II. CVP Monitoring Flashcards
(121 cards)
1
Q
Location of CV catheter tip
A
junction of SVC & RA
2
Q
What is the CV catheter attached to?
A
pressure tubing & transducer
3
Q
CV catheters measure CVP. CVP is akin to what other two pressures?
A
Right Atrial Pressure & Jugular Venous Pressure
4
Q
What law explains the changes in venous compliance and their subsequent effects on cardiac output?
A
Frank-Starling Law
5
Q
In healthy individuals, venous return is correlated to ____.
A
cardiac output
6
Q
8 indications for CVC
A
- IV access (pts with poor peripheral access)
- Infusion of caustic substances
- CVP monitoring
- Venous blood sampling
- Aspiration of VAE
- Advanced hemodynamic monitoring
- Extracorporeal Therapies (ECMO, CRRT)
- Access point for other modalities
HINT: CHASEE
Caustic Substances, Hemodynamic Monitoring, Access Point, Sampling (blood), Embolism aspiration, ECMO
7
Q
Examples of caustic infusion substances:
A
- NE, Dopamine
- IV nutrition (TPN)
- Chemo
- Prolonged antibiotics
- Renal replacement therapy, plasmapheresis, or apheresis
8
Q
Examples of advanced hemodynamic monitoring
A
- PICCO(Pulse index Continuous Cardiac Output)
- CVO2
- PA Catheter
9
Q
Other modalities that may use CVC as access point (3)
A
- IVC filter replacement
- Venous Stenting
- Transvenous Pacing
10
Q
C/I for CVC placement
A
- Infection
- SVC syndrome
- Thrombus of target vessel
- Patient intolerance
- Coagulopathy
- New Pacemaker wires
- Some providers avoid on side of previous CEA
HINT:TWIICS
Thrombus, Wires (pacemaker), Intolerance, Infection, Coagulopathy, SVC Syndrome
CHASE TWIICS
11
Q
Thresholds for coagulopathy C/I for CVC placement
A
INR > 1.5
PLT<50,000
12
Q
Complications of CVC
A
- Erroneous Data, Misinterpretation, or Misuse of equipment
- Arrhythmia (PVCs)
3..Other
- Thrombophlebitis
- Pericardial effusion / Cardiac tamponade
- Chylothorax (more common with Left IJ & SCV approaches)
- Tracheal injury
- Direct nerve injury- Brachial plexus,
- stellate ganglion,
- phrenic nerves all close to IJ
HINT: MATTT
Misuse/Misinterpretation, Arrhythmia, Thrombophlebitis, Tamponade, Tracheal Injury
13
Q
____ ga or smaller “finder needle”
Not problematic with normal coagulation
A
22
14
Q
____ ga or larger introducer needle
Risk for hematoma, hold pressure 5+ min
A
18
15
Q
Large bore introducer
If accidentally dilated, hold pressure for ____ min!
A
30
16
Q
If CVC placed in artery, what should we do?
A
leave it in & get vascular consult
17
Q
Localized hematoma may expand → ____
A
airway compression
18
Q
Sights of CVC placement
A
- Right & Left IJ
- Subclavian
- EJ
- Femoral
- Antecubital
19
Q
Can be easily visualized with ultrasound
Most direct route to heart
Straight in-line course to right atrium
A
RIGHT Internal jugular vein
20
Q
CVC placement site
Angled course through brachiocephalic vein
Increased risk of chylothorax (thoracic duct injury) → lymphatic fluid (chyle) accumulates in the pleural cavity
A
Left IJ
21
Q
Subclavian has a ____ success rate compared to IJV
A
lower
22
Q
Subclavian has what advantages compared to IJ
A
Better tolerated by patient
↓risk of infection
Can be performed on pt. in cervical collar
23
Q
Subclavian has what complications compared to IJ?
A
-Greatest risk of pneumothorax
-Also Hemothorax / Mediastinal hematoma
(Chylothorax risk similar to LIJ)
24
Q
What central venous catheter placement site is both superficial, has a minimal risk of pneumothorax and has a low success rate?
A
External jugular
25
What is the approximate success rate of placing an external jugular central venous catheter?
80%
26
What central venous catheter location is uncommon for intraoperative monitoring, but has a high success rate?
Femoral
27
Femoral, central venous catheter placement may be necessary in patients with what type of complication?
Superior vena cava obstruction
28
Antecubital placement involves which two veins potentially?
1. Basilica
2. Cephalic
29
Which central venous catheter placement, location is used for peripherally, inserted, central, venous, catheters, or PICC lines?
Antecubital
30
Antecubital placement will exhibit **lower/higher** central, venous pressures.
Slightly higher
31
What are the available sizes of central venous catheters?
7.5 - 9.0 Fr
32
What size lumens are available for central venous catheters?
1-4
33
What are the various lengths for CVC?
12-24
34
What two types of materials are CVC composed of?
1. Silicone.
2. Polyurethane.
35
CVC can have what three types of coatings?
1. Antimicrobial. (chlorhexidine based.)
2. Heparin.
3. Radiopaque (confirms tip placement.)
36
What are the four types of CVC catheters? I
1. Non-tunneled central catheters.
2. Tunneled central catheters.
3. Peripherally inserted central catheters (PICC)
4. Implantable ports.
37
What is the most common type of catheter used in the hospital setting?
Single lumen
38
What is the most common type of CVC used by Anesthesia personnel?
Triple lumen
39
What are the two considerations made when determining length of CVC?
1. Site of insertion.
2. Patient height.
40
Which port is used for CVP monitoring in a triple lumen catheter?
Distal port
41
What type of catheter is used as a trauma line with a PA catheter introducer?
Large bore triple lumen
42
T/F: all lumens of a triple lumen port can be used for administration of IV solutions and medication.
True
43
Which port is used for withdrawing blood samples on a CVC triple lumen, why?
The proximal port, because it has the least contamination from other infusions.
44
Which port on a triple lumen is used for administration of TPN (total parenteral nutrition)?
The medial port, because it is safest.
45
Which port is used for blood administration and why on a triple lumen?
The distal port, because it is the largest lumen.
46
List the equipment needed for placement of CVC:
1. Syringe and needle for localanesthetic (1% lidocaine)
2. Scalpel.
3. Sterile gel for ultrasound guidance
4. Introducer needle (18ga) attached to syringe with saline (to detect backflow of blood, upon vein penetration)
5. Guidewire.
6. Tissue dilator (8.5 Fr)
7. Indwelling catheter (16ga)
8. Additional fasteners, suture and needle
9. Sterile dressing
47
What position can patients be placed in in order to increase jugular vein, size with hydrostatic pressure in order to reduce placement difficulty?
Trendelenburg
48
What physical locations on the patient should be prepped with chlorhexidine?
Earlobe to sternal notch
49
The internal jugular vein is positioned ____ and ____ to the carotid artery.
- Lateral
- Slightly anterior
50
What landmarks are we looking for when locating the entry point for the right internal jugular vein?
The triangle formed by the sternocleidomastoid muscle and clavicle.
51
After the triangle has been identified During identification of the right internal jugular vein, what are the next steps for catheter placement?
1. Palpate carotid pulse.
2. Enter at Apex of triangle, lateral of carotid, pulse, and aiming at ipsilateral nipple. (30-45 degree angle of entry)
3. The vein is usually 3 to 5 cm from the skin surface.
52
Which of the two methods is preferred when placing a subclavian central veinous cat catheter?
Infraclavicular is preferred
53
How should the patient be positioned when preparing for an infraclavicular subclavian CVC?
1. Supine, head, neutral, arm abducted.
2. Trendelenburg (10-15º)
3. Shoulders, neutral with mild retraction.
54
Describe the steps of placement for subclavian CVC:
1. Index finger on suprasternal notch.
2. Thumb on Costoclavicular junction.
3. Enter the skin about 1 cm inferior to the clavicle.
4. Aiming towards index finger, posterior to clavicle, with needle parallel to the skin.
55
During CVC placement, insert and advance the needle while ____.
Continuously aspirating
56
Follow the needle tip into the vessel using ____ to confirm.
Ultrasound, guidance
57
Successfully cannulate the vessel, and ensure free return of ____ blood.
Dark red, non-pulsatile
58
After calculating the vessel and visualizing return of dark, red, non-pulsatile blood, what is the next immediate step?
Sit down the probe, and stabilize the needle with left hand. Disconnect the syringe, without changing angle of needle.
59
After removing the syringe from the catheter, what should be done next?
Insert the guidewire through the needle to a depth of 20 cm.
60
What should we watch for while inserting the guidewire through the catheter?
Ectopy on the ECG (often a run of PVCs)
61
After the guidewire has been inserted, what should we do next?
Remove the needle while maintaining control of the guidewire. Then confirm the guidewire is in the vessel using ultrasound.
62
Steps for dilating, the vessel and tissue:
1. Make a small incision adjacent to the guidewire (scalpel)
2. Advance the dilator over the guidewire and into the skin with the twisting motion while maintaining control of the guidewire.
3. Ensure the guidewire moves freely within the dilator, then remove the dilator.
63
Once the dilator has been placed, what do we do next?
1. Advance the catheter over the guidewire, using Seldinger’s technique into the vessel to the appropriate depth.
2. Remove the guidewire.
3. Aspirate and flush each lumen.
4. Place capless valves.
64
Which port should be kept covered while removing the guidewire in order to prevent air entry?
The brown port
65
What is used to confirm catheter position at the end of procedure?
X-ray
66
Ideal placement location of a central venous catheter
1. Distal and within the superior, vena cava, above the right atrium.
2. Below inferior border of clavicles.
3. T4 to T5 interspace
4. At the level of carina
67
How to perform a jugular occlusion test
1. Apply external pressure on the internal jugular vein for 10 seconds and observed change in central venous pressure.
2. Increased central venous pressure 3 to 5 mm of mercury, indicate a misplaced catheter into the internal jugular vein. 
68
Normal range of central venous pressure during SV
0-5 mmHg
69
Normal range of central venous pressure during mechanical ventilation
5-10 mmHg
70
T/F: central, venous pressure is used as a guide for fluid therapy
True
71
T/F: central, venous pressure, does not always reflect intravascular volume
True
72
Wow, there is no target central Venus pressure, a drop in Venus pressure by ____ mmHg indicates fluids may be effective.
3-5 mmHg
73
What may occur if we exceeded normal central venous pressure values?
Pulmonary and tissue edema
74
1 cmH2O = ____ mmHg
1.3
75
CVP ____ with increased venous tone (i.e., SNS stimulation)
Increases
76
Decreased compliance will ____ volume and ____ pressure.
- decrease
- increase
77
Decreased cardiac output ____ CVP due to ____ volume in venous system.
- increases
- increased
78
Changing from standing to supine body posture ____ CVP.
Increases
*due to increased volume*
79
Arterial dilation ____ CVP.
Increases
*due to increased volume*
80
Forced expiration ____ CVP due to ____.
- increases
- decreased compliance
81
Muscle contraction ____ CVP due to ____ volume & ____ compliance.
- Increases
- increased
- decreased
82
A CVP A wave corresponds to ____, and occurs in ____.
- Right atrial contraction
- End Diastole (after P-wave on ECG)
83
A CVP C-wave corresponds to ____ and occurs during ____.
- Right ventricular contraction
- Early Ventricular systole (always follows R wave of ECG)
84
The CVP ____-wave is caused by bulging of the tricuspid valve into the atrium.
C
85
The X descent wave indicates ____.
Atrial relaxation downward movement of the ventricle
*occurs during ventricular systole*
86
The V-wave signifies ____
Atrial filling against a closed tricuspid valve
*occurs during late ventricular systole*
*HINT:Villing against Valve*
87
The Y-descent wave indicates:
- tricuspid valve opening, and bullet quickly entering the ventricle.
*occurs during early ventricular diastole*
88
- increased resistance to ventricular filling
- Increased atrial contraction
The preceding to physiological changes will result in what CVP manifestation?
Elevated A waves (“Cannon A Waves”)
*Causes: heart failure, **tricuspid stenosis**, atrioventricular disassociation (Junctional rhythms, AV dissociation, PVCs)*
89
Which two waves are the descent waves
X & Y
90
Sequential Cannon A Waves can be observed in what syndrome?
Pacemaker Syndrome
91
Elevated V Waves (higher than A waves) often have what physiological cause?
Tricuspid Regurgitatant flow (against a already contracting right atrium = increased pressure)
* tricuspid regurgitant flow due to heart failure*
92
SV causes ____ intrathoracic pressure = ____ CVP
Decreased
Decreased
93
PPV causes ____ ITP = ____ CVP.
increased
Increased
94
CVP should always be read at ____
End-expiration
95
Every 5 cmH2O PEEP will increase CVP ____ mmHg
~2 mmHg
*but will decrease true filling volumes*
96
RV compliance is represented as what mathematically
V/P
97
T/F: cardiac filling pressures estimate cardiac filling volumes.
True
98
T/F: CVP alone is an excellent indicator of volume status.
False
*CVP is most useful as a trend rather than an absolute value*
99
other sites of CVP cannulation picture
100
CVC Triple Lumen Picture
101
Equipment needed for CVP placement picture
102
Equipment for CVP Placement Picture 2
103
Ultrasound Supine vs Trendelenberg Picture
104
Ultrasound planes comparison picture
105
Right IJ Triangle Placement Picture
106
CVC placement depth Table Picture
107
CVP pressures throughout body Picture
108
CVP Interpretaion Picture
109
Normal CVP & ECG Waveform Picture
110
A-Wave (Atrial Contraction) Picture
111
C-Wave (AV Closes) Picture
112
X-Descent Wave (Atrial Relaxation) Picture
113
V-Wave (Atrial Filling) Picture
114
Y-Descent Wave ( AV Valve Opens) Picture
115
Cannon A Wave & PVC Picture
116
Pacemaker Syndrome Picture
117
Elevated V Waves Picture
118
Abnormal CVP Waveform Conditions Picture
119
120
Spontaneous Ventilation CVP waveform picture
121
Mechanical Ventilation CVP Waveform Picture
