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Hemodynamic Monitoring Flashcards

1
Q

At what value would you expect to see cardiogenic shock?

A

In cardiogenic shock, the value will fall below:

1.8 L/min/m2

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2
Q

Your patient presents with a systolic blood pressure of 90 with a heart rate of 125. What is this indicative of?

A

Circulatory collapse and shock!

Shock Index: 
Heart Rate (HR) ÷ Systolic Blood Pressure (SBP)

125 ÷ 90 = 1.38

** a value of > 0.9 is an early sign of circulatory collapse and shock **

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3
Q

When is the RVP measurement taken?

A

The Right Ventricular Pressure (RVP) measurement is taken only during insertion.

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4
Q

During transport, you inflate the PAC balloon to assess the PAWP. Prior to deflation, you get distracted with an unrelated monitoring device alarm. You realize after 10 minutes that the balloon has been left inflated. What has likely occurred to the patient?

A

Pulmonary infarction secondary to continuous, prolong wedging.

** inflation should no last longer than 15 seconds **

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5
Q

In patients with a Pulmonary Artery Catheter, what should you ask for PRIOR to initiating transport?

A

Prior to initiating transport, you should ask for a current wedge pressure

PAWP - Pulmonary Arterial Wedge Pressure
PCWP - Pulmonary Capillary Wedge Pressure
PAOP - Pulmonary Occlusion Wedge Pressure
“Wedge” Pressure

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6
Q

Measuring a patient’s ejection fraction (EF) is an analysis of ___________.

A

Cardiac contractility -

Measuring a patient’s ejection fraction (EF) is an analysis of cardiac contractility.

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7
Q

What are acceptable sites for Swan Ganz Pulmonary Artery Catheter (PAC) insertion?

A

Acceptable sites for Swan Ganz Pulmonary Artery Catheter (PAC) insertion are:

  1. Right Jugular Vein (preferred)
  2. Subclavian Vein
  3. Femoral Vein
  4. Antecubital vein
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8
Q

What is the pressure you should inflate the IV pressure bag to to insure adequate infusion with the Swan Ganz Pulmonary Artery Catheter (PAC)?

A

300 mmHg is the pressure you should inflate the IV pressure bag to to insure adequate infusion with the Swan Ganz Pulmonary Artery Catheter (PAC).

this ensures accurate pressure readings

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9
Q

What is considered a standard RVP?

A

Right Ventricular Pressure -

Systolic: 15 - 30 mmHg
Diastolic: 0 - 8 mmHg

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10
Q

During insertion of a PAC, the patient rapidly presents with decreasing blood pressure and increased heart rate, resulting in the onset shock which ultimately leads to cardiac arrest. What do you suspect happened?

A

Right Ventricle Perforation

** Pulmonary Artery Catheter **

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11
Q

What will likely occur if the Swan Ganz Pulmonary Artery Catheter (PAC) transducer is placed/mounted in a position higher then the phlebostatic axis?

A

The pressure will be falsely low if the Swan Ganz Pulmonary Artery Catheter (PAC) transducer is placed/mounted in a position higher then the phlebostatic axis.

inverse reaction

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12
Q

What are some conditions that will likely increase the oxygen demand of patients.

A

Conditions that will likely increase the oxygen demand of patients:

1. Fever (each rise of one degree C will increase   
               demand by 10%)
2. Severe Infection (60% increase)
3. Skeletal Injuries (10-30% increase)
4. Work of Breathing (40% increase) 
5. Burns (100% increase)
6. Shivering (50-100% increase)
7. Agitation (18% increase)
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13
Q

When should you “zero” the Swan Ganz Pulmonary Artery Catheter (PAC) transducer?

A
  1. Whenever a reading is taken
  2. Insertion
  3. Change in patient’s position
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14
Q

What is the normal approximate value for adult urine output?

A

The normal approximate value for adult urine output is:

0.5 ml/kg/hr

used as a surrogate of kidney perfusion

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15
Q

What is a normal range value for the Shock Index?

A

Shock Index Range:

0.5 - 0.7

> 0.9 is an early sign of circulatory collapse and shock

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16
Q

You patient has a long history of pulmonary hypertension. The current PAWP is 10 mmHg? What do you suspect?

A

The Pulmonary Artery Wedge Pressure (PAWP) at this time is within normal, standard limits.

Standard Range Value: 4 - 12 mmHg

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17
Q

Your patient has been administered 2 doses of 400 mcg NTG/SL. How would you expect the CVP to respond?

A

The central Venous Pressure would (most likely) decrease as Systemic Vascular Resistance (SVR) is decreased.

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18
Q

What does the PAC “C” wave, commonly found at the dicrotic notch indicate?

A

Closure of the tricuspid valve

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19
Q

Regarding a patient presenting with shock, why is hemodynamic monitoring so important?

A

Hemodynamic monitoring allows for providers to identify the root cause(s) of the patient’s shock.

  • Hypovolemic
  • Neurogenic
  • Septic
  • Cardiogenic
  • Anaphylactic
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20
Q

What is the preferred entry site for the Swan Ganz Pulmonary Artery Catheter (PAC)?

A

The preferred entry site for the Swan Ganz Pulmonary Artery Catheter (PAC) is:

The RIGHT external jugular

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21
Q

_________ is the amount of blood that goes back to the heart and is present before each contraction.

A

Preload is the amount of blood that goes back to the heart and is present before each contraction.

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22
Q

The IV flush bag should maintain a constant pressure of ______ to remain effective and reduce dampening of the PAC waveform.

A

300 mmHg

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23
Q

How does inotropic stimulation affect cardiac output (CO)?

A

Inotropic stimulation results in an elevated cardiac output.

** Inotropic - increasing the force of contraction **

CO = Stroke Volume (SV) x Heart Rate (HR)

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24
Q

What is the calculation to determine Cardiac Index?

A

Cardiac Output (CO) ÷ Body Surface Area (BSA)

[HR x SV] ÷ [(Height in cm x kg)] ÷ 3600

Normal Value: 2.5 - 4 L/min/m2

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25
What is an elevated PAWP indicative of?
Elevated PAWP (Pulmonary Arterial Wedge Pressure) is indicative of: Congestion and Acute Pulmonary Edema ``` 4 - 12 mmHg = normal finding 18 - 20 mmHg = onset of pulmonary congestion 21 - 25 mmHg = moderate congestion 26 - 30 mmHg = severe congestion > 30 mmHg = acute pulmonary edema ```
26
What is the white Swan Ganz Pulmonary Artery Catheter (PAC) port used for?
The white port is used for fluid infusion (infusion port).
27
Regarding a patient presenting with poor perfusion, why is hemodynamic monitoring so important?
Hemodynamic monitoring allows for providers to identify the root cause(s) of the patient's poor perfusion. - Burns - Sepsis - Trauma
28
What is right ventricular end diastolic pressure?
Right ventricular end diastolic pressure is: Preload
29
What is LVEDP?
LVEDP = Left Ventricular End-Diastolic Pressure (filling pressure) ***LVEDP is the same pressure as the Left Ventricular Preload***
30
You need to monitor a patient's CVP. What are the best options to accomplish this?
Central Venous Pressure (CVP) is measured with: 1. Central Line 2. Pulmonary Artery Catheter (PAC)
31
What is the normal value range for PAP?
Pulmonary Artery Pressure values: Systolic: 15 - 30 mmHg Diastolic: 5 - 15 mmHg ***LVF will elevate PAP***
32
What is a standard diastolic pulmonary artery pressure value?
5 - 15 mmHg is a standard diastolic pulmonary artery pressure value.
33
What is the formula for shock index?
Shock index formula: HR ÷ SBP ex: 80 ÷ 120 = 0.66 Normal shock value range: 0.5 - 0.7
34
What is the number one reason for right ventricular hypertension?
Right-sided heart failure
35
Which Swan Ganz Pulmonary Artery Catheter (PAC) lumen (color and location) measures pulmonary artery pressure?
The distal yellow lumen measures pulmonary artery pressure.
36
True or False: Due to inflation of the PAC balloon, the PAWP should be greater then the mean pulmonary artery pressure.
False. The Pulmonary Artery Wedge Pressure (4 - 12 mmHg) should always be less then the mean pulmonary artery pressure (15 - 30 mmHg systolic).
37
What is the continuous flow rate needed for the Swan Ganz Pulmonary Artery Catheter (PAC)?
3 - 5 mL/hr is the continuous flow rate needed for the Swan Ganz Pulmonary Artery Catheter (PAC).
38
What is a standard adult cardiac output?
Cardiac Output (CO): 4 - 8 L/min CO = Stroke Volume (SV) x Heart Rate (HR)
39
This systemic circulation is considered to be high-resistance. Which circulation value does this refer to?
Afterload.
40
What is afterload?
Afterload is the resistance (systemic vascular resistance) the Left Ventricle must overcome during systole in order to pump blood. LV Afterload = Systemic Circulation (high resistance) RV Afterload = Pulmonary Circulation (low resistance)
41
How is the patient's Left Ventricular Preload (LVP) measured?
Left Ventricular Preload (LVP) is indirectly measured by Pulmonary Artery Wedge Pressure (PAWP) via a Pulmonary Artery Catheter (PAC).
42
Your patient has a blood pressure of 100/60 with a heart rate of 70. What is this patient's shock index?
Heart Rate (HR) ÷ Systolic Blood Pressure (SBP) 70 ÷ 100 = 0.7 Standard Value Range: 0.5 - 0.7 *** a value of > 0.9 is an early sign of circulatory collapse and shock ***
43
How does inspiration in a non-ventilated patient effect blood pressure (PAWP)?
Inspiration will result in a fall of pressure Expiration will result in a rise of pressure ***vented patients are opposite due to PEEP***
44
What does left ventricle filling pressure refer to?
Left Ventricular End-Diastolic Pressure (LVEDP) *** surrogate for LAP (left Atrial Pressure) *** *** measured via PAC (pulmonary Artery Catheter) ***
45
How is the difference between the RVP and the PAP reflected?
The difference between the RVP (Right Ventricular Pressure) and the PAP (Pulmonary Artery Pressure) is reflected in the diastolic pressure. ***passing through the pulmonary valve creates a higher diastolic value***
46
When "floating" the Swan Ganz Pulmonary Artery Catheter (PAC), when is the ballon inflated?
The ballon is inflated (w/ 1.5 mL) as it approaches the Right Atrium (RA) and is "floated" through the Tricuspid Valve into the Right Ventricle (RV) and out of the pulmonary valve (semi-lunar) into the pulmonary artery.
47
The patient should be considered hypotensive with the following values:
The patient should be considered hypotensive with the following values: 1. SBP < 90 mmHg 2. SBP decreases > 40 mmHg than baseline 3. MAP < 65 mmHg
48
How is the Swan Ganz Pulmonary Artery Catheter (PAC) balloon delated after obtaining a wedge pressure?
The ballon is allowed to passively deflate and return to the pulmonary artery. * **do NOT pull back on the syringe plunger!*** * ***serious harm may occur to the patient****
49
_______ is reflective of the hydrostatic pressure within the pulmonary capillary beds.
PAWP (Pulmonary Arterial Wedge Pressure) is reflective of the hydrostatic pressure within the pulmonary capillary beds. ***higher values indicate presence of congestion and/or edema*** ``` 4 - 12 mmHg = normal finding 18 - 20 mmHg = onset of pulmonary congestion 21 - 25 mmHg = moderate congestion 26 - 30 mmHg = severe congestion > 30 mmHg = acute pulmonary edema ```
50
______ refers the the total amount of fluid in the body and whether it is adequate.
Volume status refers the the total amount of fluid in the body and whether it is adequate. ``` High = Fluid Overloaded Low = Volume-Depleted ```
51
What is Left Ventricular Preload (LVP)?
Left Ventricular Preload (LVP) is the volume of blood in the Left Ventricle before each contraction.
52
What is the normal value range for RVP?
Right Ventricular Pressure values: Systolic: 15 - 30 mmHg Diastolic: 0 - 8 mmHg * **Hypoxemia will elevate RVP*** * **CO2 is a vasoconstrictor***
53
What is Right Ventricular Preload (RVP)?
Right Ventricular Preload (RVP) is the volume of blood in the Right Ventricle (RV) before each contraction.
54
How is Left Ventricular Preload/End-Diastolic Pressure (LVP/LVEDP) indirectly measured?
Left Ventricular Preload/End-Diastolic Pressure is indirectly measured by PAWP (Pulmonary Artery Wedge Pressure).
55
How many lumen does the Pulmonary Artery Catheter (PAC) have?
The Pulmonary Artery Catheter (PAC) has FOUR lumen. Blue: Proximal (closest) Port - (measures CVP) Yellow: Distal (farthest) Port - (measures PAP) Red: Balloon Inflation Port White: Infusion Port
56
What is a standard value range for a cardiac index (CI)?
2.5 - 4 L/min/m2 is the standard value range for cardiac index. *** a value of < 1.8 L/min/m2 will generally result in cardiogenic shock ***
57
What is the absolute max time permitted for the Swan Ganz Pulmonary Artery Catheter (PAC) balloon inflation?
15 seconds is the absolute max time permitted for the Swan Ganz Pulmonary Artery Catheter (PAC) balloon inflation?
58
What is the phlebostatic axis?
The phlebostatic axis is a line level with the patient's Right Atrium (RA) in which the transducer must be placed.
59
True or False: A fluid overloaded patient can NOT be depleted intravascularly due to osmosis?
FALSE. A patient CAN be systemically overloaded and vascularly depleted.
60
What is a standard PAWP value?
8 - 12 mmHg is a standard Pulmonary Artery Wedge Pressure (PAWP) value. *** obtained via PAC balloon inflation ***
61
Which Swan Ganz Pulmonary Artery Catheter (PAC) port (color) serves as the inflatable balloon?
The red port serves as the inflatable balloon. ***1.5 mL of air to inflate with a special syringe***
62
CVP Waveform: ``` What does the "A" wave represent? What does the "C" wave represent? What does the "V" wave represent? What does the "X" wave represent? What does the "Y" wave represent? ```
Central Venus Waveform: ``` A wave = atrial contraction C wave = closure of the tricuspid valve V wave = left ventricle contraction X wave = atrial diastole Y wave = atrial diastole ```
63
What is a standard CVP?
Central venous Pressure: 2 - 8 cm H2O
64
Which Swan Ganz Pulmonary Artery Catheter (PAC) lumen (color and location) measures the Central Venous Pressure (CVP)?
The proximal blue lumen measures the Central Venous Pressure (CVP), which is the pressure within the Right Atrium (RA).
65
What is the normal value range for the right ventricular end diastolic pressure?
The normal value range for the right ventricular end diastolic pressure (Preload) is: 2 - 8 mmHg
66
What is a standard value range for urine output?
0.5 mL/kg/hr
67
What is the calculation to determine Body Surface Ares (BSA)?
(Height [cm] x kg) ÷ 3600 = m2 "squared"
68
What should you do in the event of backward catheter displacement?
Backward catheter displacement: Catheter tip is in the Right Ventricle (RV). 1. Notify MD/ Med Control 2. Ensure the balloon is deflated 3. Pull the catheter tip back into the Right Atrium (RA) ***RV displacement will be evident via wave form change and/or arrhythmia***
69
This pressure measurement is only taken during the process of PAC insertion. Which pressure value is this?
Right Ventricular Pressure (RVP) *** only measured during insertion due to the increased probability of RV irritation, resulting in arrhythmias. ***
70
What are the two main factors effecting preload?
The two main factors effecting preload are: 1. Intravascular volume (hydration) 2. Venous tone (venoconstriction)
71
What are the two main components that affect preload?
The two main components that affect the amount of blood that returns to the heart for contraction are: 1. Intravascular Volume 2. Venous Tone (venoconstriction) / SVR
72
What is a standard systolic pulmonary artery pressure?
15 - 30 mmHg is a standard systolic pulmonary artery pressure value.
73
True or False: Pulmonary circulation is high-resistance.
False. Pulmonary is a low-resistance system. *** Right Ventricle afterload and Left Atrial preload are inherently low pressure ***
74
Your patient has right sided heart failure secondary to pulmonary hypertension. What would you suspect the patient's CVP would be?
You would expect the Central Venous Pressure to be elevated. Standard Range Value: 2 - 8 cm H2O
75
True or False: In order to obtain your patient's PAP, the PAC balloon needs to be inflated.
False. In order to obtain your patient's Pulmonary Artery Pressure (PAP), the balloon must be deflated. *** inflation will result in the wedge pressure - PAWP ***
76
You notice that the PAC pressure values obtained are abnormally high/low. What should you check in order to assure the reading is accurate? (Multiple Answers)
In no specific order, Ensure that: 1. The transducer is placed at the phlebostatic axis (in line with the right atrium). 2. The pressure bag has been inflated to 300 mmHg 3. Incorrect zeroing (re-zero the transducer)
77
What effect does positive pressure ventilation have on right ventricular end diastolic pressure?
Positive pressure ventilation will INCREASE right ventricular end diastolic pressure (Preload).
78
What is Cardiac Output? What is a normal value for Cardiac Output?
Cardiac output (CO is the amount of blood ejected by the Left Ventricle each minute. Normal range is: 4 - 8 L/min CO = Heart Rate (HR) x Stroke Volume (SV)
79
What is the normal value range of SvO2 (Saturation of Venus Oxygen)?
65 - 75% is the normal value range of SvO2 (Saturation of Venus Oxygen).
80
______ is a normal product of anaerobic cell metabolism and is metabolized by the liver.
Serum lactate is a normal product of anaerobic cell metabolism and is metabolized by the liver.
81
You want to determine your patient's shock index. What is the formula you would use to do this?
Heart Rate (HR) ÷ Systolic Blood Pressure (SBP) Standard Value Range: 0.5 - 0.7 *** a value of > 0.9 is an early sign of circulatory collapse and shock ***
82
Your patient is on a ventilator. What affect would this likely have on the patient's PAP?
Pulmonary Artery Pressure - Positive Pressure Ventilation can result in elevated PAP
83
What is preload?
Preload is the amount of blood that goes back to the heart and is present before each contraction.
84
Which pressure value provide information regarding the patient's hydrostatic pressure within the pulmonary capillary bed?
Pulmonary Artery Wedge Pressure (PAWP) provides information regarding the patient's hydrostatic pressure within the pulmonary capillary bed. 4 - 12 mmHg - Standard Value 18 - 20 mmHg - Onset of Pulmonary Congestion 21 - 25 mmHg - Moderate pulmonary Congestion 26 - 30 mmHg - Severe Pulmonary Congestion > 30 - Acute Pulmonary Edema
85
What is the calculation for MAP?
Mean Arterial Pressure: MAP = [(2 x DBP) + SBP] ÷ 3 ex: 120/80 MAP = [(2 x 80) + 120] ÷ 3 MAP = [160 + 120] ÷ 3 MAP = 280 ÷ 3 MAP = 93 mmHg
86
What is Stroke Volume? What is a normal range value for Stroke Volume?
Stroke Volume (SV) is the amount of blood ejected from the ventricles in each heartbeat. Normal range is: 60 - 120 mL/beat Ejection Fraction: 60 - 65%
87
What is the ultimate goal of hemodynamic monitoring?
The goal of hemodynamic monitoring is to identify the root cause of the patient's illness: 1. Shock 2. Acute Respiratory Failure (ARF) 3. Poor perfusion
88
Regarding a patient presenting with acute respiratory failure, why is hemodynamic monitoring so important?
Hemodynamic monitoring allows for providers to identify the root cause(s) of the patient's acute respiratory failure. - Acute Respiratory Distress Syndrome (ARDS) - Pulmonary Edema - Chronic Obstructive Pulmonary Disease (COPD)
89
What is considered to be a normal Serum Lactate level?
< 2 mmol/L is considered to be a normal Serum Lactate level.
90
If Systemic Vascular Resistance (SVR) is high, will the Cardiac Output (CO) be high or low?
The Cardiac Output will be low if the SVR is high. ***Inverse relation with each other***
91
From which Swan Ganz Pulmonary Artery Catheter (PAC) port is the CVP and the RAP measured?
Proximal (blue) lumen Central Venous Pressure (CVP) Right Atrial Pressure (RAP) ***represents the pressure in the venous system***
92
What is a normal value range for cardiac index?
Normal cardiac Index: 2.5 - 4 L/min/m2
93
_____ is the amount o hemoglobin saturated with oxygen in the venous circulation.
SvO2 is the amount o hemoglobin saturated with oxygen in the venous circulation.
94
What will likely occur if the Swan Ganz Pulmonary Artery Catheter (PAC) transducer is placed/mounted in a position lower then the phlebostatic axis?
The pressure will be falsely high if the Swan Ganz Pulmonary Artery Catheter (PAC) transducer is placed/mounted in a position lower then the phlebostatic axis. ***inverse axis***
95
What is the normal value range for PAWP?
Pulmonary Artery Wedge Pressure values: 4 - 12 mmHg
96
Patients presenting with a fever will have a/n ________ oxygen demand.
Increased. Patients presenting with a fever with have an increased oxygen demand. *** for every 1ºC rise, O2 demand increases by 10%
97
The pressure in the left atrium (LAP) is a surrogate for the _________.
Left Ventricular Preload - The pressure in the left atrium (LAP) is a surrogate for the left ventricular preload. *** the LAP is the same as the Left ventricular End-Diastolic Pressure (LVEDP) ***
98
_______ is the pressure of the venous system.
CVP - Central Venous Pressure Standard Range Value: 2 - 8 cm H2O
99
A intravenously perfused patient has a urinary output of 0.1 mL/kg/hr? What is this finding suggestive of?
Decreased renal function which could be suggestive of impending circulatory collapse and shock. Assess the shock index and serum Lactate: ``` Heart Rate (HR) ÷ Systolic Blood Pressure (SBP) Standard Value Range: < 2 mmol/L ```
100
What is the purpose of hemodynamic monitoring?
The purpose of hemodynamic monitoring is to evaluate the ability of the cardiovascular system to deliver blood flow and oxygenation to the tissues.
101
A patient is having a PAC placed through the right external jugular. After advancing the catheter 15 cm, there is still no indication of a wave form. What action should be taken?
The Pulmonary Artery Catheter (PAC) should immediately be withdrawn.
102
You patient presents with a LOW cardiac index (CI) of 2 L/min/m2. If the cardiac index continues to fall, what is likely to occur?
Cardiogenic Shock - The patient will likely progress into cardiogenic shock *** is the result of inadequate blood flow due to the dysfunction of the ventricles *** *** a value of < 1.8 L/min/m2 will generally result in cardiogenic shock *** Standard Value Range: 2.5 - 4 L/min/m2
103
What are postural vitals?
Postural vitals (similar to othrostatic vitals) are measured while the patient is lying supine and then standing. Positive postural vitals are: Postural tachycardia: > 30 bpm upon standing Postural hypotension: decrease of SBP > 20 mmHg upon standing.
104
What is Stroke Volume Variation (SVV)?
Stroke Volume Variation (SVV) is the difference in SV with breathing (inhalation vs. exhalation).
105
_______ is the purpose of evaluating ability of the cardiovascular system to deliver blood flow and oxygenation to the tissues.
Hemodynamic monitoring is the purpose of evaluating ability of the cardiovascular system to deliver blood flow and oxygenation to the tissues.
106
How much air should the balloon be inflated with in order to obtain a PAWP?
Until a wedge pressure is obtained, not to exceed 1.5 mL (≤ 1.5 mL) of air. *** 1.5 mL is the maximum, NOT the absolute. ***

UMBC PACE (10 decks)

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