Cardiovascular Monitoring Part 2 Slides 47-70

Question 1

Provided abnormal PAC waveforms for the Left Heart: What 3 conditions are mentioned?

Answer 1

Mitral Regurgitation
Mitral Stenosis
Acute LV MI

Question 2

What happens to the Wedge Pressure waveform with Mitral Regurgitation?

Answer 2

Tall V wave
C wave fused with V wave
No X descent
No specificity/sensitivity to severity of MR d/t:
LA compliance
LA volume

Question 3

What happens to the Wedge Pressure waveform with Mitral Stenosis?

Answer 3

Slurred, early y descent
A wave may be absent d/t frequent assoc. with a-fib

Question 4

What happens to the Wedge Pressure waveform with Acute LV MI?

Answer 4

Tall a waves due to non-compliant LV
LV systolic dysfunction increases LVEDV and LVEDP
PAWP increases due to lack of compliance

Question 5

Practice LEFT Heart CVP waveform questions

Answer 5

https://docs.google.com/document/d/1cwM_mIvJcVQ7Z8EpKNcrrgRjcugRMNLGfQ8g6XSiaB4/edit?tab=t.0

Question 6

What is the Fick equation?

Answer 6

Used to solve for Cardiac output or any missing variable if only one is missing

Question 7

How can Fick be rearranged according to lecture?

Answer 7

Good luck

Question 8

What does each variable in the Fick equation represent?

Answer 8

SvO2 = mixed venous Hgb saturation
SaO2 = arterial Hgb saturation
VO2 = oxygen consumption
Q = cardiac output
1.34 = oxygen combining capacity of Hgb

Question 9

Where can I practice Fick equations?

Answer 9

https://docs.google.com/document/d/1QY7kOLBszQvvRptKCZZfGhc5Nf0Ko92wvi80DCISYdE/edit?tab=t.0

Question 10

Which of the variables make for a perfect Fick equation?

Answer 10

Hgb, Arterial saturation, and oxygen consumption

Mixed venous oximetry is an indirect indicator of Cardiac Output
SO…
If CO falls, mixed venous saturation decreases

THEN…
Low venous saturation may signal anemia/blood transfusion need

Changing just one variable makes the Fick Equation “less perfect”

Question 11

What is the formula for Cardiac output?

Answer 11

CO= SV x HR

Question 12

Memorize the normals for PAC values

Answer 12

Have fun

Question 13

Avg and range of CO

Answer 13

L/min

Question 14

Avg and range of SV

Answer 14

mL

Question 15

Avg and range of SVR

Answer 15

dynes/sec/cm5

Question 16

Avg and range of PVR

Answer 16

dynes/sec/cm5

Question 17

Avg and range of Mixed Venous O2 saturation

Answer 17

%

Question 18

Using a PAC, what is the gold standard of CO measurement?

Answer 18

Bolus Thermodilution

Question 19

How is Bolus thermodilution performed?

Answer 19

Cold injected (10ml)
change in temperature measured downstream

Injected RA lumen, measured PA blood by thermister

3 averaged attempts

CO inversely proportionate to degree of change
Subsequent changes of 13% significant

Question 20

Why are 3 attempts averaged?

Answer 20

User error

Question 21

Thermodulution curves:

Answer 21

Note the highlighted part of the picture

Question 22

Compare the CO of curve:
1:2
1:3
2:3

Answer 22

1 is more CO than 2
1 is less CO than 3
2 is less CO than 3

Question 23

What side of the heart does thermodilution measure? Which side does it assume?

Answer 23

Measures Right
Assumes Left

Question 24

What can cause thermodilution innacuracies?

Answer 24

Intra-cardiac shunts- ASD, VSD

Tricuspid/pulmonic regurgitation-recirculating temperature blood

Mishandling of the injectate- user error

Fluctuations in temperature following bypass

Rapid fluid infusion at the same time as temperature measurement
Cold blood?

Question 25

How is CONTINUOUS Cardiac Output performed and what does it do?

Answer 25

Small quantities of heat are released from filament in RV and measured at thermistor Updated q 30-60 seconds; averaged over 3-6 minutes Compared to thermodilution -Reproducibility/precision better -BUT Delays updated information in unstable patients More accurate during positive pressure

Question 27

What can a Pulse Contour Device measure? What is it's purpose?

Answer 27

it ESTIMATES: - CO - pulse pressure - Stroke volume variation (from test 1) Its purpose is to indicate whether the patient's HYPOTENSION will likely respond to fluid (volume responsive)

Question 28

What percentage indicates that hypotension will be responsive to fluids?

Answer 28

>10%

Question 29

Pulse Contour Device Algorithm

Answer 29

Relies on an algorithm -From end diastole to end systole -Calculates ventricular compliance +/- 0.5 L/min compared to thermodilution

Question 30

Causes of Pulse contour inaccuracies:

Answer 30

Atrial fibrillation Site of arterial puncture The quality of arterial trace is affected by vasopressors -Requires frequent re-calibration Ideally calibrated initially with a known CO

Question 31

What is this called?

Answer 31

TTE- transthoracic echocardiogram

Question 32

How does a TTE get its image on a screen?

Answer 32

From high frequency ultrasound waves that bounce off of tissue

Question 33

Out of M-mode, 2-D, and Doppler, which mode is described as: "-Narrow beams to measure tissue planes ie. Ventricular wall mass"

Answer 33

M-mode

Question 34

Out of M-mode, 2-D, and Doppler, which mode is described as: "-Real time motion -Shows function"

Answer 34

2-D

Question 35

Out of M-mode, 2-D, and Doppler, which mode is described as: "-Can determine speed and direction -Color"

Answer 35

Doppler

Question 36

Out of M-mode, 2-D, and Doppler, which modes can see motion?

Answer 36

All of them

Question 37

Using the FoCUS method for TTE, how many views are in a comprehensive exam?

Answer 37

28 views

Question 38

True or False: the FoCUS exam is a yes/no, present absent test

Answer 38

Yes, it is a simple, quick way to determine if abnormalities exist.

Question 39

What silly phrase did Kane use to describe low contractility of the left ventricle?

Answer 39

"spider doing pushups on a mirror"

Question 40

What are the 3 "windows" that a TTE uses to get its images?

Answer 40

Parasternal, Apical, and Subcostal

Question 41

Match the 3 windows to their location on this picture

Answer 41

Parasternal: 3-5 ICS Apical: @PMI Subcostal: just below xiphoid

Question 42

FoCUS views: Parasternal Long Axis

Answer 42

Parasternal Long Axis Great overall view Measures LA, LV, and Ao root

Question 43

FoCUS views: Parasternal Short Axis

Answer 43

LV function LV volume assessment

Question 44

FoCUS views: Apical Four Chamber

Answer 44

RV vs LV size TV and MV function Descending Ao

Question 45

FoCUS views: Subcostal Four Chamber

Answer 45

4 chambers Pericardial effusion often next to right heart

Question 46

FoCUS views: Subcostal IVC

Answer 46

Diameter, collapsibility esp. in spontaneous respiration

Question 47

According to Kane, what is a quick way to reference wall movement if you just cant properly see the movement?

Answer 47

Put your finger on the echo machine and use it as a reference point

Question 48

What is a TEE? What can be said about it?

Answer 48

Roles: Intraoperative monitor Rescue tool Assessment of valvular function Decision making *posterior structures are closer to transducer…at top of image

Question 49

What are absolute contraindication to a patient receiving a TEE?

Answer 49

-Esophageal varices -Laparoscopic banding

Question 50

How do you know that you are looking at the aortic valve when using a TEE?

Answer 50

Mercedes Sign

Question 51

When would the aortic valve not look like a Mercedes sign?

Answer 51

Congenital bicuspid aortic valve (leads to aortic stenosis early in life)

Question 52

What would be a concerning sighting when looking at the aorta with a TEE?

Answer 52

Calcification