Hemodynamics #5 Flashcards Preview

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Flashcards in Hemodynamics #5 Deck (24):
1

Phosphodiesterase Inhibitors action / indication

Second line drug not used often. (For beta receptor down regulation)
-Beta Receptor stimulation causes ATP to be converted to cyclic AMP
-CAMP makes everything happen with cell.
-cAMP broken down w/ phosphodiesterase
-beta downregulation due to continuous beta receptor stimulation.
-beta drugs are DC, phosphodiesterase inhibitors initiated.

2

Beta downregulation & steroid administration

Steroids tell RNA in cells to go into overdrive and create proteins which are used to create beta receptors

3

Cardiogenic shock vasopressin considerations

Pump failure - vasopressor stick a cork in the aorta.
-dopamine & Levophed May bridge temporarily.

4

Cardiogenic shock treatment

-Adding volume helps to a point then hurts,
-dopamine until dobutamine works
-dobutamine assists w/ decreasing afterload
-sodium Nitroprusside (nitropress) for vasodilation once BP maintained w/ dobutamine (let ventricles clear & prevent cardiomyopathies)
-IABP & LVAD therapy.

5

Normal Pressures:
CVP
CI
PA
PCWP
SVR

CVP: 2-6
CI: 2.5-4.2
PA: 15-25(PAS) / 8-15 (PAD)
PCWP: 4-12
SVR: 800-1200

6

CVP Waveform

Preload for R side of heart
-hydration 1st, then RV function
Waveform: Sloppy cursive M
-A, C, V wave
-CVP range: mean average of waves

7

Low CVP

1. Hypovolemia
2. Vasodilation / decrease preload
3. Negative pressure ventilation
-spontaneous ventilation
-hyperventilation

8

High CVP

1. Hypervolemia
2. Obstruction upstream
-RV failure or RVI
-cardiac Tampanade
-positive pressure ventilation (always drops preload)
-pulmonary hypertension
-tight lungs
-PE
-pulmonic valve stenosis
-tricuspid stenosis / regurgitation

9

IJ Depth of Insertion (cm)
CVP/ RA
RVP
PAP
PCWP

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 20
RVP: 30
PAP: 40
PCWP: 50

10

Subclavian Depth of Insertion (cm)

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 25
RVP: 35
PAP: 45
PCWP: 55

11

Femoral Depth if Insertion (cm)

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 40
RVP: 50
PAP: 60
PCWP: 70

12

Positive pressure ventilation benefits and complication

Right heart friendly during failure (gives Chambers ability to clear)

Not left heart friendly during failure (need to improve preload on left side)

13

RVP

-Not typically monitored
-can irritate ventricle causing VF/VT
-looks similar to VT
-Sharp upstroke and down stroke
-notching on ascending side indicates atrial kick
-Anachrotic Notch
-norm: systolic: 15-25, diastolic:0-5
(Diastolic Must be lower than CVP)

14

Pressures: Single vs fractional numbers

Single: mean numbers (preloads)
2 numbers: arterial (after loads)

15

PA waveform

R heart output, L heart preload
-Pulmonary compliance
-PAS: same as RVP
-PAD: higher than RVDP (pulmonic valve closes and hold pressure for backflow into RV)

16

Low PAP

-Dehydration
-RV failure or RVI (upstream blockage)
-pulmonary stenosis (upstream blockage)

17

High PAP

Blockage downstream
-fluid overload
-mitral stenosis or regurgitation
-left ventricular failure
-aortic stenosis/regurgitation
-high pulmonary vascular resistance / HTN (hypoxia)
-AV Communication (hole between AV chambers)
-PE, ARDS, HPVR

18

PA Placement

-head up R Tilt position
-Cath balloon down via jugular, subclavian, femoral into vena cava.
-balloon inflated upon CVP waveform.
-RVP waveform: balloon sails toward RV septum toward PA
-PA waveform (same systolic, higher diastolic than RVP) balloon is deflated.

19

PCWP Waveform

-balloon inflated (1.5 ml) wedges in R lung
-occluded blood from R heart, eliminating R heart pressures.
-Low amplitude rolling waveform (similar to CVP, looks like fine VF)
-diastole, mitral open. LVEDP

20

High PCWP

-Obstruction downstream
-left ventricular failure
-high SVR
-constrictive pericarditis
-mitral stenosis and regurgitation
-fluid overload
-pulmonary hypertension
-hypoxia
-ARDS
-aortic stenosis

21

Low PCWP

-Obstruction upstream
-RV failure
-dehydration
-vasodilation

22

Inadvertent wedge troubleshooting

Caused by migration or balloon inflation
1. Confirm balloon is fully deflated
2. Have patient cough forcefully or roll to side and back (increases intrathoracic pressure's and can pop back in to PA)
3. Withdraw catheter until waveform returns to PA waveform (pullback very slowly and carefully)

23

Inadvertent RV waveform troubleshooting

Step 1: inflate balloon
-pads tip of Cath
-sail back into PA

Step 2: deflate balloon, drawback until CVP waveform obtained.
-safest technique
-confirm balloon deflated otherwise tricuspid damage will occur

24

CHF Treatment (5)

1. Decrease preload (nitro, MS, Lasix)
2. Decrease afterload (Nitroprusside (Nipride), nesiritude (natrocor))
3. Decrease rate (beta blocker: Carvedilol (coreg) only(alpha& beta properties))
4. Inhibit RAA System (ace inhibitors (prils-analapril))
5. Improve Contractility (dobutamine B1&2 2:vasodilation(after load reduction) & phosphodiesterase inhibitors)