CVL and pulm artery catheter Flashcards
(87 cards)
1
Q
10 indications for central venous line placement
A
cvp monitoring pulm artery cath HD aspiration air emboli TPN vasoactive drugs repeated blood samples cannulae placement bad peripheral access areas
2
Q
CVP measures
A
right atrial pressure: located junction of SVC and RA
3
Q
CVP indicates 2 things:
A
venous return (preload)(volume) intravascular fluid volume
4
Q
what two things cause falsely high CVP readings.
A
PEEP and positive pressure ventilation
5
Q
normal CVP
A
1-8 mmHg
6
Q
atrial contraction produces an initial spike then descent as blood leaves atrium and fills the ventricle.
A
a wave
7
Q
Closed tricuspid elevates during isovolumic ventricular contraction.
A
c wave
8
Q
downward movement of tricuspid valve during systole and atrial relaxation when the base of the heart descends
A
x descent
9
Q
venous return against a closed tricuspid valve during systole
A
v wave
10
Q
opening of tricuspid valve during diastole as atrial pressure is higher than ventricular pressure
A
y descent
11
Q
what are the three systolic components of cvp waveform
A
a and c waves, x descent
12
Q
what are the two diastolic components of cvp waveform
A
v wave and y descent
13
Q
what 3 pathologies cause a large A Wave
A
- AV asynchrony
- pulm htn
- decrease RV compliance
14
Q
what pathology causes no A wave and prominent C - V waves?
A
atrial fib (think, atria dont contract)
15
Q
this pathology causes broad, tall systolic C - V waves
A
tricuspid regurg (regurg v wave)
16
Q
this pathology causes tall end diastolic A wave with an early diastolic y descent
A
tricuspid stenosis
17
Q
what two factors cause a distortion in CVP and PAOP monitoring due to a loss of A waves or only V waves
A
atrial fib and ventricular pacing (atrial asystole)
18
Q
what 8 factors cause a distortion in CVP and PAOP monitoring due to giant A waves
A
junctional rhythms complete av block pvcs vent pacing tricuspid/mitral stenosis diastolic dysfunction myocardial ischemia vent hypertrophy
19
Q
what 2 factors distort cvp and paop monitoring due to large V waves
A
tricuspid/mitral regurg
acute increase in intravascular volume
20
Q
what is the large a wave seen with AV asynchrony/disassociation caused by
A
due to atrium
contracting against a closed tricuspid during
ventricular systole.
21
Q
clinical conditions listed that cause high cvp
A
lv failure rv failure pulm htn cardiac tamponade pulm embolism
22
Q
clinical condition that causes low cvp
A
hypovolemia
23
Q
causes of high cvp (right side of heart)
A
rv failure tricuspid stenosis/regurg cardiac tamponade constrictive pericarditis volume overload pulm htn chronic lv failure
24
Q
causes of high PAP [pulmonary arterial pressure] (lungs)
A
lv failure mitral stenosis/regurg l-r shunting asd or vsd volume overload pulm htn catheter whip
25
causes of high paop (left side heart)
```
lv failure
mitral stenosis/regurg
cardiac tamponade
constrictive pericarditis
volume overload
ischemia
```
26
Multitude of direct and indirect measurements
assessing volume and pressure which yield a
picture of cardiovascular and pulmonary function
PA pressure monitoring
27
two most important measurements from pac
cardiac
| output and PAOP
28
common indications for pac
- hemodynamic monitoring
- differential diagnosis and managment of shock
- diagnostic eval of major cardiopulmonary disorders
- titration of therapys
- optimization of vent support
29
4 contraindications for pac insertion
coagulopathy
thrombolytic treatment
prosthetic heart valve
endocardial pacemaker
30
complications of pac placement
```
dysrhythmias
catheter knotting
thromboembolism
pulmonary infarction
infection - endocarditis
valvular damage
pulm vascular injury
```
31
Inflated balloon occludes a small segment of pulmonary circulation. The pressure
obtained is by
looking through the non-active occluded segment of the pulmonary circulation forward to the hemodynamically active pulmonary veins and LA.
32
paop (wedge pressure) reflects
representation of pulmonary venous and left atrial pressures
33
measures the back pressure (LV
| preload) from the pulmonary venous system.
PAOP (PCWP)
34
Gives a more accurate estimation of LAP and thus
| left ventricular preload than CVP
paop
35
normal paop
8-12 mmHg
36
In supine position tip needs to be in lung zone
3
| where a continuous full column of blood resides
37
what three things could cause the pac balloon to reside in zone 1 and zone 2
PPV, hypovolemia and various positioning
38
lung zone 1
PA>Ppa>Ppv
39
lung zone 2
Ppa>PA>Ppv
40
lung zone 3
Ppa>Ppv>PA
41
lung zone 4
Ppa>PISF>Ppv>PA
42
what lung zone is a continuous open system
lung zone 3
43
what three zones do not have continous open system
1,2,4
44
The uppermost part of the lung. Pulmonary capillaries are consistently compressed by alveoli, and no blood flow occurs. There are no visible a and v waves. The PAC tip in zone 1 records only alveolar pressures. Zone 1 PA pressures and PWP are meaningless
zone 1
45
The upper third part of the lung. The pulmonary capillaries are open in systole and compressed by alveoli during diastole. The PAC tip in zone 2 records true PA systolic pressure, but PA diastolic pressure and PWP are meaningless.
zone 2
46
The most dependent part of the lung (lower two thirds of the lungs). Pulmonary capillaries are consistently patent. PA systolic and diastolic, PA wedge pressures are all valid. In a supine patient most of the lung is in zone 3 and the majority of PACs are advanced to and wedge in zone 3 of the lung.
zone 3
47
PEEP or hypovolemia can lead to
more lung areas becoming zones 1 and 2
48
Conditions of PAOP > LVEDP
```
Tachycardia greater than 130 bpm
• PEEP (5 cmH20 of PEEP ↑’s PAOP by 1
mmHg)(*↑PVC)
• Catheter tip in zone 1 or 2 (↑PVC)
• COPD (*↑ PVC)
• Pulmonary venoocclusive disease
• Mitral regurgitation
• Mitral stenosis
```
49
normal pap diastolic
1-4 mmHg > paop
50
If PA diastolic climbs 4-5 mmHg higher than
| PAOP it indicates
an increase in Pulmonary artery vascular resistance
51
increase in Pulmonary artery vascular resistance is caused by
hypoxemia, pulmonary
| embolism, acidosis and pulmonary vascular dz
52
3 pathological conditions that result in normal PAOP
pulmonary embolism
pulm htn
rv failure
53
3 pathological conditions that cause paop to be high
restrictive cardiomyopathy
cardiac tamponade
lv failure
54
pathologic condition that causes paop to be low
hypovolemia
55
no a and v waves noted
values unusable
balloon hyperinflation or prolonged inflation
false elevation in values
overwedging
56
what causes a double peak look to pa wave
mitral regurg
57
what wave is seen during pa balloon inflation
v wave
58
most preferred site cvl insertion
rij
59
most preferred site for longterm use cvl
sc vein
60
insertion sites for cvl
```
Subclavian vein
• Femoral vein
• Basilic vein
• External jugular vein
Right internal jugular
```
61
distance to the junction of the venae cava and right atrium from subclavian
10 cm
62
distance to the junction of the venae cava and right atrium from rij
15 cm
63
distance to the junction of the venae cava and right atrium from lij
20 cm
64
distance to the junction of the venae cava and right atrium from fem vein
40 cm
65
distance to the junction of the venae cava and right atrium from right median basilic vein
40 cm
66
distance to the junction of the venae cava and right atrium from left medial basilic vein
50 cm
67
5 CVL Insertion Complications listed
```
Vascular structure injury (carotid most common)
• Pleura injury
• Nerve bundle injury
• Lymphatic system injury
• Rare spinal canal injury
```
68
Right Internal Jugular Vein (IJV)
| Advantages
```
–Easily identifiable landmarks
–Straight course to the SVC
–Easily accessible at the patient’s head
–High success rate (91-99%)
–Bleeding easily recognized and controlled
–Reduced risks of pneumothorax
```
69
RIJ Disadvantages:
–Increased risk of infection
–Increased risk of unintentional carotid artery
puncture.
–Unable to access if patient is in cervical collar.
70
right ij landmarks
found in groove between two heads of sternocleidomastoid
71
Left IJV Site
| • Advantages:
–Easily identifiable landmarks
–Easily accessible at the patient’s head
–Bleeding easily recognized and controlled
72
Left IJV Site disadvantages
– Greater risk for pneumothorax because pleura is higher
– Thoracic duct enters the venous system at the junction of the LIJ and subclavian veins.
– Smaller vessel with a more overlap of the carotid artery.
– Catheter must traverse the innominate and enter the SVC more perpendicular leading to more vascular injuries.
73
Subclavian Vein Site
| • Advantages
–Infection risks are reduced
–Cervical instability (C-collar) trauma patients.
–Patient comfort
–Larger vessel doesn’t risk collapse.
74
Subclavian Vein Site disadvantages
–Increased risk of pneumothorax
–More difficult landmarks in obese
–Less accessible
–More difficult to identify bleeding.
75
External Jugular Vein(EJV) Site advantages
–Closer to surface
–More easily identified
–Preferred with patient with coagulopathy
–Less risk for IC puncture.
76
External Jugular Vein(EJV) Site disadvantages
–Smaller vessel, more difficult to advance catheter
| –Can be more easily kinked
77
Advantages of U/S guided CVL Placement
- less error
| - real time feedback
78
long axis of ultrasound shows
longitudinal plane
79
short axis of ultrasound shows
transverse plane
80
High Frequency Transducer frequency and advantages
7-15 mHz
| superficial structure depth and crisp sharp images
81
low frequency transducer frequency and advantage
2-5 mHz
| deeper stucture depth
82
waves bounce and return to probe for processing
Reflection:
83
waves bounce away from probe
Refraction:
84
Using 2-D, the CA can be differentiated from IJV
| by assessing
compressibility and expandability - IJ compresses and exands
85
flow blue
away
86
flow red
toward
87
transducer oriented caudad (down)
carotid is red
| IJ is blue
