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Patient Monitoring/Instrumentation & SIM > Advanced Hemodynamic Monitoring > Flashcards

Advanced Hemodynamic Monitoring Flashcards

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1
Q

Normal value for cardiac index

A

2.2-4.2 L/min/m2

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2
Q

Normal value for central venous pressure

A

5-12 mmHg

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3
Q

When is CVP most accurate?

A

When measured at the end of expiration

If the backrest position is between 0 to 60 degrees

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4
Q

Normal value for coronary perfusion pressure

A

Autoregulated between 50-120 mmHg

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5
Q

Normal value for mixed venous oxygen saturation (mvO2)

A

60-80% in an awake patient

Roughly equal to central venous oxygen saturation (ScvO2)

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6
Q

Normal value for pulmonary artery pressure (PAP)

A

15-30/10 mmHg

Accurate if backrest position is between 0-60 degrees

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7
Q

Normal value for pulmonary hypertension (mild, moderate and severe)

A

Mild: 36-49 mmHg systolic
Moderate: 50-59 mmHg systolic
Severe: >60 mmHg systolic

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8
Q

Normal value for pulmonary capillary wedge pressure

A

<12 mmHg (mean pressure)
1-4 mmHg less than pulmonary artery diastolic pressure
Accurate if backrest position is between 0-60 degrees

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9
Q

Normal pulmonary vascular resistance (PVR)

A

100-300 dynesseccm^-5

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10
Q

Normal value for stroke volume in adults

A

60-90 mL/beat

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11
Q

Normal value for stroke volume index

A

20-65 mL/beat/m2

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12
Q

Normal value for systemic vascular resistance (SVR)

A

700-1200 dynesseccm^-5

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13
Q

Normal value for central venous oxygen saturation (ScvO2)

A

25-30% below SaO2 OR 70-75% if pt’s SaO2 is normal

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14
Q

Baroreceptor reflex

A
  • Responds to changes in blood pressure in carotid sinus and aortic arch
  • When BP is low, HR increases
  • When BP is high, HR decreases
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15
Q

Bainbridge reflex

A

-Responds to changes in blood volume in the heart
-If R atrial pressure increases, the Bainbridge reflex causes increased HR and vasodilation
(try to get excess blood out of R atrium and causes venous pooling in legs, which decreases venous return)

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16
Q

What causes an increase in HR in the Bainbridge reflex and Baroreceptor reflex?

A

Low CVP through Baroreceptor reflex

High CVP through Bainbridge reflex

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17
Q

Why is a cardiac output of 5L/min not accurate?

A

It may be normal for a 70kg patient, but it is too low for a 200 kg patient and too high for a 30 kg patient

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18
Q

What is the cardiac index equation?

A

Cardiac output/surface area

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19
Q

Stroke volume index equation

A

stroke volume/surface area

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20
Q

Coronary perfusion pressure equations

A
  1. CPP = DBP - LVEDP
  2. CPP = DBP - CVP
  3. CPP = DBP - Pulmonary artery diastolic pressure
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21
Q

How do you estimate Left Ventricular Diastolic Pressure? (LVEDP)

A
  1. LVEDP = left atrial pressure
  2. Left atrial pressure = PCWP
  3. PCWP = Pulmonary artery diastolic pressure
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22
Q

What is the thermodilution technique?

A
  1. Inject 10ml cold saline in the R atrium through the Swan Ganz catheter CVP port in <4 seconds
  2. The cold fluid travels to the PA where it encounters the thermistor (the fluid is warmed to a degree before encountering the thermistor)
  3. The monitor produces a waveform depending on how cold it is
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23
Q

If cardiac output is high, what happens to the temperature of the fluid at the thermistor?

A

It warms up quickly

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24
Q

What does the thermistor curve look like for high cardiac output?

A

The area under the curve is lower than normal (small wave)

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25
If cardiac output is low, what happens to the temperature of the fluid at the thermistor?
It will stay cold for a longer period
26
What does the thermistor curve look like for low cardiac output?
The area under the curve is larger than normal (large wave)
27
What happens if the saline is injected too slowly to the thermistor?
The curve would be larger than normal, underestimating cardiac output
28
A patient has a right to left intracardiac shunt. Would thermodilution lead to an overestimation or underestimation of cardiac output, and why?
Overestimation; Some cold fluid is lost to the L side, so blood in the pulmonary artery will be warmer and the curve will be smaller
29
A patient has a left to right intracardiac shunt. Would thermodilution lead to an overestimation or underestimation of cardiac output, and why?
Overestimation; Cold fluid is diluted by warm blood in the L side, so fluid will be warmer and the curve will be smaller
30
A patient has tricuspid regurgitation. Would thermodilution lead to an overestimation or underestimation of cardiac output, and why?
Underestimation; The blood at the thermistor will stay colder for a longer period and the curve will be larger
31
What has replaced thermodilution?
1. Continuous cardiac output pulmonary artery catheters | 2. Transesophageal echocardiography (TEE)
32
Oxygen saturation of superior vena cava
Central venous O2 saturation
33
How is ScvO2 drawn?
Central venous line port
34
What is a mixed venous oxygen saturation?
Blood from the SVC, IVC and coronary sinus taken at the distal tip of the pulmonary artery catheter
35
What is the difference between ScvO2 and mvO2?
mvO2 will be slightly lower because it has venous blood from the heart (coronary sinus blood)
36
How do ScvO2 and mvO2 relate to low cardiac output, and why?
Low CO = low mvO2/ScvO2 Blood is more deoxygenated by the time it reaches the heart because it traveled slowly through the body and had more time to unload oxygen to the tissues
37
How do ScvO2 and mvO2 relate to high cardiac output, and why?
High CO = high mvO2/ScvO2 Blood is less deoxygenated by the time it reaches the heart because it traveled quickly throughout the body and had less time to unload oxygen to the tissues
38
Why are ScvO2 and mvO2 rarely used to estimate cardiac output now?
1. It requires drawing blood from central line or Swan catheter 2. Cardiac output can be estimated through other effective methods such as TEE, CCO Swan, FloTrac sensor
39
What is the equation for Ohm's law and what is each variable?
V= IR Voltage I: Current Resistance
40
What part of Ohm's law is analogous to cardiac output?
The current (I)
41
What part of Ohm's law is analogous to peripheral and systemic vascular resistance?
Resistance (R)
42
What in the body is analogous to voltage in Ohm's law?
The difference between the blood pressure at the arterial end of the body and the blood pressure at the venous end of the body MAP- CVP
43
What is Ohm's law in terms of cardiac output systemically?
(MAP-CVP) = (SVR)(CO)
44
Rewrite Ohm's law to solve for cardiac output
CO = [(MAP-CVP)/SVR]*80
45
Rewrite Ohm's law to solve for SVR
SVR= [(MAP-CVP)/CO] *80
46
Why use the number "80" in the equations for cardiac output and SVR?
80 converts the units for blood pressure and SVR into units for cardiac output
47
How can you calculate PVR using Ohm's law?
PVR = [(PAP-PCWP)/CO] *80
48
How can you calculate cardiac output with pulmonary pressures?
CO= [(PAP-PCWP)/PVR] *80
49
What are factors that affect pulse pressure?
1. Stroke volume (increased stroke volume = increased systolic pressure) 2. SVR (increased SVR/vasoconstriction = increased systolic pressure) 3. Aortic compliance (good compliance = decreased systolic pressure)
50
Will pulse pressure be wide or narrow in a hypovolemic patient, and why?
Narrow | Low SV and vasoconstriction
51
Will pulse pressure be wide or narrow in a patient with CHF, and why?
Narrow | Low SV and vasoconstriction
52
Will pulse pressure be wide or narrow after running 3 miles on the treadmill, and why?
Wide | Inc SV and vasodilation
53
Will pulse pressure be wide or narrow in a patient with cardiac tamponade, and why?
Narrow | Low SV and vasoconstriction
54
Will pulse pressure be wide or narrow in a patient with aortic stenosis, and why?
Narrow | Low SV and vasoconstriction
55
Will pulse pressure be wide or narrow in a patient with a milrinone drip, and why?
Wide | Increases cardiac contractility and decreases SVR
56
Will pulse pressure be wide or narrow in a patient with aortic regurgitation, and why?
Wide | Inc SV and dec DBP
57
What causes high CVP?
1. Fluid overload 2. Heart failure 3. Pulmonarty HTN 4. Trendelenburg 5. High intrathoracic pressure (tension PNX)
58
What causes low CVP?
1. Hypovolemia | 2. Sitting position
59
Causes of low SVR
Vasodilation
60
Causes of high SVR
Vasoconstriction
61
Causes of low cardiac index
1. Decreased cardiac contractility 2. Bradycardia 3. Hypovolemia 4. Hypervolemia (in CHF patient) 5. Increased afterload (aortic stenosis or high SVR)
62
Causes of high cardiac index
1. Increased contractility/stroke volume 2. Tachycardia 3. Vasodilation
63
Types of hypotension
1. Hypovolemia 2. Vasodilation 3. Heart failure (dec contractility)
64
Treatments for hypovolemia
Fluids and/or blood products
65
Treatments for vasodilation
1. Vasopressors | 2. Reversing of vasodilation such as decreasing level of anesthetic
66
Treatments for heart failure
1. Inotropes | 2. Diuretics
67
What happens to cardiac index, CVP and SVR when a patient is hypotensive due to hypovolemia?
Cardiac index: Decreased CVP: Decreased SVR: Increased
68
If a patient has hypotension due to vasodilation, what happens to cardiac index and SVR?
Cardiac index: Increased | SVR: Decreased
69
If a patient has hypovolemia due to decreased contractility, what happens to cardiac index, CVP and SVR?
Cardiac index: Decreased CVP: Increased SVR: Increased
70
What would be best to treat this patient with a BP of 88/40, HR of 98, cardiac index of 3.0 and SVR of 400?
Vasopressor
71
What would be best to treat this patient with a BP of 85/40, HR of 65, SVR of 1100, and cardiac index of 1.8?
Inotrope
72
What would be best to treat this patient with a BP of 170/105, HR of 60, SVR of 1700, cardiac index of 2.8 and PVR of 350?
Vasodilator
73
What would be the best treatment for a patient with a BP of 84/55, HR of 100, SVR of 1500, PVR of 100, cardiac index of 2, CVP of 2, and PAP of 20/5?
Fluid bolus
74
Stroke volume and systolic blood pressure fluctuating during inspiration and expiration
Stroke volume variation or pulse pressure variation
75
How much does systolic blood pressure decrease during inspiration in spontaneously ventilating patients?
5-10 mmHg
76
Why does systolic blood pressure decrease during inspiration in spontaneously ventilating patients?
It decreases 5-10 mmHg due to: 1. Pulmonary vessels vasodilating 2. Vasodilation causes blood to pool in lungs 3. Less blood is available to pump to the body 4. Slight drop in BP during inspiration
77
What is the expected effect on HR if the patient is hypervolemic? Hypovolemic? and why?
HR increases due to the Bainbridge reflex
78
In healthy mechanically ventilated patients, how much does the systolic blood pressure change during inspiration and why?
Increases 5-10% 1. Displaces L ventricular wall inward during systole, assisting ventricular contraction (increasing ejection fraction) 2. Squeezes blood out of the pulmonary capillaries, into the L atrium and increasing blood volume and stroke volume during inspiration
79
When the stroke volume/systolic blood pressure has wider than expected fluctuations during inspiration and expiration
Pulsus paradoxus
80
How do you detect pulsus paradoxus?
SpO2 and arterial line waveforms
81
Most common cause of pulsus paradoxus
Hypovolemia
82
Other causes of pulsus paradoxus
cardiac tamponade, tension pneumothorax, vasodilation, CHF, hypervolemia, and PEEP
83
Cardiac tamponade mechanism for pulsus paradoxus
1. During normal inspiration, blood volume in the R ventricle increases 2. With cardiac tamponade, the R ventricular wall cannot expand, so it forces the interventricular septum to bulge to the L 3. This causes a decrease in the volume of the L ventricle, decrease in SV and greater decrease in BP during inspiration
84
Tension PNX mechanism for pulsus paradoxus
1. R ventricular wall cannot expand, causing the interventricular septum to bulge into the L 2. This causes a decrease in the volume of the L ventricle, decrease in SV and greater decrease in BP during inspiration
85
What does the FloTrac sensor do?
Tells us exact stroke volume variation
86
"Cool things" about the FloTrac sensor
1. Noninvasive 2. Gives real time blood pressure 3. Measures stroke volume variation, stroke volume and SV index, SVR (from waveform downstroke) 4. Can calculate cardiac index
87
Disadvantages of FloTrac sensor
1. Arterial lines give access for drawing labs while EV1000 does not 2. EV1000 is not always accurate
88
Common methods to assess volume status
1. Urine output 2. hypotension/tachycardia 3. CVP monitoring
89
How do you manage fluids with the FloTrac sensor?
The FloTrac Sensor can give us stroke volume variation. When stroke volume increases by >10-15% on mechanically ventilated patients, hypovolemia is expected. Titrate until the stroke volume variation is closer to 10%
90
Limitations of the FloTrac Sensor?
1. Patient must be 100% mechanically ventilated for accurate stroke volume variation 2. Respiratory rate needs to be constant 3. Tidal volume needs to be >8ml/kg 4. Regular heart rhythm 5. PEEP and vasodilators can alter SVV
91
Fluid management protocol for hypotensive patients
1. Give fluids until SVV <10% 2. If SVV does not respond to therapy, look at the SVI - if SVI is <20%, give inotropes - if SVI is 40-50%, give vasopressors - if SVI is >50%, give diuretics

Patient Monitoring/Instrumentation & SIM (12 decks)

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