Test 5 Flashcards
hemodynamics
Indications for Arterial line
- Continuous blood pressure monitoring (Right radial artery
- Pt who needs frequent ABGs
- Able to draw blood samples for lab
- Can titrate drugs, give immediate response (appropriate drug/ fluids response, Vassopressors/ dilators
Gold standard BP
noninvasive BP. Comes from aorta (L.heart)
Can you give meds through arterial line?
no.. against flow (cardiac and systemic)
Arterial line insertion sites
only catheter going against stream 1. Radial (most common): easy access 2. Brachial 3. Femoral RISK CAN BLEED OUT EVERY BEAT
Transducer
Gives waveform, zeroing the CVP line- automatic flushing system, keep level with rt atrium (heart).
Pressure keeps blood in body.
Transducer raised= Lower number/ pressure
Lower transducer = Higher numbers/ pressure
Pressure bag
Contains normal saline: cant contain air -> be above systolic pressure, above 300mmhg. Pressure keeps blood in body
Dicrotic notch on waveform
when aortic valve closes
Arterial pressure waveforms
Should have a clear upstroke on the left with a dicrotic notch representing aortic valve closure on the descending side of the waveform,
If dicrotic notch is not visible, the pressure tracing
is dampened and is probably inaccurate
-Your blood pressure reading will read higher or lower. you can use it to trend with noninvasivve blood pressure
Complications from arterial line
-Ischemia: Embolism, thrombus, arterial spasm
Prevented by irrigating with diluted heparin solution
-Hemorrhage: if arterial line becomes disconnected
-Infection: incidence increases over time
Types of Centrally located catheter lines: Central Venous lines
PICC (pick)-ICU pts
Porta Catheter-Chemo pts
Swan-Ganz- Cardiogenic shock pts
Tunneled catheter- Long term use
PICC
ICU pts
Peripherally inserted central (venous) catheter, brachial vein far from heart
-More stable invasive line
Porta Catheter
under the skin port, commonly used to administer chemotherapy. Nothing exposed (disk)
-Can cause heart damage
Swan-Ganz
Cardiogenic shock pts
Flow directed pulmonary artery catheters.
-Most invasive, used cautiously
Tunneled Catheter
catheter is tunneled under the skin reducing the risk of infection
Under the skin before getting to blood supply, far from heart
-Ex: Groshong, Hickman, Broviac=Common brand names
Lumen
How many things can connect to central line
mixed venous sample
only venous, mixed with blood from head and toes together
PICC is less likely for
pneumothorax (unlike subclavian)- atrogenic (med. caused)
-more stable invasive line
CVP insertion sites
Central Venous pressure -Subclavian Vein -Internal Jugular Vein -Femoral Vein =risk of causing pneumothorax -Connect to septic shock, Provide fluid (guide fluid)
Common CVP catheter size
Most common: Size 7 french
-3 lumens
Indications for monitoring CVP
-Monitor circulating blood volume
-Monitor venous return (should increase)
-Monitor rt ventricular pressures
pts with:
-Trauma with major blood loss
-Severe dehydration
-Pulmonary edema, to guide fluid therapy
-Right sided myocardial infarction
Arterial Stenosis
Narrowing of tricuspid= increase CVP
Central venous line should be placed when
- Pt has hypotension and is not responding to fluid resuscitation
- Continued hypovolemia secondary to fluid shifts or continued fluid loss
- Pt requires inotropes and or vasopressors
Benefits of having a CVP line
Rapid infusion of meds or fluids
You can draw blood for labs
Three different ports allow for both meds to be delivered, blood to be drawn, and injections for CO measurement
How is CVP measured
Transducer
Water Manometer
CVP pressure
of the blood in the vena cava, right atrium, and right ventricle during diastole
CVP Measures, and reflects
right heart function and reflects:
- Preload and end diastolic filling pressure
- Ability of the right heart to pump blood into the pulmonary system into the left side of the heart
Increase in CVP
- Increased venous return
- Increased Intra-thoracic pressure
- Decreased ability of the right heart to move blood
Decrease in CVP
- Decreased venous return
- Decreased intra-thoracic pressure
- Increased ability of the heart to move blood forward
Respiration and CVP
- CVP decreases with inspiration (neg pressure)
- CVP increases with positive pressure vent
- CVP increases with PEEP
- Respiratory factors skew CVP readings
- CVP are used to trend
Complications of invasive central lines
Infection (can run labs on line) Bleeding Pneumothorax Air Embolus Development of a clot around the catheter: check perfusions of hand (nail bed)
Swan Ganz, measurements obtainable
Balloon tipped flow directed catheter
- CVP: rt heart, venous return
- PAP: lung
- PCWP/PAOP: left heart
what can the swan ganz/ PA catheter do
- Pace heart: temp internal pacing
- Measure CO
- Measure PCWP
- Measure CVP
- Measure PA
=While placing swan: Possible disrythmias
Risk with balloon inflation
pulmonary infaction
Measure SV
Echo
Who gets a Swan-Ganz catheter
- Benefits outweigh the risks
- Recent studies (20years worth) suggest no significant change in improvement or mortality of pts
- must be individualized
Risks of Swan-Ganz catheter
- Invasion of the catheter may cause dysrhythmias
- Chance of pulmonary infarction with balloon occlusion
- Air embolism
Critical conditions where PA catheters are considered
- Severe cardiogenic pulmonary edema, unstable angina, ventricular pathology
- ARDS pts who are hemodynamically unstable
- Major coronary bypass surgery with MI and poor ventricular function
- Pts with cardiogenic (fix pump) or septic shock (fix underlying cause)
Placement of PA catheter
When it reaches the superior vena cava or the rt atrium the balloon is inflated
- waveforms change as it advances into the pulmonary artery
- Eventually a wedge pressure will be obtained
Wedge
occurs when the balloon drifts into the PA that is too small to allow further advancement of the catheter
Most common cause of an increase in PCWP is
left heart failure
Systolic heart failure
Heart muscle isnt strong enough to pump blood
Diastolic heart failure
Heart cant relax
Both systolic and diastolic heart failures
Decrease in CO
Hemodynamic medications
Inotropes: Contraction
Chronotropes: Time, increase or decrease HR
-ex atropine: increase HR, Beta blockers Decrease HR
Dromotropic Effect: conduction
-Speed of conduction, Amiodorone
Pressors-Dilators
-Systemic Purpose: Norepinephrine
Septic shock, circ issues
-Pulmonary Purpose: Veletri-Pulm dilators
ARDS, Pulm hypertension
-Coronary Purpose: Nitroglycerine Coronary Vassodilators
Angina
Blood flow [right side of heart]: diastole
Blow flows into the atria and ventricle [85% of blood in the heart is received)
- tricuspid valve remains open
- ventricle is in a relaxed state (pressure below that of vena cava)
Atrial contraction
Sa mode causes atrial contraction filling the ventricles another 10-30% ( increases the volume of blood into the ventricles)
Transition
Tricuspid valve closes (lub) when the ventricular pressure exceeds that of the attia
Normal systemic BP, pulmonary, MAP
Systemic= 120/80 Pulmonary= 25/8 MAP= sBP + (2xdBP) / 3, keep above 60
Normal average PAP
13.67
Cardiac output
CO= Hr x av
Normal 4-8, athlete can have up to 35 lpm
Why do we worry about left side heart
Provides blood flow/ pulse to body
Satisfies the bodies o2 demand
Removes waste
Transports hormones and nutrients
Cardiac index
Varies with body size
CI= CO/ BsA
Body surface area
Calc using pts weight and height
Found on monogram
Norm2.5-4.0
Universal
Venous Return
All the blood coming back to heart
Venous system holds 64% of total blood vol for emergencies
10 in arteries
75 in pulmonary capillary bed
Stroke volume
Measure by echo or indirectly
Amount of blood ejected by left ventricle with each contraction
Norm 60-130
Composed of.. preload, contractility, afterloadMeasure by echo or indirectly
Amount of blood ejected by left ventricle with each contraction
Norm 60-130
Composed of.. preload, contractility, afterload
Ventricular volume
End systolic volume and EDV
ESV
Norm 50-60ml
Amount of blood in ventricle at the end of emptying
EDV
amount of blood in the ventricle at the end of filling
Measure indirectly with end diastolic pressure
Norm 120-180
Ejection fraction
Percent of the end diastolic vol that is rejected with each beat
Norm 50-70
?measure directly echo
