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8361 Exam I > Mod1: Monitoring for Cardiac Surgery - Pulmonary artery catheter > Flashcards

Mod1: Monitoring for Cardiac Surgery - Pulmonary artery catheter Flashcards

1
Q

Pulmonary artery catheter

When was the PA catheter introduced?

A

Invented in 1970 by Swan, Ganz and colleagues for hemodynamic assessment of patients with acute myocardial infarction

Became routine monitoring for the ICU

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2
Q

Pulmonary artery catheter

Recently, why are providers begining to shy away from using the PA catheter?

A

They are begining to see that the risks of PAC outweight its benefits

Not only are survival rates the same between those who have it and those who don’t, but studies have also shown that PA catheter-groups suffer more pulmonary complications

Influence on patient outcomes has become controversial as clinical studies fail to show positive outcomes

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3
Q

PULMONARY ARTERY CATHETER

What are the physical characteristics of the PA catheter?

(#lumens, lenght)

A

5 lumen catheter

110 cm long

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4
Q

PULMONARY ARTERY CATHETER

Which port is used for pulmonary artery pressure monitoring and measuring mixed venous gas?

A

Distal port

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5
Q

PULMONARY ARTERY CATHETER

Which port is used for CVP monitoring, CO injections

A

A port located 30 cm from tip (CVP port)

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6
Q

PULMONARY ARTERY CATHETER

Which port is used for RV pacing/Infusion output

A

Port located 20 cm from tip (RV port)

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7
Q

PULMONARY ARTERY CATHETER

Which port houses wiring to connect the thermistor near the catheter tip to monitor thermodilution for CO once the blood circulates and reaches the pulmonary artery?

A

Thermistor port

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8
Q

PULMONARY ARTERY CATHETER

Which port is used to inflate the ballon at the tip of the catheter?

A

Air channel

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9
Q

PULMONARY ARTERY CATHETER - INDICATIONS

What is a major benefit of the PA catheter in assessing cardiac function that is not possible just with clinical s&s?

A

Provides Quantitative assessment cardiac function that cannot be otherwise be accurately predicted from standard clinical signs and symptoms

Evaluate & guide treatment of hemodynamic alterations

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10
Q

PULMONARY ARTERY CATHETER - INDICATIONS

For which conditions is the use of the PA catheter indicated?

A

CABG

Recent MI or Unstable Angina

Valvular disease

Presence pulmonary HTN

Combined coronary stenosis & valvular disease

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11
Q

PULMONARY ARTERY CATHETER - INDICATIONS

For which conditions is the PA catheter not usually indicated for?

A

EF > 50%

Good ventricular wall motion present

Monitoring CVP sufficient

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12
Q

PULMONARY ARTERY CATHETER - INDICATIONS

T/F: For a pt to undergo cardiac surgery, you mus consult with the surgeon before making the decision to forego a PA catheter

A

True

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13
Q

PULMONARY ARTERY CATHETERIZATION

Why does the insertion of a PA catheter require a large-bore introducer (usually a 9Fr)?

A

To facilitate PAC insertion

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14
Q

PULMONARY ARTERY CATHETERIZATION

Why does PA catherization require a catheter that has a hemostasis valve?

A

Because the PA catheter is then inserted through the hemostasis valve

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15
Q

PULMONARY ARTERY CATHETERIZATION

What’s the next step after the catheter is inserted throught the hemostasis valve?

A

Nonsterile connections are made to monitoring devices

The 5 ports are then handed to a non-sterile assistant who connects all five ports and zeroe the transducers in the following sequence:

  • Connect the distal port(yellow) to the pulmonary artery pressure transducer (yellow to yellow)*
  • Blue port is connected to CVP (blue to blue)*
  • 3 cc syringe connected to red balloon port*
  • Flush connected to orange port*
  • Level the transducer at the level of the pt’s heart*
  • Zero the transducer*
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16
Q

PULMONARY ARTERY CATHETERIZATION

T/F: It is recommended that the PA catheter be zeroed prior to floating the Swan

A

True

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17
Q

PULMONARY ARTERY CATHETERIZATION

When the PA catheter is inserted through the subclavian or internal jugular vein, what position should the pt be in?

A

Flat or Reverse trendelenburg

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18
Q

PULMONARY ARTERY CATHETERIZATION

Eventhough you want to verify placement according to the waveform on the screen, what other information could you use for confirmation?

A

The numbers on the screen

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19
Q

PULMONARY ARTERY CATHETERIZATION

Why is continuous pressure monitoring during PAC insertion required?

A

To determine location of the catheter tip

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20
Q

PULMONARY ARTERY CATHETERIZATION

Why is the PA catheter initially inserted through the hemostasis valve to the 20 cm mark?

A

Because the 20 cm mark places the tip of the catheter at the RA

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21
Q

PULMONARY ARTERY CATHETERIZATION

What’s the next step once the the 20 cm mark is at the hub of the introducer?

A

Inflate the balloon when the 20 cm mark is at the hub of the introducer

Advance the catheter in a smooth foward fashion while watching the monitor for changes in the waveform

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22
Q

PULMONARY ARTERY CATHETERIZATION

While advancing the PA catheter, what level corresponds to the Right ventricle?

A

30-35 cm

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23
Q

PULMONARY ARTERY CATHETERIZATION

While advancing the PA catheter, what level corresponds to the Pulmonary artery?

A

40-45 cm

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24
Q

PULMONARY ARTERY CATHETERIZATION

The catheter is advanced until what pressure is obtained? At what level is this anticipated to occur?

A

Advance the PAC until the PCWP is obtained

Usually around 45-55 cm at the hub

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25
Q

PULMONARY ARTERY CATHETERIZATION

T/F: The catheter should always move smoothly and should not be advanced against any resistance

A

True

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26
Q

PULMONARY ARTERY CATHETERIZATION

While advancing PA catheter, what should be use to guide positioning?

A. Change in waveform

B. Change in values on the monitor

A

A. Change in waveform

B. Change in values on the monitor

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27
Q

PULMONARY ARTERY CATHETERIZATION

T/F: Catheter depths can be used to verify catheter position

A

False

Depths are only used as a guide.

Must always follow waveform morphology to verify catheter position

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28
Q

PULMONARY ARTERY CATHETERIZATION

T/F: Catheter site affects catheter depth

A

True

There are variations in depth depending on catheter site

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29
Q

PULMONARY ARTERY CATHETERIZATION

How much should be added to normal depth when the catheter is inserted in the left IJ?

A

An additional 5-10 cm

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30
Q

PULMONARY ARTERY CATHETERIZATION

How much should be added to normal depth when the catheter is inserted from femoral vein?

A

15 cm additional

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31
Q

PULMONARY ARTERY CATHETERIZATION

How much should be added to normal depth when the catheter is inserted from antecubital veins?

A

30-35 cm

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32
Q

PULMONARY ARTERY CATHETERIZATION

What are the 4 main different pressure tracing displayed by the PA catheter as it is being floated?

A

RA pressure

RV pressure

PAP

Pulmonary artery occlusive (“wedge”) pressure

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33
Q

PULMONARY ARTERY CATHETERIZATION

What does the waveform looks like at 20 cm?

A

At 20 cm the waveform resembles the CVP, and

Displays a, c & v waves

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34
Q

PULMONARY ARTERY CATHETERIZATION

What are the normal values of the RA pressure?

A

0-8 mmHg

CVP: 1-6mmHg* (from slide 72)

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35
Q

PULMONARY ARTERY CATHETERIZATION

What are normal RV pressures?

How do they compare to RA pressures?

A

15-30/0-8 mmHg

RV pressure show a higher systolic pressure than seen in the RA, but end-diastolic pressures are equal

36
Q

PULMONARY ARTERY CATHETERIZATION

What are normal PA pressures?

How do they compare to RV pressures?

A

15-30/11-12 mmHg

PA pressures show a diastolic step up compare to RV pressures

37
Q

PULMONARY ARTERY CATHETERIZATION

What are normal values for Pulmonary artery occlusive (“wedge”) pressure?

A

5-12 mmHg

6-12mmHg* (slide 72)

38
Q

PULMONARY ARTERY CATHETERIZATION

How does Pulmonary artery occlusive (“wedge”) pressure compare to CVP?

A

PAOP have the same morphology as CVP pressures

But the a, c & v waves appear much later in the cardiac cycle relative to the EKG

39
Q

PULMONARY ARTERY CATHETERIZATION

On the chest x-ray used to verify PA catheter placement, where should the tip of the catheter be located?

A

The tip of the catheter should be within 2 cm of the cardiac silhouette on the anterior posterior chest film

40
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Which hemodynamic values can be measured by the PA catheter?

A

CVP - CO - PAP - PCWP

Mixed venous oxygen saturations ( SVO2)

41
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Where is the Central Venous Pressure (CVP) recorded?

A

From proximal port in the SVC at the junction or RA

CVP = RAP

42
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

CVP = RVEDP under which condition?

A

No obstruction exist between atrium & ventricle

For example: No Tricupsid stenosis

43
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

What technique is used to calculate Cardiac output?

A

The thermodilution technique

44
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

When Pulmonary Artery Pressure (PAP) are measured at the tip/distal port, how is the balloon?

A

Balloon is deflated

45
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Which hemodynamic parameter do PA pressures reflect?

A

RV function

PVR

LA filling pressures

46
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

When the Pulmonary Capillary Wedge Pressure (PCWP) is measured at the tip/distal port, how is the balloon?

A

Balloon is inflated

47
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Under which condition are PAD = PCWP = LAP = LVEDP?

A

Indirectly & when no obstruction exists between atrium and ventricle (ie. mitral stenosis/Pulmonary HTN)

48
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Why should we look at the numbers from the PA catheter as changes in pressure but not changes in volume?

A

Changes in compliances of the heart may change pressures whithin the heart, but not necessarily the volumes in the heart

This is how you may have a pt with high wedge pressures and normal cardiac compliance and function, and they are categorized as hypervolemic and not in heart failure

49
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

What is assessed via Mixed venous oxygen saturations (SVO2) measurement?

A

Indirect assessment of total body O2 supply and demand

50
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

What are the Determinants of SvO2?

A

O2 delivery/supply

O2 extraction/demand

51
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

What are the normal SvO2 values?

A

Normal SVO2 is 60-80%

With a normal oxygen tension of 35-40 mmHg

52
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Changes in which factors could cause a decreased in SVO2?

A

↓O2 delivery (anemia/↓CO) or ↑O2 consumption

53
Q

HEMODYNAMIC PARAMETERS MEASURED BY THE PAC

Where should accurate sampling of SVO2 blood be done?

A

From the PA port of the PA catheter

54
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Cardiac Index (CI) = ?

Normal values?

A

CI = CO/BSA

Normal CI: 2.4 - 4.0L/min/m2

55
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS ​

Stroke Volume Index (SVI) = ?

Normal values?

A

SVI = CI/HR

Normal SVI: 40 - 70mL/beat/m2

56
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Systemic Vascular Resistance (SVR) =?

What does Systemic Vascular Resistance (SVR) reflect?

A

SVR = 80 x (MAP – CVP) /CO

Reflects impendence of the systemic vascular tree

57
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal values for Systemic Vascular Resistance Index (SVRI)?

A

Normal SVRI: 1600-2400 dynes-sec-m2/cm5

58
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Pulmonary Vascular Resistance (PVR) = ?

What does PVR reflect?

A

PVR = 80 x (PAP – PCWP)/CO

Reflects impendence of pulmonary circuit

59
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal values for the Pulmonary Vascular Resistance Index (PVRI)?

A

Normal PVRI: 200-400 dynes-sec-m2/cm5

60
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Left Ventricular Stroke Index (LVSI) = ?

A

LVSI = (MAP – PCWP) x SVI x 0.136

61
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal values for Left Ventricular Stroke Work Index (LVSWI)?

A

Normal LVSWI: 40-60 g.m/m2

62
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Right Ventricular Stroke Index (RVSI) = ?

A

RVSI = (PAP – CVP) X SVI x 0.136

63
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal values for Right Ventricular Stroke Work Index (RVSWI)?

A

Normal RVSWI: 4-8 g.m/m2

64
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal RV Ejection fraction:

65
Q

DERIVED/CALCULATED PAC HEMODYNAMIC PARAMETERS

Normal RV End-diastolic volume (RVEDV):

A

80-150 mL/m2

66
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

T/F: From a treatment decision standpoint, information gathered from PAC data can beneficially change therapy

67
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

How could information gathered from a PA catheter prior to surgery be used?

A

Lead to cancellation or modification of surgical procedure or anesthetic management

Thereby preventing morbidity and mortality

68
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

What does the PA catheter allow to monitor perioperatively?

A

Provides invasive hemodynamic monitoring during surgery

Assess volume status/guide perioperative fluid management

69
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which changes in PA catheter values are indicative of RV dysfunction?

A

↑CVP

↓ CVP to mean PA gradient, no change in PCWP

↓CO

70
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which changes in PA catheter values are indicative of LV dysfunction?

A

↑ PAP, ↑ CVP, ↑PCWP

↓BP, ↓CO

71
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which changes in PA catheter values are indicative of pulmonary HTN?

A

PA diastolic pressure > PCWP

72
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

How can the PA catheter be used to assess valvular disease?

A

By measuring pressure gradients across the valves

73
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which pressure gradient changes noted on PA catheter may indicate Tricuspid stenosis

A

CVP-RVEDP gradient

74
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which pressure gradient changes noted on PA catheter may indicate Pulmonic stenosis?

A

RV systolic-PA systolic pressure gradient

75
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Mitral valve disease may be assessed from which PA catheter value?

76
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which changes in PA catheter values are indicative of Mitral valve insufficiency?

A

↑pulmonary venous pressure = abnormal V wave

77
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Which changes in PA catheter values are indicative of Mitral valve Stenosis?

A

Not routinely done in OR

78
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

Although EKG remains cornerstone for diagnosing ischemia, it is not always sensitive. Which type of ischemia could be diagnozed early via PA catheter?

A

Subendocardial ischemia

79
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

How does Subendocardial ischemia presents on PA catheter monitoring?

A

​Associated with ↓ventricular compliance

↑ PA pressures or ↑PCWP

80
Q

BENEFITS OF THE PULMONARY ARTERY CATHETER

How does ischemia of papillary muscle presents on PA catheter monitoring?

A

Pathologic V waves may occur

81
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

Which complications may occur with PA catheter placement?

A

Arrhythmias

Complete heart block (Transcutaneous pacing may be needed)

Thromboembolism

Pulmonary infarction (continued wedging)

Cardiac perforation

PA rupture (has a 45% mortality rate)

Intracardiac knotting

Endocarditis

Balloon rupture

Tricuspid/pulmonary valve injury

82
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

Because of its high mortality rate (45%) which risks factors of PA rupture should you be aware of?

A

Advanced age

Female

Primary HTN

Overinflation of the balloon (you should never need more than 1.5cc)

Distal tip being too far deep into the PA

83
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

When inflating PA catheter balloon, you realize than you need a lot less than 1.5cc of air to wedge. What would you conclude and what would do?

A

The catheter may be too far in

Deflate the balloon

Pull the catheter out

84
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

Which PA catheter complications are associated with the vascular access?

A

Hematoma

Air embolism

Thrombosis

Catheter shearing (embolization)

Pneumo/hemothorax

Vagal nerve or brachial plexus injury

Thoracic duct injury

85
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

Which PA catheter insertion site is associated with Vagal nerve or brachial plexus injury?

A

IJ approach

86
Q

COMPLICATIONS OF THE PULMONARY ARTERY CATHETER

Which PA catheter insertion site is associated with Thoracic duct injury ?

A

Left IJ approach

8361 Exam I (18 decks)

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