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Invasive Monitoring > Invasive Clinical Monitoring: Intro & Indications > Flashcards

Invasive Clinical Monitoring: Intro & Indications Flashcards

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1
Q

Determinants of choosing CVC / Why do I need it?

A

Patient condition / Type of procedure / Potential fluid losses / Surgeon skill / Post op Mgmt

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2
Q

Practical Considerations for potential CVC need / What can I do with it?

A

Obtaining HD information / IV access needed / TPN, special infusions post op / Risk for VAE (by type of surgery)

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3
Q

Invasive Monitoring Guidelines: 3 key variables

A

1- disease severity 2- magnitude of surgery 3- practice setting

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4
Q

Disease states with poss PA Cath need

A

CAD, CHF, CM, Valvular disease

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5
Q

Misc PA Cath recommendations

A

CV disease, Resp failure, Thoracic Ao Sx, Poss/known PE, Hx of Cardiac Sx, major thoracic/pulm Sx / large fluid shifts expected, sepsis pt, vasopressor therapy, Pulmo HTN, Severe lung disease, Reduced EF <40%

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6
Q

Uses of PA Cath

A

Use derived indices to guide therapy. SVR for afterload reduction, monitor HD changes, fluid shift assessment, Mixed venous sat

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7
Q

PA Cath in heart surgery: recommendations

A

Poor LV fxn, valvular disease, CM, LM disease, Septal defect, Recent infarct, IABP, HD instability

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8
Q

PA Cath Contraindications

A

Severe coagulopathy, thrombocytopenia < 50K, Tricupsid/Pulmonic valve prosthesis, Endocardial pacemaker, site infection, severe Vasc disease at site, Ventricular Dysrhythmias, Pulmo HTN, LBBB, Pt refusal

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9
Q

Guidelines for site selection

A

Surgical site, medical hx, surgical hx, compressibility of chosen location

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10
Q

Poss CVC Sites: External Jugular

A

Ext Jugular - head of bed access, low complication risk, valves and acute angle hinder passage

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11
Q

Poss CVC Sites: Antecubital

A

AC - easy to learn, pt sitting, easy to kink, high failure rate, stasis/venospasm common

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12
Q

Poss CVC Sites: Internal Jugular / landmarks are SCM muscle triangle -> needle to top of triangle to ispa nipple TBurg

A

IJ - easy access, can thread multiple line types (pacer, pac, intro), lower Ptx than SCV, risk of carotid puncture, hgher infection risk d/t secretions / L sided complications (PTx, thoracic duct injury)

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13
Q

Poss CVC Sites: Subclavian / 1cm infraclav @ Midclavicular line, needle to sternal notch, keep in coronal, Tburg

A

SCV - noncollapsable (fixed to clavicle) makes good for emergency, longer use, lower infection, easy to dress, higher Ptx/Htx risk, vasc injury risk, non compressible vein (no coagulated pts)

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14
Q

Poss CVC Sites: Femoral / @ inf inguinal ligament, 1cm medial to fem artery / Lateral: Nerve/Artery/Vein/Lymph/Ligament:Medial

A

Femoral - good for large volumes (dialysis caths), no placement verification, little complications, easy to learn, does hinder mobility, high infection/short length of use, risk of thrombosis

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15
Q

PA Cath Acceptable Sites

A

In order of ease of insertion: RIJ (no LIJ, L sided risks from above) / External Jugular, Femoral, Scv, Basilic

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16
Q

CVC Fun Facts

A

place under surgical asepsis / use a seeking needle & j-tip wire / avoid 30cm catheters (placed too far) / flush all lumens / never w/d wire thru needle

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17
Q

CVP Cath Tip Location

A

Just above SVC/RA, 3-5 cm outside RA. Tip below clavicles at level of T-4. At level of carina. Depth = Ht in cm/10 + 2(RScv 10cm)), Ht in cm/10(RIJ 20cm, LIJ + 5)

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18
Q

PA Cath Tip

A

Easiest to pass RIJ, LScv, waveform guided. Must monitor pressure obtained and distance passed. Reasons for not passing: perforation and coiling.

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19
Q

PA Cath RIJ tip markers

A

RA 20-30cm 6-8 mmHg / RV 30-40cm 25/0 mmHg/ PA 40-50cm 25/12 mmHg/ PA Wedge 50-60cm 2-12 mmHg

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20
Q

Wedge Location/Process

A

monitor wave from distal port / minimize balloon inflation time / w/d cath 1-2 cm if spont wedging occurs or balloon inflates < 1.25cc

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21
Q

CVC Complications

A

Venous access issues / Issue surrounding catheter residence(infection) / Issues specific to PA cath

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22
Q

CVC Complication: Ptx

A

0-15% incidence, exacerbated by N2O use, may not be seen on CXR, SOB/DeSat/Incr AW pressures. Tx with Ctube.

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23
Q

CVC Complication: Vascular Perf

A

Htx (blood), Hydrotx (IV fluids), Chylotx (lymph) via thoracic duct rupture (worse kind). Carotid punc leads to AW compromise/stroke.

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24
Q

CVC Complication: Myocardial Perf

A

Leads to cardiac tamponade. Incidence 0.2%, 66% mortality. Equalization of cardiac pressures, beck’s triad. Tx with pericardiocentesis.

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25
CVC Complication: Emboli
Air Emboli: s/s of PE. 50-100cc can be fatal. LLD Tburg and aspirate air from CVC. Tx 100%, no N2O. Wire/Cath emboli: retrieved in IR. Thromboemboli: high incidence but 5% clinically sig. coat catheters to prevent.
26
CVC Complication: Infection
Most common complication. Colonization in 50% of cases. Prevention is most important. Dressing changes, removed when not needed. Limit access.
27
PAC Complication: Dysrhythmia
Most common complication is vent ectopy. Pacer present when inserting with LBBB present.
28
PAC Complication: Pulm Vasc Infarct
Result of overwedging in small vasc space, prolong wedging. Dont inflate if spont wedged already.
29
PAC Complication: knotting
Too much catheter in pt for waveform that you see. Can coil around structures or be sutured into tissue. Get CXR if diff to remove.
30
PAC Complication: PA Rupture
PA rupture is most severe complication. Risk elevated in presence of PulmoHTN, adv age, coag disorder. 50% mortality. s/s hemoptysis, hypoxia, hypotension. Tx with bad lung down, PEEP, volume resusc, lung isolation with dual lumen tube. Need thoracotomy
31
Indications for Arterial Line
Elective hypotension (decr blood loss) / Anticipated labile BP (Xclamping) / Systemic disease warranting close BP monitoring (espc with induction) / Need for vasc access/blood draws (long cases)
32
Aline vs NIBP
Aline provides direct, beat to beat BP measurements. Not "sampling" with NIPB, which measures flow, AL measures pressure. NIBP low flow -> underestimates pressure / high flow -> overestimates pressure.
33
When to put in ALine
Pre vs post induction. Pre for disease states warranting close monitoring for induction (CAD). After for procedural issues ie blood sampling.
34
Aline Site Selection: Radial/Ulnar/Brachial
Radial - easy to locate, superficial, minimal pain, good collateral circ. Susceptible to sys augment, occluded flow. Ulnar - mirror to radial, deeper and more tortuous. Brachial - easier/larger, prone to kinking, motion. Injury risk high to entire arm.
35
R vs L radial site
Thoracic Ao aneurysm -> Rt side as LSca gets occluded. Mediastinoscopy ->Rt side to asses for vasc compression innom or Rsca.
36
Aline Site Selection: Axillary/Pedal&PostTib/Femoral
Ax - similar to Ao pressures, large vessel, risk of air embolism and nerve trauma. DP/PT - good collateral, sig sys augmentation, diff to cannulate and not rec for PVD patients. Femoral - safe as radial, risk of embolization with vasc disease, hematoma and pseudoany risk. Ax and femoral at risk for hematoma/compartment syndrome.
37
Allen's Test
Determines presence of adequate collateral circulation (palmar arch incomplete in 3-6%)
38
ALine Complications: Thrombosis
6 contributing factors: prolonged cathterization / catheter size 18g vs 20g / catheter material / proximal emboli / prolonged shock / pre-existing vasc disease
39
Aline Complications: Disconnection
Can lead to exsanguination. Check connections, stopcocks and caps. Vented caps must be replaced.
40
ALine Complications: Accidental Injection
Can cause limb necrosis: barbiturates, vasopressors, ketamine are worst.
41
ALine Complications: Infection
Related to length of time in place. Must place in sterile fashion, mask/gloves/hat.
42
ALine Complications: Nerve injury
R/t trauma w/ insertion, direct nerve damage or r/t compartment syndrome. Also possible with prolonged dorsiflexion of wrist.
43
ALine Pressure waveforms
Further from Ao Root the steeper the upstroke (sys augmentation). More peripheral location -> greater increase in SBP, pulse pressure and lower DBP, narrower waveform. Points of greatest sys augment -> radial/ulnar/DP/PT
44
PA Catheter sizing/characteristics
7 French most common size. Balloon capacity of #5 PAC is 1.5 cc. Prox lumen 30cm rom tip, thermistor is distal.
45
HD Monitoring Sys Components and accuracy
1-fluid filled tubing system 2-electronic system (transducer) / must prime tubing, level and zero to phlebo axis 4th ICS Midax line (nearest to RA)
46
Most important derived indices
Aline - SVR/PVR PA - RAP/PaoP Contractility - SV/SVI
47
Best Location for PAC
Prefer in zone 3 where arterial pressure is the greatest. Provides most communication between pulmo caps and LAP. Limits influence of alveolar pressure on tracing.
48
Pressure relations/gradient within heart
PAEDP (PVR, HR) PCWP (AWP, PEEP) LAP (mitral stenosis) LVEDP (vent compliance) LVEDV
49
RV waveform
Often seen with ectopy. Sharp sys upstroke, little to no diastolic pressure, 15-30/0-8 (dia approx RAP). RVEDP (gold std for preload) measured at R wave.
50
LV waveform
Measured only in cath lab. Similar app to RV wave but with near 5x pressures, 100-140/0-12. LVEDP measured at R wave. LV-Ao gradient incr with AO stenosis.
51
PA waveform
Similar appearance to Aline/sys pressure readings, but with near 1/5th pressure. sys upstroke/peak, sys decline with dicrotic notch and dia runoff, 15-30/4-12. Normal pts can sub PAD for LVEDP (instead of PAOP). Measured after QRS.
52
Systemic Arterial waveform
Similar to PA cath, but near 5x pressures. Also read after QRS. Antercotic limb/upstroke -> sys peak -> dicrotic limb -> dicrotic notch -> dia runoff -> diastole
53
Right Atrial waveform
5 components: A wave - atrial contraction. C wave - Tricup valve bulging d/t isovolumic contraction. V wave - venous filling of atria. X descent - atrial relaxation, floor pulled by ventricle. Y descent - Tricup valve opens, blood flows RA -> RV. A wave after p wave, c/v waves after QRS. CVP/RA is mean of a-x slope at R wave. 1-8 mmHg
54
Disease states altering CVP
1- PulmoHTN 2-Rt heart failure 3-Lt heart failure. Clinical signs: distended veins, incr R side filling pressures, Incr HR, bounding pulses, sys edema, decr pulm compliance, S-3 gallop. Decreased w/ hypovolemia
55
PAOP waveform
Surrogate for LAP (LVEDP reflection) LAP = 2-12 / PAOP = 5-15 (mean of A wave). When wedged, PAC see static column of blood between cath tip and LA. Waveform has dampening d/t extensive pulmo cap bed being transduced. Delay places A wave follow R wave.
56
Disease states altering PAOP
Increased d/t fluid overload, LV failure, Mitral stenosis/regurg, tamponade/pericarditis. Decreased d/t hypovolemia
57
Respiratory effects on pressure tracings
Spont breathing - decr intrathoracic and intravasc pressures. Positive press breathing - incr intrathoracic and intravasc pressures. Measure HD waves at end expiration. High PEEP makes PAOP unreliable.
58
Cardiac Output
CO=HR x SV, NL = 5L/min. measured via Fick method or thermodilution. Must inject right amount, small amount = false high CO. Regurg R sided valves = false high CO. Should average 3 CO attempts. CI = 2.5-4L
59
Stroke Volume
SVI = 40-60ml/beat. NL SV for 70kg male = 60-90 ml.
60
SVR & PVR
MAP-CVP / CO x 80 (900-1500) / PAP-PAOP / CO x 80 (<250)
61
Mixed Venous O2
NL = 65-75%. Sust <65%, compromise of one determinant of O2 delivery/transport. Elevation may reflect excess FiO2 or poor extraction.
62
PAOP not = to LVEDP
PAOP>LVEDP - mitral stenosis, atrial tumor, pulmo venous congestion, incr AW pressure // PAOP
63
Abnormal atrial waveforms
Cannon waves - large A waves, combo of A&C waves, measure at R wave. Seen in AFib, jxnl rhythms (may not have any A waves), pacemaker w/o AV sequencing (no A-kick), Tricup/Mitral stenosis. Large V waves usually r/t valve regurg. C+V wave, RAP may look like PAP w/ tricup regurg. PAOP may look PAP with mitral regurg.

Invasive Monitoring (1 decks)

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