJ)

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24
Q

What central venous catheter placement site is both superficial, has a minimal risk of pneumothorax and has a low success rate?

A

External jugular

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25
Q

What is the approximate success rate of placing an external jugular central venous catheter?

A

80%

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26
Q

What central venous catheter location is uncommon for intraoperative monitoring, but has a high success rate?

A

Femoral

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27
Q

Femoral, central venous catheter placement may be necessary in patients with what type of complication?

A

Superior vena cava obstruction

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28
Q

Antecubital placement involves which two veins potentially?

A
  1. Basilica
  2. Cephalic
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29
Q

Which central venous catheter placement, location is used for peripherally, inserted, central, venous, catheters, or PICC lines?

A

Antecubital

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30
Q

Antecubital placement will exhibit lower/higher central, venous pressures.

A

Slightly higher

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31
Q

What are the available sizes of central venous catheters?

A

7.5 - 9.0 Fr

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32
Q

What size lumens are available for central venous catheters?

A

1-4

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33
Q

What are the various lengths for CVC?

A

12-24

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34
Q

What two types of materials are CVC composed of?

A
  1. Silicone.
  2. Polyurethane.
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35
Q

CVC can have what three types of coatings?

A
  1. Antimicrobial. (chlorhexidine based.)
  2. Heparin.
  3. Radiopaque (confirms tip placement.)
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36
Q

What are the four types of CVC catheters? I

A
  1. Non-tunneled central catheters.
  2. Tunneled central catheters.
  3. Peripherally inserted central catheters (PICC)
  4. Implantable ports.
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37
Q

What is the most common type of catheter used in the hospital setting?

A

Single lumen

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38
Q

What is the most common type of CVC used by Anesthesia personnel?

A

Triple lumen

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39
Q

What are the two considerations made when determining length of CVC?

A
  1. Site of insertion.
  2. Patient height.
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40
Q

Which port is used for CVP monitoring in a triple lumen catheter?

A

Distal port

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41
Q

What type of catheter is used as a trauma line with a PA catheter introducer?

A

Large bore triple lumen

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42
Q

T/F: all lumens of a triple lumen port can be used for administration of IV solutions and medication.

A

True

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43
Q

Which port is used for withdrawing blood samples on a CVC triple lumen, why?

A

The proximal port, because it has the least contamination from other infusions.

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44
Q

Which port on a triple lumen is used for administration of TPN (total parenteral nutrition)?

A

The medial port, because it is safest.

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45
Q

Which port is used for blood administration and why on a triple lumen?

A

The distal port, because it is the largest lumen.

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46
Q

List the equipment needed for placement of CVC:

A
  1. Syringe and needle for localanesthetic (1% lidocaine)
  2. Scalpel.
  3. Sterile gel for ultrasound guidance
  4. Introducer needle (18ga) attached to syringe with saline (to detect backflow of blood, upon vein penetration)
  5. Guidewire.
  6. Tissue dilator (8.5 Fr)
  7. Indwelling catheter (16ga)
  8. Additional fasteners, suture and needle
  9. Sterile dressing
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47
Q

What position can patients be placed in in order to increase jugular vein, size with hydrostatic pressure in order to reduce placement difficulty?

A

Trendelenburg

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48
Q

What physical locations on the patient should be prepped with chlorhexidine?

A

Earlobe to sternal notch

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49
Q

The internal jugular vein is positioned ____ and ____ to the carotid artery.

A
  • Lateral
  • Slightly anterior
50
Q

What landmarks are we looking for when locating the entry point for the right internal jugular vein?

A

The triangle formed by the sternocleidomastoid muscle and clavicle.

51
Q

After the triangle has been identified During identification of the right internal jugular vein, what are the next steps for catheter placement?

A
  1. Palpate carotid pulse.
  2. Enter at Apex of triangle, lateral of carotid, pulse, and aiming at ipsilateral nipple. (30-45 degree angle of entry)
  3. The vein is usually 3 to 5 cm from the skin surface.
52
Q

Which of the two methods is preferred when placing a subclavian central veinous cat catheter?

A

Infraclavicular is preferred

53
Q

How should the patient be positioned when preparing for an infraclavicular subclavian CVC?

A
  1. Supine, head, neutral, arm abducted.
  2. Trendelenburg (10-15º)
  3. Shoulders, neutral with mild retraction.
54
Q

Describe the steps of placement for subclavian CVC:

A
  1. Index finger on suprasternal notch.
  2. Thumb on Costoclavicular junction.
  3. Enter the skin about 1 cm inferior to the clavicle.
  4. Aiming towards index finger, posterior to clavicle, with needle parallel to the skin.
55
Q

During CVC placement, insert and advance the needle while ____.

A

Continuously aspirating

56
Q

Follow the needle tip into the vessel using ____ to confirm.

A

Ultrasound, guidance

57
Q

Successfully cannulate the vessel, and ensure free return of ____ blood.

A

Dark red, non-pulsatile

58
Q

After calculating the vessel and visualizing return of dark, red, non-pulsatile blood, what is the next immediate step?

A

Sit down the probe, and stabilize the needle with left hand. Disconnect the syringe, without changing angle of needle.

59
Q

After removing the syringe from the catheter, what should be done next?

A

Insert the guidewire through the needle to a depth of 20 cm.

60
Q

What should we watch for while inserting the guidewire through the catheter?

A

Ectopy on the ECG (often a run of PVCs)

61
Q

After the guidewire has been inserted, what should we do next?

A

Remove the needle while maintaining control of the guidewire. Then confirm the guidewire is in the vessel using ultrasound.

62
Q

Steps for dilating, the vessel and tissue:

A
  1. Make a small incision adjacent to the guidewire (scalpel)
  2. Advance the dilator over the guidewire and into the skin with the twisting motion while maintaining control of the guidewire.
  3. Ensure the guidewire moves freely within the dilator, then remove the dilator.
63
Q

Once the dilator has been placed, what do we do next?

A
  1. Advance the catheter over the guidewire, using Seldinger’s technique into the vessel to the appropriate depth.
  2. Remove the guidewire.
  3. Aspirate and flush each lumen.
  4. Place capless valves.
64
Q

Which port should be kept covered while removing the guidewire in order to prevent air entry?

A

The brown port

65
Q

What is used to confirm catheter position at the end of procedure?

66
Q

Ideal placement location of a central venous catheter

A
  1. Distal and within the superior, vena cava, above the right atrium.
  2. Below inferior border of clavicles.
  3. T4 to T5 interspace
  4. At the level of carina
67
Q

How to perform a jugular occlusion test

A
  1. Apply external pressure on the internal jugular vein for 10 seconds and observed change in central venous pressure.
  2. Increased central venous pressure 3 to 5 mm of mercury, indicate a misplaced catheter into the internal jugular vein. 
68
Q

Normal range of central venous pressure during SV

69
Q

Normal range of central venous pressure during mechanical ventilation

70
Q

T/F: central, venous pressure is used as a guide for fluid therapy

71
Q

T/F: central, venous pressure, does not always reflect intravascular volume

72
Q

Wow, there is no target central Venus pressure, a drop in Venus pressure by ____ mmHg indicates fluids may be effective.

73
Q

What may occur if we exceeded normal central venous pressure values?

A

Pulmonary and tissue edema

74
Q

1 cmH2O = ____ mmHg

75
Q

CVP ____ with increased venous tone (i.e., SNS stimulation)

76
Q

Decreased compliance will ____ volume and ____ pressure.

A
  • decrease
  • increase
77
Q

Decreased cardiac output ____ CVP due to ____ volume in venous system.

A
  • increases
  • increased
78
Q

Changing from standing to supine body posture ____ CVP.

A

Increases

due to increased volume

79
Q

Arterial dilation ____ CVP.

A

Increases

due to increased volume

80
Q

Forced expiration ____ CVP due to ____.

A
  • increases
  • decreased compliance
81
Q

Muscle contraction ____ CVP due to ____ volume & ____ compliance.

A
  • Increases
  • increased
  • decreased
82
Q

A CVP A wave corresponds to ____, and occurs in ____.

A
  • Right atrial contraction
  • End Diastole (after P-wave on ECG)
83
Q

A CVP C-wave corresponds to ____ and occurs during ____.

A
  • Right ventricular contraction
  • Early Ventricular systole (always follows R wave of ECG)
84
Q

The CVP ____-wave is caused by bulging of the tricuspid valve into the atrium.

85
Q

The X descent wave indicates ____.

A

Atrial relaxation downward movement of the ventricle

occurs during ventricular systole

86
Q

The V-wave signifies ____

A

Atrial filling against a closed tricuspid valve

occurs during late ventricular systole

HINT:Villing against Valve

87
Q

The Y-descent wave indicates:

A
  • tricuspid valve opening, and bullet quickly entering the ventricle.

occurs during early ventricular diastole

88
Q
  • increased resistance to ventricular filling
  • Increased atrial contraction

The preceding to physiological changes will result in what CVP manifestation?

A

Elevated A waves (“Cannon A Waves”)

Causes: heart failure, tricuspid stenosis, atrioventricular disassociation (Junctional rhythms, AV dissociation, PVCs)

89
Q

Which two waves are the descent waves

90
Q

Sequential Cannon A Waves can be observed in what syndrome?

A

Pacemaker Syndrome

91
Q

Elevated V Waves (higher than A waves) often have what physiological cause?

A

Tricuspid Regurgitatant flow (against a already contracting right atrium = increased pressure)

  • tricuspid regurgitant flow due to heart failure*
92
Q

SV causes ____ intrathoracic pressure = ____ CVP

A

Decreased

Decreased

93
Q

PPV causes ____ ITP = ____ CVP.

A

increased

Increased

94
Q

CVP should always be read at ____

A

End-expiration

95
Q

Every 5 cmH2O PEEP will increase CVP ____ mmHg

A

~2 mmHg

but will decrease true filling volumes

96
Q

RV compliance is represented as what mathematically

97
Q

T/F: cardiac filling pressures estimate cardiac filling volumes.

98
Q

T/F: CVP alone is an excellent indicator of volume status.

A

False

CVP is most useful as a trend rather than an absolute value

99
Q

other sites of CVP cannulation picture

100
Q

CVC Triple Lumen Picture

101
Q

Equipment needed for CVP placement picture

102
Q

Equipment for CVP Placement Picture 2

103
Q

Ultrasound Supine vs Trendelenberg Picture

104
Q

Ultrasound planes comparison picture

105
Q

Right IJ Triangle Placement Picture

106
Q

CVC placement depth Table Picture

107
Q

CVP pressures throughout body Picture

108
Q

CVP Interpretaion Picture

109
Q

Normal CVP & ECG Waveform Picture

110
Q

A-Wave (Atrial Contraction) Picture

111
Q

C-Wave (AV Closes) Picture

112
Q

X-Descent Wave (Atrial Relaxation) Picture

113
Q

V-Wave (Atrial Filling) Picture

114
Q

Y-Descent Wave ( AV Valve Opens) Picture

115
Q

Cannon A Wave & PVC Picture

116
Q

Pacemaker Syndrome Picture

117
Q

Elevated V Waves Picture

118
Q

Abnormal CVP Waveform Conditions Picture

120
Q

Spontaneous Ventilation CVP waveform picture

121
Q

Mechanical Ventilation CVP Waveform Picture

I&M II (7 decks)

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