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Invasive Monitoring > Invasive Clinical Monitoring: Intro & Indications > Flashcards

Invasive Clinical Monitoring: Intro & Indications Flashcards

1
Q

Determinants of choosing CVC / Why do I need it?

A

Patient condition / Type of procedure / Potential fluid losses / Surgeon skill / Post op Mgmt

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2
Q

Practical Considerations for potential CVC need / What can I do with it?

A

Obtaining HD information / IV access needed / TPN, special infusions post op / Risk for VAE (by type of surgery)

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3
Q

Invasive Monitoring Guidelines: 3 key variables

A

1- disease severity 2- magnitude of surgery 3- practice setting

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4
Q

Disease states with poss PA Cath need

A

CAD, CHF, CM, Valvular disease

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5
Q

Misc PA Cath recommendations

A

CV disease, Resp failure, Thoracic Ao Sx, Poss/known PE, Hx of Cardiac Sx, major thoracic/pulm Sx / large fluid shifts expected, sepsis pt, vasopressor therapy, Pulmo HTN, Severe lung disease, Reduced EF <40%

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6
Q

Uses of PA Cath

A

Use derived indices to guide therapy. SVR for afterload reduction, monitor HD changes, fluid shift assessment, Mixed venous sat

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7
Q

PA Cath in heart surgery: recommendations

A

Poor LV fxn, valvular disease, CM, LM disease, Septal defect, Recent infarct, IABP, HD instability

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8
Q

PA Cath Contraindications

A

Severe coagulopathy, thrombocytopenia < 50K, Tricupsid/Pulmonic valve prosthesis, Endocardial pacemaker, site infection, severe Vasc disease at site, Ventricular Dysrhythmias, Pulmo HTN, LBBB, Pt refusal

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9
Q

Guidelines for site selection

A

Surgical site, medical hx, surgical hx, compressibility of chosen location

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10
Q

Poss CVC Sites: External Jugular

A

Ext Jugular - head of bed access, low complication risk, valves and acute angle hinder passage

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11
Q

Poss CVC Sites: Antecubital

A

AC - easy to learn, pt sitting, easy to kink, high failure rate, stasis/venospasm common

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12
Q

Poss CVC Sites: Internal Jugular / landmarks are SCM muscle triangle -> needle to top of triangle to ispa nipple TBurg

A

IJ - easy access, can thread multiple line types (pacer, pac, intro), lower Ptx than SCV, risk of carotid puncture, hgher infection risk d/t secretions / L sided complications (PTx, thoracic duct injury)

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13
Q

Poss CVC Sites: Subclavian / 1cm infraclav @ Midclavicular line, needle to sternal notch, keep in coronal, Tburg

A

SCV - noncollapsable (fixed to clavicle) makes good for emergency, longer use, lower infection, easy to dress, higher Ptx/Htx risk, vasc injury risk, non compressible vein (no coagulated pts)

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14
Q

Poss CVC Sites: Femoral / @ inf inguinal ligament, 1cm medial to fem artery / Lateral: Nerve/Artery/Vein/Lymph/Ligament:Medial

A

Femoral - good for large volumes (dialysis caths), no placement verification, little complications, easy to learn, does hinder mobility, high infection/short length of use, risk of thrombosis

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15
Q

PA Cath Acceptable Sites

A

In order of ease of insertion: RIJ (no LIJ, L sided risks from above) / External Jugular, Femoral, Scv, Basilic

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16
Q

CVC Fun Facts

A

place under surgical asepsis / use a seeking needle & j-tip wire / avoid 30cm catheters (placed too far) / flush all lumens / never w/d wire thru needle

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17
Q

CVP Cath Tip Location

A

Just above SVC/RA, 3-5 cm outside RA. Tip below clavicles at level of T-4. At level of carina. Depth = Ht in cm/10 + 2(RScv 10cm)), Ht in cm/10(RIJ 20cm, LIJ + 5)

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18
Q

PA Cath Tip

A

Easiest to pass RIJ, LScv, waveform guided. Must monitor pressure obtained and distance passed. Reasons for not passing: perforation and coiling.

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19
Q

PA Cath RIJ tip markers

A

RA 20-30cm 6-8 mmHg / RV 30-40cm 25/0 mmHg/ PA 40-50cm 25/12 mmHg/ PA Wedge 50-60cm 2-12 mmHg

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20
Q

Wedge Location/Process

A

monitor wave from distal port / minimize balloon inflation time / w/d cath 1-2 cm if spont wedging occurs or balloon inflates < 1.25cc

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21
Q

CVC Complications

A

Venous access issues / Issue surrounding catheter residence(infection) / Issues specific to PA cath

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22
Q

CVC Complication: Ptx

A

0-15% incidence, exacerbated by N2O use, may not be seen on CXR, SOB/DeSat/Incr AW pressures. Tx with Ctube.

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23
Q

CVC Complication: Vascular Perf

A

Htx (blood), Hydrotx (IV fluids), Chylotx (lymph) via thoracic duct rupture (worse kind). Carotid punc leads to AW compromise/stroke.

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24
Q

CVC Complication: Myocardial Perf

A

Leads to cardiac tamponade. Incidence 0.2%, 66% mortality. Equalization of cardiac pressures, beck’s triad. Tx with pericardiocentesis.

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25
Q

CVC Complication: Emboli

A

Air Emboli: s/s of PE. 50-100cc can be fatal. LLD Tburg and aspirate air from CVC. Tx 100%, no N2O. Wire/Cath emboli: retrieved in IR. Thromboemboli: high incidence but 5% clinically sig. coat catheters to prevent.

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26
Q

CVC Complication: Infection

A

Most common complication. Colonization in 50% of cases. Prevention is most important. Dressing changes, removed when not needed. Limit access.

27
Q

PAC Complication: Dysrhythmia

A

Most common complication is vent ectopy. Pacer present when inserting with LBBB present.

28
Q

PAC Complication: Pulm Vasc Infarct

A

Result of overwedging in small vasc space, prolong wedging. Dont inflate if spont wedged already.

29
Q

PAC Complication: knotting

A

Too much catheter in pt for waveform that you see. Can coil around structures or be sutured into tissue. Get CXR if diff to remove.

30
Q

PAC Complication: PA Rupture

A

PA rupture is most severe complication. Risk elevated in presence of PulmoHTN, adv age, coag disorder. 50% mortality. s/s hemoptysis, hypoxia, hypotension. Tx with bad lung down, PEEP, volume resusc, lung isolation with dual lumen tube. Need thoracotomy

31
Q

Indications for Arterial Line

A

Elective hypotension (decr blood loss) / Anticipated labile BP (Xclamping) / Systemic disease warranting close BP monitoring (espc with induction) / Need for vasc access/blood draws (long cases)

32
Q

Aline vs NIBP

A

Aline provides direct, beat to beat BP measurements. Not “sampling” with NIPB, which measures flow, AL measures pressure. NIBP low flow -> underestimates pressure / high flow -> overestimates pressure.

33
Q

When to put in ALine

A

Pre vs post induction. Pre for disease states warranting close monitoring for induction (CAD). After for procedural issues ie blood sampling.

34
Q

Aline Site Selection: Radial/Ulnar/Brachial

A

Radial - easy to locate, superficial, minimal pain, good collateral circ. Susceptible to sys augment, occluded flow. Ulnar - mirror to radial, deeper and more tortuous. Brachial - easier/larger, prone to kinking, motion. Injury risk high to entire arm.

35
Q

R vs L radial site

A

Thoracic Ao aneurysm -> Rt side as LSca gets occluded. Mediastinoscopy ->Rt side to asses for vasc compression innom or Rsca.

36
Q

Aline Site Selection: Axillary/Pedal&PostTib/Femoral

A

Ax - similar to Ao pressures, large vessel, risk of air embolism and nerve trauma. DP/PT - good collateral, sig sys augmentation, diff to cannulate and not rec for PVD patients. Femoral - safe as radial, risk of embolization with vasc disease, hematoma and pseudoany risk. Ax and femoral at risk for hematoma/compartment syndrome.

37
Q

Allen’s Test

A

Determines presence of adequate collateral circulation (palmar arch incomplete in 3-6%)

38
Q

ALine Complications: Thrombosis

A

6 contributing factors: prolonged cathterization / catheter size 18g vs 20g / catheter material / proximal emboli / prolonged shock / pre-existing vasc disease

39
Q

Aline Complications: Disconnection

A

Can lead to exsanguination. Check connections, stopcocks and caps. Vented caps must be replaced.

40
Q

ALine Complications: Accidental Injection

A

Can cause limb necrosis: barbiturates, vasopressors, ketamine are worst.

41
Q

ALine Complications: Infection

A

Related to length of time in place. Must place in sterile fashion, mask/gloves/hat.

42
Q

ALine Complications: Nerve injury

A

R/t trauma w/ insertion, direct nerve damage or r/t compartment syndrome. Also possible with prolonged dorsiflexion of wrist.

43
Q

ALine Pressure waveforms

A

Further from Ao Root the steeper the upstroke (sys augmentation). More peripheral location -> greater increase in SBP, pulse pressure and lower DBP, narrower waveform. Points of greatest sys augment -> radial/ulnar/DP/PT

44
Q

PA Catheter sizing/characteristics

A

7 French most common size. Balloon capacity of #5 PAC is 1.5 cc. Prox lumen 30cm rom tip, thermistor is distal.

45
Q

HD Monitoring Sys Components and accuracy

A

1-fluid filled tubing system 2-electronic system (transducer) / must prime tubing, level and zero to phlebo axis 4th ICS Midax line (nearest to RA)

46
Q

Most important derived indices

A

Aline - SVR/PVR PA - RAP/PaoP Contractility - SV/SVI

47
Q

Best Location for PAC

A

Prefer in zone 3 where arterial pressure is the greatest. Provides most communication between pulmo caps and LAP. Limits influence of alveolar pressure on tracing.

48
Q

Pressure relations/gradient within heart

A

PAEDP (PVR, HR) PCWP (AWP, PEEP) LAP (mitral stenosis) LVEDP (vent compliance) LVEDV

49
Q

RV waveform

A

Often seen with ectopy. Sharp sys upstroke, little to no diastolic pressure, 15-30/0-8 (dia approx RAP). RVEDP (gold std for preload) measured at R wave.

50
Q

LV waveform

A

Measured only in cath lab. Similar app to RV wave but with near 5x pressures, 100-140/0-12. LVEDP measured at R wave. LV-Ao gradient incr with AO stenosis.

51
Q

PA waveform

A

Similar appearance to Aline/sys pressure readings, but with near 1/5th pressure. sys upstroke/peak, sys decline with dicrotic notch and dia runoff, 15-30/4-12. Normal pts can sub PAD for LVEDP (instead of PAOP). Measured after QRS.

52
Q

Systemic Arterial waveform

A

Similar to PA cath, but near 5x pressures. Also read after QRS. Antercotic limb/upstroke -> sys peak -> dicrotic limb -> dicrotic notch -> dia runoff -> diastole

53
Q

Right Atrial waveform

A

5 components: A wave - atrial contraction. C wave - Tricup valve bulging d/t isovolumic contraction. V wave - venous filling of atria. X descent - atrial relaxation, floor pulled by ventricle. Y descent - Tricup valve opens, blood flows RA -> RV. A wave after p wave, c/v waves after QRS. CVP/RA is mean of a-x slope at R wave. 1-8 mmHg

54
Q

Disease states altering CVP

A

1- PulmoHTN 2-Rt heart failure 3-Lt heart failure. Clinical signs: distended veins, incr R side filling pressures, Incr HR, bounding pulses, sys edema, decr pulm compliance, S-3 gallop. Decreased w/ hypovolemia

55
Q

PAOP waveform

A

Surrogate for LAP (LVEDP reflection) LAP = 2-12 / PAOP = 5-15 (mean of A wave). When wedged, PAC see static column of blood between cath tip and LA. Waveform has dampening d/t extensive pulmo cap bed being transduced. Delay places A wave follow R wave.

56
Q

Disease states altering PAOP

A

Increased d/t fluid overload, LV failure, Mitral stenosis/regurg, tamponade/pericarditis. Decreased d/t hypovolemia

57
Q

Respiratory effects on pressure tracings

A

Spont breathing - decr intrathoracic and intravasc pressures. Positive press breathing - incr intrathoracic and intravasc pressures. Measure HD waves at end expiration. High PEEP makes PAOP unreliable.

58
Q

Cardiac Output

A

CO=HR x SV, NL = 5L/min. measured via Fick method or thermodilution. Must inject right amount, small amount = false high CO. Regurg R sided valves = false high CO. Should average 3 CO attempts. CI = 2.5-4L

59
Q

Stroke Volume

A

SVI = 40-60ml/beat. NL SV for 70kg male = 60-90 ml.

60
Q

SVR & PVR

A

MAP-CVP / CO x 80 (900-1500) / PAP-PAOP / CO x 80 (<250)

61
Q

Mixed Venous O2

A

NL = 65-75%. Sust <65%, compromise of one determinant of O2 delivery/transport. Elevation may reflect excess FiO2 or poor extraction.

62
Q

PAOP not = to LVEDP

A

PAOP>LVEDP - mitral stenosis, atrial tumor, pulmo venous congestion, incr AW pressure // PAOP<LVEDP - decr LV compliance, Ao regurg

63
Q

Abnormal atrial waveforms

A

Cannon waves - large A waves, combo of A&C waves, measure at R wave. Seen in AFib, jxnl rhythms (may not have any A waves), pacemaker w/o AV sequencing (no A-kick), Tricup/Mitral stenosis. Large V waves usually r/t valve regurg. C+V wave, RAP may look like PAP w/ tricup regurg. PAOP may look PAP with mitral regurg.

Invasive Monitoring (1 decks)

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