Module 2 - Hemodynamic Monitoring Flashcards
Normal value for PA pressures
15-25/8-15 mmHg
Identify this tracing [RV Pressure]
Looks like VT
Rise in pressure corresponds to Ventricular Depolarization
Normal value for CVP pressures
2-6 mmHg
aka RA Pressure
Normal value for RV pressures
15-25/0-5 mmHg
PAWP/PCWP
8-12 mmHg
Pulmonary Artery Wedge Pressure
Pulmonary Capillary Wedge Pressure
CO
4-8 L/min
CI
2.5-4.2 L/min
SV
60-135 mL
PVR
50-250 dynes
Pulmonary Vascular Resistance
SVR
800-1200 dynes
Systemic Vascular Resistance
LAP
Indirect measurement of Left Atrial Pressure
4-12 mmHg
If hemodynamic tracing indicates you are in the RV, what is your course of action?
Inflate the balloon to attempt to float catheter out of the RV into the PA. If unsuccessful, pull catheter back into the RA, and relabel lines to indicate positioning.
What is consequence of leaving PA catheter in RV?
Patient may develop PVC’s or VT
Where is this tracing taken from [PA tracing waveform with ECG]
PA
The change in pressure corresponds to the QRS.
The rise in systolic pressure occurs after the QRS
Where is this tracing taken from [PA tracing waveform into PAWP with ECG]
PA into PAWP
The WP should always be lower than the mean pulmonary artery pressure (PAP)
Pulmonary Catheter Markings
10 cm - Single thin black line
50 cm - Single thick black line
100 cm - Double thick black line
3 common PA Catheter insertion sites
R Internal Jugular - Shortest/Straightest path to the heart
L Subclavian - Does not enter superior vena cava at acute angle as R Sub, and L Internal Jugular do
Femoral veins - Distant site = more difficulty
PAC positions
RA = 25-30 cm (proximal port/lumen) RV = 35-45 cm PA = 50-55 cm (distal port/lumen)
Balloon Lumen holds ___ mL of air in distal tip.
1.5 mL of air
Thermistor lumen
bead 4 cm from tip of catheter that measures temperature
Uses of PA
Assessment of Volume status where CVP is unreliable
Sampling of Venous blood to calculate shunt fraction
Measurement of CO using thermodilution
Derivation of other cardiovascular indices such as PVR, O2 delivery, and uptake.
Complications of PAC insertion
Valve rupture PE PA rupture/hemorrhage Dysrhythmias Infection Pneumothorax Respiratory distress Dampened waveform Balloon rupture Knotting of catheter in RV
6.The patient’s PA catheter is exhibiting a large, well defined hemodynamic waveform with an obvious “notch” on the left side of the waveform. The distal tip is most likely located in the
Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 53). Xlibris. Kindle Edition.
right ventricle (clue: obvious notch on the left side of the waveform)
Clues that will assist in determining an RV waveform are: the wave will look taller in appearance than a PA waveform an RV waveform is symmetrical in shape; there is no dicrotic notch seen on the right side (downslope) of the waveform
the right ventricular pressure rise is closer to the QRS than with PAP waveform
inflation of the catheter balloon fails to produce a PAWP waveform.
Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 68). Xlibris. Kindle Edition.
What is happening in this tracing [PA tracing waveform into PAWP with ECG]
PAWP into PA waveform. PAWP is lower than PAD.
Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (pp. 68-69). Xlibris. Kindle Edition.
A waves are created by [image]
Rise in atrial pressure as a result of atrial contraction.
CVP/RAP - A wave is generally seen during the PR interval before the onset of the QRS on the ECG.
PAWP/LAP - “A” wave slightly later after the PR interval due to the timing delay on the ECG.
C Waves are created by [image]
Not always visible rise in pressure as result of rise in atrial pressure with closure of tricuspid/mitral valve
Usually coincides with mid to late QRS on ECG
PAWP/LAP slightly later than CVP/RAP
V waves are created by [image]
Rise in atrial pressure as it refills during ventricular contraction. (passive filling)
V wave is generally seen immediately after the peak of the T wave on the ECG.
PAWP/LAP slightly later than CVP/RAP
X waves are created by [image]
Decline in right/left atrial pressure during atrial relaxtion (“X” in relaxation).
Y waves are created by [image]
Decline in right/left atrial pressure: atrial emptying (“Y” in emptying).
9.A common cause of elevated PA pressures is
mitral valve stenosis
mitral valve regurgitation
left ventricular failure
What are some causes of decreased CVP/RAP
Normal 2-6 mmHg
Hypovolemia
Vasodilation
Decreased venous return (preload)
Negative pressure ventilation
What are some causes of increased CVP/RAP
Normal 2-6 mmHg
Hypervolemia Right-sided heart failure Cardiac tamponade Positive pressure ventilation COPD Pulmonary HTN Pulmonary embolus Pulmonic stenosis Tricuspid stenosis Tricuspid regurgitation
What are some causes of increased RVP pressures
reading only obtained when catheter is being inserted
Pulmonary HTN caused by left heart failure
COPD
Pulmonary embolus
What are some causes of increased PAP’s
Normal 15-25/8-15 mmHg
Fluid overload Atrial or ventricular defects Pulmonary diseases LV failure Mitral stenosis Mitral regurgitation
What are some causes for decreased PAWP/PCWP
Normal 8-12 mmHg
Hypovolemia
Venodilating drugs
What are some causes for increased PAWP/PCWP
Normal 8-12 mmHg
LV failure Constrictive pericarditis Mitral stenosis Mitral regurgitation Fluid overload Renal failure
What are some causes of increased PVR pressures
50-250 dyn
Pulmonary disease
Hypoxia
What are some causes of decreased SVR pressures
800-1200 dyn
Septic shock
Neurogenic shock
Anaphylactic shock
Vasodilators
What are some causes of increased SVR pressures
800-1200 dyn
Hypovolemic shock Cardiogenic shock Right ventricular MI Aortic stenosis Vasoconstrictors
What Increased PAWP Readings May Signify
Early pulmonary congestion = 20 mmHg
Moderate pulmonary congestion = 25 mmHg
Severe pulmonary congestion = 30 mmHg
The patient’s peripheral A-line is showing a very sharp waveform with readings that appear exaggerated.
This may be due to
Catheter whip, which can be caused by hypertension. (Clue: the word “exaggerated.”
Phlebostatic axis is
is the point of the junction of the vena cava and the right atrium where the blood will have the lowest pressure.
What is happening with this waveform [Underdamped waveform]
Underdamped Waveform
Shows many oscillations before returning to baseline. More than two oscillations are considered underdamped.
This can be caused by air in the system loose connections low pressure in the bag altitude changes.
What is happening with this waveform [Overdamped waveform]
Overdamped waveform
When the fast flush is terminated, the waveform just slowly returns to baseline.
This can be caused by:
kinking of the catheter
tip of the catheter against the wall
increased pressure in the bag.
When attempting to “wedge” a PA catheter, you should always fill the balloon with _____ or until _____ is obtained.
Balloon should only be filled until waveform is obtained but only up to no more than 1.5 mL.
Balloon volumes greater than 1.5 mL can rupture the balloon
Your patient’s PA waveform has suddenly changed to resemble a low-amplitude rolling waveform. This is most likely an
Inadvertent wedge (Clue is the word rolling waveform)
Your patient’s PA waveform is in wedge position.
You would
Have the patient cough forcefully in an attempt to dislodge the balloon.
Assure that the balloon is completely deflated
Have the patient lie on their side.
16.Your patient presents with the following: CVP 2, CI 6.4, PA S/D 34/16, wedge 7, and SVR 400. What is your diagnosis?
A.hypovolemic shock
B.septic shock
C.left ventricular failure
D.neurogenic shock
septic shock
Your patient presents with following parameters: CVP 20, CI 1.1, PA S/D 8/4, wedge 3, and SVR 1,800. What, is your diagnosis?
A.hypovolemic shock
B.right ventricular MI
C.Congestive heart failure (CHF)/left ventricular failure D.sepsis
B.right ventricular MI
Hypovolemic Shock - Values High/Low CVP/RAP Cardiac index (CI) PAWP/PCWP (Wedge) SVR
CVP/RAP - LOW
Cardiac index (CI) - LOW
PAWP/PCWP (Wedge) - LOW
SVR - HIGH
Cardiogenic shock - Values High/Low CVP/RAP Cardiac index (CI) PAWP/PCWP (Wedge) SVR
CVP/RAP - HIGH
Cardiac index (CI) - LOW
PAWP/PCWP (Wedge) - HIGH
SVR - HIGH
RVMI - Values High/Low CVP/RAP Cardiac index (CI) PAWP/PCWP (Wedge) SVR
CVP/RAP - HIGH
Cardiac index (CI) - LOW
PAWP/PCWP (Wedge) - LOW
SVR - HIGH
Septic Shock - Values High/Low
Cardiac index (CI)
SVR
Cardiac index (CI) - HIGH SVR - LOW
Neurogenic Shock - Values High/Low
Cardiac index (CI)
SVR
Cardiac index (CI) LOW (HR normal or slow) SVR - LOW
Anaphylactic
Cardiac index (CI)
SVR
Cardiac index (CI) - LOW (HR fast) SVR - LOW
How to assess for shock -
1st assess AFTERLOAD If SVR < 800 think Distributive —look at the CI (2.5-4.3) - Right side - PVR - Left Side - SVR If high - *Septic shock—CI high If low - * Neurogenic shock—CI low •Heart rate slow or normal Anaphylactic shock —CI low •Heart rate fast
2nd assess PRELOAD - filling pressures
If SVR is high > 1200 —look at the CVP/RA (2-6 mmHg)
* if CVP/RA is low - Hypovolemia
* if CVP/RA is highlook at PAWP(8-12 mmHg)
Cardiogenic shock —CVP/RA high •PAWP high
RVMI —CVP/RA high •PAWP low
Identify this waveform [Image: Arterial Waveform]
Arterial waveform
when possible note the scale range if provided.
Arterial lines and pulmonary artery pressures are categorized as arterial waveforms.
The dicrotic notch is seen on the downslope of the right side of the waveform and indicates
closure of the aortic valve.
As pressure falls, the aortic valve closes, signaling the onset of diastole. Aortic valve closure produces a characteristic waveform known as the dicrotic notch.
The lowest point of the arterial waveform is the ____, what is its normal range?
diastolic pressure, with a normal range of 60-90 mmHg
Formula for: Coronary perfusion pressure (CPP)
CPP = DBP-PAWP (normal 50-60 mmHg)
Formula for: Mean arterial pressure (MAP)
MAP = 2 × DBP + SBP / 3 (normal 80-100 mmHg)
Allen’s Test
aka the blanching test
must be performed prior to insertion to ensure adequate radial and ulnar circulation.
Two benefits of Arterial lines
Allows for continuous BP monitoring and rapid recognition of problems requiring intervention.
Easy access to blood gases
Slurring of the dicrotic notch occurs with
aortic valve disease
Pressure Monitoring Setup
Purge and flush lines Pressurize fluid Place transducer at phlebostatic axis Attach tubing Close stopcock to patient Calibrate to ZERO Open to patient and fast flush
Invasive Line Transport Considerations
- Air is removed from the system to prevent air embolus and dampened waveforms.
- Tape transducer at the phlebostatic axis or on the bicep during transport.
- Limit the amount of tubing to decrease the chances of dislodgment and artifact due to aircraft vibration.
- Boyle’s law will cause changes in pressure bag necessitating close attention of the flight crew members.
- Needs to be rezeroed with changes in altitude to ensure accuracy of readings.
Central venous pressure (CVP)
Right atrial pressure (RAP)
reflects:
Reflection of right atrial pressure preload
Pulmonary artery pressure (PAP) is
PA pressures reflect right—and left-sided heart pressures. Dicrotic notch is closure of the aortic valve and signals the end of systole
Pulmonary artery wedge pressure (PAWP)
Evaluates pressure of the left side of the heart-preload
Cardiac output (CO) is product of
SV x HR
Cardiac index (CI) is
Is based on body surface area and is more accurate; it assesses blood flow
Stroke volume (SV) is
Amount of blood ejected with each heartbeat from the ventricles during systole
Stroke index (SI) is composed of
The three components of SV are:
preload, afterload, and contractility
Pulmonary vascular resistance (PVR)
Measures afterload for the right heart
Systemic vascular resistance (SVR)
Measures afterload for the left heart
Left atrial pressure (LAP)
Reflects filling pressure in left ventricle
The higher the LAP, the lower the ejection fraction from the left ventricle
Pulmonary artery pressure reflects
A.the filling pressure in the left ventricle
B.the amount of blood ejected with each heart beat from the ventricles during systole
C.right atrial pressures
D.right- and left-sided heart pressures
D: right and left-sided heart pressures
The pulmonary artery wedge pressure (PAWP) evaluates
A.the right side of the heart
B.stroke volume
C.the left side of the heart
D.afterload of the left side of the heart
D.preload of the left side of the heart
CO normal range is
4-8 L/min
PAWP normal range is
8-12 mmHg
RAP normal range is
2-6 mmHg
SVR measures
PVR measures
SVR measures afterload of the left side of the heart
PVR measures afterload of the right side of the heart
A decrease in the patient’s CVP can indicate all of the following, except A.vasodilation B.hypovolemia C.decrease in venous return D.right-sided heart failure
D.right-sided heart failure
A decrease in the patient’s SVR can indicate all of the following, except A.septic shock B.hypovolemic shock C.neurogenic shock D.anaphylactic shock
B: hypovolemic shock
SVR will be greater than 1,200 in shock states associated with hypovolemia, cardiogenic, and right ventricular infarction (RVI, also called rightventricular myocardial infarction-RVMI).
SVR less than 800 are associated with distributive shock states, which include septic, neurogenic, and anaphylactic shock.
An increase in SVR can indicate all of the following, except A.cardiogenic shock B.right ventricular infarction C.septic shock D.hypovolemic shock
C.septic shock
—this is a type of distributive shock.
Drug of choice recommended for a distributive shock state is Levophed (norepinephrine), indicated in profound hypotension. It has both alpha and beta effects, thereby increasing coronary artery blood flow.
Initial adult dose is 2-12 μg/minute and titrated to desired effect.
Medications that can decrease preload include all of the following, except A.morphine sulfate B.nitroglycerin C.vasopressin D.furosemide
C.vasopressin
Drugs that decrease preload
NTG
Morphine
Lasix
Drugs that increase preload
Vasoconstrictors
Fluids
Drugs that decrease afterload
Nipride Corlopam Calcium-channel blockers Dobutrex Natrecor
Drugs that increase afterload
Dopamine
Neosynephrine
Levophed
Epinephrine
Atrial waveforms are described as “filling pressures” and include which of the following?
A.ventricular pressures
B.right atrial and left atrial pressures
C.right atrial pressure only
D.left atrial pressure only
B: Waveforms obtained from the right and left atria
CVP (right atrium; right atrial pressure)
PAWP (left atrium; left atrial pressure - obtained indirectly)
The PAWP tracing is an indirect measurement of A.right atrial pressure
B.right ventricular pressure
C.left atrial pressure
D.central venous pressure
C.left atrial pressure
The “a” wave seen on an atrial waveform indicates
A.rise in atrial pressure as a result of atrial contraction B.decrease in atrial pressure as a result of atrial relaxation C.rise in ventricular pressure as result of ventricular contraction
D.decrease in ventricular pressure as a result of ventricular relaxation
A.rise in atrial pressure as a result of atrial contraction
The “A” wave represents a rise in atrial pressure as a result of atrial contraction.
The “c” wave, when seen (not always visible) on an atrial waveform, indicates
A.rise in atrial pressure when the AV valves are open
B.rise in atrial pressure when the AV valves are closed
C.rise in atrial pressure as it refills during ventricular contraction
D.rise in atrial pressure as a result of atrial contraction
B.rise in atrial pressure when the AV valves are closed
The “c” wave represents a rise in atrial pressure when the closed AV valves bulge upward into the atrium following valve closure
The “v” wave seen on an atrial waveform indicates
A.rise in atrial pressure when the AV valves are open
B.rise in atrial pressure when the AV valves are closed
C.rise in atrial pressure as it refills during ventricular contraction
D.rise in atrial pressure as a result of atrial contraction
C.rise in atrial pressure as it refills during ventricular contraction
The “v” wave represents a rise in the atrial pressure as it refills during ventricular contraction.
The “a” wave, when assessing a right atrial pressure waveform, coincides with which area of the ECG cycle? A.mid- to late QRS B.at the end of the T wave C.in the PR interval D.after the QRS
C: The “a” wave in a right atrial pressure waveform coincides with the PR interval on the ECG.
The “a” wave begins to form as depolarization begins.
In a right atrial waveform, if the “c” wave is present, it generally coincides with which area of the ECG cycle?
A.mid- to late QRS
B.immediately after the peak of the T wave
C.in the PR interval
D.after the QRS
A: The “c” wave in a right atrial pressure waveform coincides with mid- to late QRS on the ECG.
As the pressure builds in the ventricle, the closed AV valves begin to bulge upward into the atria, producing a small rise in the pressure. This pressure rise in the atria is called the “c” wave. The “c” wave is not always visible, but when present, can be seen as a notch on the downslope of the “a” wave or as a separate wave in between the “a” wave and the “v” wave.
The “v” waves, when assessing a right atrial pressure waveform, coincides with which area of the ECG cycle?
A.mid- to late QRS
B.immediately after the peak of the T wave
C.in the PR interval
D.after the QRS
B: The “v” wave in a right atrial pressure tracing appears immediately after the peak of the T wave.
The downslope on the “v” wave represents atrial emptying, which is called A.isovolumetric contraction B.diastasis C.X descent D.Y descent
C: The downslope of the “a” wave, which represents a decline in the atrial pressure is referred to as the X descent, which indicates atrial relaXation
The period following diastole when all the four heart valves are closed is called A.isovolumetric contraction B.diastasis C.X descent D.Y descent
A: The closed valves prevent blood flow. The period when all four heart valves are closed is called “isovolumetric contraction,” which is due to depolarization.
Arterial lines have which of the following pressure characteristics as compared to pulmonary artery pressures? A.much higher pressures B.much lower pressures C.pressures are equal D.none of the above
A: Arterial lines have much higher pressures than pulmonary artery pressures.
Positive pressure ventilation will cause cardiac pressure to A.rise upon inspiration B.rise upon expiration C.fall upon inspiration D.fall upon expiration
A: Cardiac pressures rise and fall with breathing, which can be identified by increased and decreased changes in the waveform that coincide with ventilation.
Positive pressure ventilation will cause cardiac pressure to rise upon inspiration.
Spontaneous breathing usually produces the largest respiratory artifact, which causes a drop in vascular pressures immediately before inspiration with a gradual rise until end-expiration.
Diastasis is known as
middiastole and is the period when atrial and ventricular pressures are very similar, just prior to atrial depolarization.
Hemodynamic pressures should be assessed and recorded at the A.end of exhalation B.beginning of exhalation C.end of inspiration D.beginning of inspiration
Record pressure measurements at the end of exhalation.
For positive pressure ventilation, this will usually be at the lowest point on the waveform tracing.
For spontaneously breathing patients, the measurement point will be just prior to the dip in respiratory artifact.
Roller-coaster in appearance due to pressure changes associated with respirations.
Peak - Patient
Valley - Vent
Which of the following is used as standard for measuring atrial pressures?
A.top or peak of the “v” wave
B.top of peak of the “a” wave
C.identification of the “Z” point from the end of the QRS to the waveform
D.bottom or base of the “a” wave on the right side of the downslope
C: The end-diastolic pressure can be estimated by identifying the “Z” point.
