Invasive Cardiac Monitoring Flashcards
(164 cards)
1
Q
What are the 6 potential indications for arterial line placement?
A
- current or anticipated hypotension
- wide blood pressure variations (CAD,AAA, crani’s)
- end organ disease viability (renal dx, CAD, coronaries)
- multiple or concerning co-morbidities (increased risk for MI or CVA)
- blood gas analysis
- frequent use of vasoactive medications
2
Q
What are potential contraindications of arterial line placement?
A
- placement in arteries with inadequate collateral blood flow
- infection at the site
- limb placement in which major vascular insufficiency exists
- inexperience
- caregiver that is not vigilant
- air embolus
3
Q
Common complications and risks of arterial line placement?
A
- hematoma
- bleeding (site or disconnection of line or connection)
- vasospasm
- arterial thrombosis (clots and air)
- nerve damage
- skin necrosis
- infection (local or ischemic)
- intra-arterial drug injection
- limb or digit ischemia (loss if uncorrected)
4
Q
Compressing both radial and ulnar arteries when assessing for arterial line placement is referred to as what?
A
Allens test
5
Q
Describe the process of performing an Allens test.
A
Compress both radial and ulnar arteries, ask patient to make a fist to exsanguinate the palm and then reopen hand. Release the ulnar artery (under pinky).
6
Q
Describe a normal response to the Allens test.
A
Color returns to the palm within 6-10 seconds.
7
Q
Is the Allens test a good predictor of collateral circulation flow?
A
no, poor predictive results
8
Q
What is the most commonly used arterial line site?
A
radial (good collateral flow; 5% will not have good collateral flow)
9
Q
Is the ulnar artery easier or harder to perform than the radial arterial line?
A
Harder; deeper
10
Q
Which arterial site is large, easy to identify and in the antecubital fossa, predisposed to kinking?
A
brachial
11
Q
Which arterial site is most prone to pseudoaneurysm and an increased infection risk?
A
femoral
12
Q
Which arterial site displays distorted waveform?
A
dorsalis pedis/posteriar tibial
13
Q
Which arterial site has an increased risk for nerve damage?
A
axillary (damage to the brachial plexus secondary to trauma and hematoma)
14
Q
Adding heparin to arterial line fluid bags increases patient risk for what?
A
HIT
15
Q
Arterial line measurement is zeroed at the level of what?
A
right atrium/phlebostatic axis; 4th intercostal space, mid-axillary line (mid A-P chest wall)
16
Q
If a transducer is lower than the phlebostatic axis, what does this do to the pressure?
A
falsely high
17
Q
If a transducer is higher than the phlebostatic axis, what does this do to the pressure?
A
falsely low
18
Q
The correct order for placing a radial arterial line?
A
dorsiflex wrist
palpate artery (with tips of fingers not pads)
localize site
insert 20 or 22 guage cath at 45% angle
get flashback
lower to 30% angle
slide guidewire into artery (seldinger technique)
advance cath into artery
hold pressure 2-3” above the insertion site
connect tubing
tape/suture/dress
neutralize the wrist, avoid extreme dorsiflexion to prevent median nerve damage
19
Q
As the pulse moves more peripherally, throughout the arterial system, the arterial waveform becomes distorted resulting in what?
A
exaggeration of the systolic and diastolic pressure
20
Q
What is the exception to the exaggeration of systolic and diastolic pressure as the pulse moves peripherally?
A
when a patient is coming off hypothermic coronary artery bypass, the radial will underestimate central pressures, due to a change in vascular resistance of the hand, distal locations will vasodilate and pressures will be lower there than aortic root
21
Q
the dicrotic notch represents what?
A
closure of the aortic valve
22
Q
the beginning and ends of the arterial waveform represents what?
A
EDP (end diastolic pressure)
23
Q
False blood pressure readings is referred to as what?
A
dampening
24
Q
what are some causes for dampening?
A
increasing tubing, stop-coks or air in the system
25
Displays of an underestimated systolic pressure is referred to as what?
overdampened
26
Displays a falsely high systolic pressure is referred to as what?
underdampened
27
Underdampening occurs as a result of what?
poor vascular compliance, severe hypothermia, and some dysrhythmias.
28
Overdampening is displayed during a square wave test by what?
<1.5 oscillations; underestimation of systolic pressures, diastolic may not be affected
29
Underdampening is displayed during a square wave test by what?
>2 oscillations; overestimation of systolic pressures; diastolic pressures may not be affected
30
The bottom oscillation in an arterial waveform represents what in terms of the respiratory phase?
end expiratory phase
31
The difference in pulse pressure max and pulse pressure min is what?
SPV
32
Calculation for MAP?
(SBP+2DBP)/3
33
Why is DBP multiplied by 2 in MAP calculations?
because the heart spends twice as much time in diastole than systole; making this calculation unreliable in tachycardic or arrhythmia states
34
How is MAP measured with arterial line?
area under the curve
35
How are the pressures derived from non-invasive methods different from those measured with a line?
Usually 20mmHg higher with a line
36
15cm increase in height results in what?
decreases 10mmHg in blood pressure
37
1cm is how many inches?
0.39 inches = 1cm
38
what are indications for central venous catheter insertion?
- cvp monitoring
- fluid administration
- TPN administration
- aspiration of air emboli
- insertion of transcutaneous pacing leads
- venous access
- caustic drug administration
39
What is the position required to trap and aspirate a venous air embolism?
the Durant position; LLD and tburg; aspirate out of the RA
40
What are contraindications to central venous catheter insertion?
```
tumors
tricuspid valve vegetation
clots
ipsilateral previous carotid endarterectomy
*all relative*
```
41
What are risks associated with central line insertion?
```
infection
air or thrombus formation
arrhythmia
hematoma
pneumothorax (short/obese necks)
hemothorax/hematoma (carotid puncture, pull out and hold pressure for 5 minutes)
nerve or arterial injury (stellate ganglion and brachial plexus)
cardiac tamponade
```
42
What is the most common site of central line insertion?
right IJ
43
what is an associated risk for left IJ?
pleural effusion and chylothorax
44
What site is a higher risk for pneumothorax?
subclavian
45
Why are the external jugulars not used as often?
join great veins at more acute angle
46
What site has an increased risk of sepsis?
femoral
47
What position is the patient placed in for central line placement?
tburg
48
What is the landmark for central line placement?
2 heads of the sternocleidomastoid muscle and the clavicle OR cricoid, 2 fingerbreadths lateral and 3 from clavicle.
49
Where do you advance a 23-25g seeker needle when placing a central line?
medial border of lateral head of the SCM towards the ipsilateral nipple at 30-degree angle with continuous aspiration (Apex of triangle
50
What gauge is the introducer needle that is advanced along the same path
18g
51
What is the technique used to check for venous blood vs arterial blood in central line placement?
Fabian test (want this test to be negative)
52
What is important to remember after placing dressing on central line?
draw blood through ports and then flush with saline OR flush saline prior to insertion and clamp ports, don't want to inject air
53
CVP approximates what pressure?
right atrial pressure
54
Normal CVP is what?
2-8mmHg
55
where is the optimal location to obtain a CVP?
just superior to or at the junction of the superior vena cava and the right atrium; NOT RA
56
What does a high CVP indicate?
```
non-compliant right ventricle
volume overload
pulmonary HTN
tamponade
tricuspid stenosis or regurg
RHF
PEEP
```
57
When should CVP be measured on a mechanically ventilated patient?
10-15 seconds after disconnection of the vent; PEEP could falsely elevate CVP by 5mmHg
58
What is the distance of venae cavae and right atrium from the subclavian?
10cm
59
What is the distance of venae cavae and right atrium from the right IJ?
15cm
60
What is the distance of venae cavae and right atrium from the left IJ?
20 cm
61
What is the distance of venae cavae and right atrium from the femoral vein?
40cm
62
What is the distance of venae cavae and right atrium from the right median basilic vein?
40cm
63
What is the distance of venae cavae and right atrium from the left median basilic vein?
50cm
64
What part of the CVP waveform represents systole?
from the beginning of the C waveform to the end of the V waveform
(S-after T wave on ECG)
65
What part of the CVP waveform represents diastole?
from the end of the V waveform to the end of the A waveform
| after T to beginning of QRS
66
"a" on the CVP waveform represents what?
RA pressure increase in RA contraction
67
"c" on the CVP waveform represents what?
bulging of a closed tricuspid valve into the RA during the beginning of ventricular systole
68
"x" descent on a CVP waveform represents what?
atrial relaxation, ventricular systole; simultaneously descent
69
"v" on the CVP waveform represents what?
filling of RA with closed tricuspid
70
"y" on the CVP waveform represents what?
tricuspid opening and RA emptying into the RV
71
atrial fibrillation is seen on a CVP waveform as what?
loss of "a" wave and a prominent "c"
72
AV dissociation on a CVP is seen as what?
cannon "a" wave
73
Tricuspid regurg on CVP is seen as what?
tall "c" wave and loss of "x" descent
74
Tricuspid stenosis on CVP is seen as what?
tall "a" wave
75
cardiac tamponade on CVP is seen as what?
dominant "x" descent (and slurred "y")
76
What are indications for PA catheter insertion?
-monitoring cardiac index, preload, volume status, mixed venous oxygenation
-if patient is at high risk for hemodynamic instability
surgical procedures with high incidence of hemodynamic --complications (thoracic AA repair, bypass)
77
what are contraindications for PA catheter insertion?
L BBB (increased risk of complete block
WPW
*both relative*
78
What are risks associated with PA catheter insertion?
-same as CVC
-endocarditis
-pulmonary infarction
-hemorrhage
-bacteremia
-pulmonary artery ruprutre
-arrhythmias
-valvular damage
-catheter kinking and knotting
increased with duration of placement (72 hours)
79
Who are at an increased risk for hemorrhage during PA catheter placement?
anticoagulated pts, women, elderly, pulmonary hypertension
80
If patient experiences hemoptysis during PA catheter insertion, what should be the next step?
suspect pulmonary artery rupture; STOP and insert double lumen endotracheal tube
81
when should the balloon be tested and lumens be flushed with saline?
prior to insertion (1.5mL of air)
82
how many ports are on the catheter?
5 ports; 3 are flushed
83
The right atrium is usually encountered by the distal tip at how many cm and where the balloon is usually inflated?
15-20cm
84
Is ectopy usually permanent or transient on ECG during insertion of PA cath?
transient
85
The yellow port of the PA cath is what?
pulmonary artery/distal port
86
blue port on PA cath is what?
RA/CVP
87
the white port on a PA cath is what?
proximal infusion port
88
the red port on the PA cath is what?
balloon port
89
If the balloon is in the right ventricle, the balloon is likely where?
the RV
90
What generally propels the balloon forward out of the RV?
RV CO
91
Entry to the pulmonary artery is noted with what?
sudden increase in diastolic pressure (40-45cm in adults) and PA waveform should appear
92
further advancement of PA cath after LV entry has been made should stop when?
when PAOP waveform appears (few cm past PA waveform appearance)
93
where should the inflated ballon wedge?
wes zone 3 to decrease swings in alveolar pressure that we can't control
94
pressures of 0-8 would indicated PA cath is located where?
RA
95
systolic pressure of 20-30 mmHg and diastolic pressures of 0-8mmHg would indicate a PA cath is where?
RV (increased SBP)
96
systolic pressure of 20-30mmHg and diastolic pressures of 8-15mmHg would indicate PA cath is where?
pulmonary artery
97
the notch that resembles the dicrotic notch on an arterial waveform is actually what on a PA cath?
closure of pulmonic valve
98
normal value for SVO2
60-75%
99
normal value for stroke volume
50-100mL
100
normal value for stroke index
25-45mL/M2
101
normal value for CO
4-8L/min
102
normal value for CI
2.5-4.0 L/min/m2
103
normal value for MAP
60-100mmHg
104
normal value for CVP
2-8 mmHg
105
normal value for PAP systolic
20-30 mmHg
106
normal value for PAP diastolic
5-15 mmHg
107
normal value for PAOP (wedge pressure)
8-12 mmHg
108
normal value for SVR
900-1300 dynes-secon-cm-5
109
What estimates LVEDP?
PAOP
110
decreased SV in the presence of low PAOP indicates waht?
hypovolemia
111
decreased SV with high PAOP indicates full heart with need for what?
inotropy/squeeze
112
normal or increased SV int he setting of hypotension can be treated with what
pressors
113
when is PAOP an unreliable estimate of LVEDP?
mitral valve dysfunction
change in ventricular or atrial compliance
high pulmonary vein resistance
114
normal CO
4-8 L/min
115
when CO is produced with a PA cath it is done through the method of what?
thermodilution
116
what is thermodilution?
fluid below body temperature is injected into the RA and changes the temp of blood that is in contact with the thermistor at the tip of the PA cath; degree of temp change is inversely proportionate to CO
117
If temp change is minimal the CO/outflow is what?
increased (inversely proportional)
118
if temp change is great, the CO or outflow is what?
decreased (inversely proportional)
119
how does one achieve an accurate thermodilution estimate of CO?
smooth rapid injection
consistent temp
consistent volume
avoid measuring during cautery
120
poor injection waveform would look like what?
uneven upslope
121
low CO thermodiluation waveform looks like what?
large (increased temp change)
122
high CO thermodilution waveform looks like what?
small (decreased temp change)
123
what is an example of a pulse contour device?
FloTrac
124
what is decreased during PPV?
SV and pulse pressure
125
with greater variation of pulse pressure during inspiration and expiration the patient is more likely to improve hemodynamically from what?
fluid administration
126
a pulse pressure variation of what indicates need for fluid?
>13
127
pulse pressure variation of waht indicates treatment with other measures?
<13
128
SVO2 monitoring measures what?
returned O2 concentrations of venous blood
129
How much O2 do the tissues normally extract?
25%
130
Normal Sv02 is what?
60-80%
131
SVO2 levels are altered by what?
tissue oxygen consumption and CO
132
where is the best place to measure SVO2?
PA because its the last place to check before becoming arterial blood
133
factors resulting in increased SVO2
```
anesthesia
paralysis
hypothermia
increased CO2
Increased hemoglobin
sedation
septic shock
```
134
factors resulting in decreased SVO2
```
cardiogenic shock (all but septic)
seizures
decreased hemoglobin
shivering
hyperthermia
decreased CO2
```
135
When using a CVC where can you measure SVO@?
superior vena cava
136
What are indications for TEE?
```
diagnose structureal and valvular abnormalities
estimate hemodynamic parameters
guide surgical interventions
diagnose source of hemodynamic instability
ischemia
systolic and diastolic heart failure
fluid status evaluation
diagnose tamponade
```
137
what are contraindications for TEE?
```
esophageal pathology
prior esophageal sugery
pharyngeal tumors
cervical instability
varices
```
138
How will mitral regurg present on TEE?
red and blue in LA
139
TEE utilizes ultrasound at the range of what?
2-10mHz
140
UA penetrates through what during TEE?
tissues, blood and other structures
141
true or false, images that are generated can be manipulated to permit visualizations of the hearts structures?
true
142
what does a TEE utilize to evaluate direction and velocity of blood flow?
doppler
143
red on a TEE indicates what direction of blood towards the probe?
red
144
blue on a TEE indicates what direction of blood away from the probe?
blue
145
What are indications for an intra-aortic balloon pump?
pump failure
intraoperative MI
low CO
periop for pts with suspected high grade lesions
146
what are contraindications for an IABP?
severe aortic regurgitation
aortic aneurysm
severe peripheral vascular disease
147
what are common complications of IABP?
```
clot on balloon surface
extension or rupture of an aortic aneurysm
limb ischemia
fem or iliac arter perforation
fem artery occlusion
sepsis
```
148
what is the main function of IABP?
mechanicaly displaces blood within the aorta
149
where does the IABP enter and where does the tip lie?
in the fem artery; and lies with the tip just distal to subclavian artery
150
what is a secondary feature of an IABP?
monitors myocardial perfusion and effects of drugs on the myocardium
151
what are the effects of myocardial oxygen demand on IABP?
increase supply and decreases demand
152
balloon of IABP inflates at the beginning of diastole and is timed with what?
mid T wave of the arterial waveform
153
balloon of IABP deflates just before systole and is time with what on the EG?
peak R
154
what are the effects of a ventricular assist device on cardiac status?
decrease workload and increase cardiac output in pts with ventricular failure
155
what is useful as a bridge to heart transplant, cardiogenic shock and inability to wean from CPB
VAD
156
what instances are VADs contraindicated?
```
sepsis
irreversible hepatic or renal dysfunction
severe pulmonary HTN
metastatic cancer
bleeding disorders
```
157
where do right VADs work?
diverts blood from failing right ventricle or atrium to VAD that pumps into the left pulmonary artery
158
where do left VADs work?
diverts from LV and runs through VAD back into body through aorta
159
common complications of VAD placement?
```
thrombus formation
PE
stroke
heart failure
bleeding
tamponade
infection
```
160
what does ECMO do?
provides both systemic and pulmonary arterial support
161
how long can ECMO be used?
up to 30 days
162
when is ECMO utilized?
```
cardiogenic shock
failure to weak from CPB
right heart failure
severe respiratory failure
ARDS
```
163
what is necessary in addition to ECMO?
anticoagulation to prevent clot formation
164
what limits the use of ECMO duration?
infection
bleeding
emobolus
