Invasive monitoring

Question 1

When deciding whether to use a CVC?

Answer 1

1- patient condition, disease severity
2- procedure, magnitude of surgery
3- practice setting

Question 2

Practical considerations with CVC

Answer 2

• what hemodynamic info do we need?? L and R side of heart??
• IV access needed?
• TPN, pressors??
• VAE risk

Question 3

Recommendations for PAC

Answer 3

• known CV disease
• XC of thoracic or abdominal aorta
• resp failure
• known or suspected PE
• hx of cardiac surgery
• pneumonectomy

Question 4

Recommendations for PAC cont.

Answer 4

• anticipated fluid shifts
• sepsis
• inotropes or vasodilators
• pulm HTN
• cor pulmonale
• treated with bleomycin - pulm fibrosis

Question 5

Recommendations for PAC

EF

Answer 5

<2.1L/min/m2
indicates CHF
normal EF 60%

Question 6

Internal jugular CVC risks

Answer 6

• VAE
• pneumo possible on LIJ
• thoracic duct injury - left side
• carotid puncture

Question 7

5 acceptable sites for inserting a PAC

Answer 7

1- Right IJ 
2- external jugular 
3- femoral 
4- subclavian 
5- basilic- hardest!!

Question 8

Positioning tip of CVP

Answer 8

just above junction of the SVC and RA
3-5cm outside of RA
below clavicles at the 4th thoracic vertebra

Question 9

2 reasons why PA cath not reaching PA

Answer 9

• perforation

- coiling

Question 10

Positioning tip of PAC (Right IJ)

- RA distance and pressure

Answer 10

18-22cm

6-8 torr

Question 11

Positioning tip of PAC (Right IJ)

- RV distance and pressure

Answer 11

28-32cm

25/0

Question 12

Positioning tip of PAC (Right IJ)

- PA distance and pressure

Answer 12

40-50cm

25/12

Question 13

Positioning tip of PAC (Right IJ)

- PA wedge distance and pressure

Answer 13

45-50cm

2-12

Question 14

CVC complication

- pneumo

Answer 14

0-15% chance

can occur after a negative CXR (N2O)

Question 15

Most common complication of CVC

Answer 15

infection

Question 16

most common PAC complication

Answer 16

ventricular ectopy- usually self limiting

Question 17

Most severe PAC complication

Answer 17

PA rupture

Question 18

PA rupture treatment

Answer 18

• LLD position (left lateral decubitus)
• position with bleeding lung down (dependent)
• isolate lung with dual lumen ETT
• reverse anticoagulation
• PEEP
• Volume resuscitation
• surgery for thoracotomy

Question 19

When do you want to place A-line on RIGHT side only??

Answer 19

• thoracic aneurysm
• mediastinoscopy
• in Open heart if left internal mammary is harvested for bypass.

Question 20

6 factors that can contribute to A-line thrombosis

Answer 20

1- prolonged duration 
2- catheter size (18G vs 20G)
3- catheter material (Teflon less thrombogenic) 
4- proximal emboli
5- prolonged shock 
6- pre existing vascular disease

Question 21

what is the most commonly used PA catheter size

Answer 21

7 french

Question 22

what is the balloon capacity of a #5 PAC

Answer 22

1.5cc

Question 23

Diastole

Answer 23

opening of tricuspid and bicuspid valves

Question 24

Systole

Answer 24

closing of tri and bicuspid valves

Question 25

Right ventricular waveform

Answer 25

- observed only at the passage of a PAC - often accompanied by ectopy - RVEDP measured at R wave - normal RV pressure = 15-30/0-8 torr***

Question 26

LV waveform

Answer 26

seen during left heart cath normal LV pressure 100-140/0-12 torr*** LVEDP measured at R wave

Question 27

PA waveform

Answer 27

- normal 15-30/4-12 torr | - PAD in normal pts can be used as alternative to PAOP to estimate LVEDP

Question 28

Systemic arterial waveform (a-line) waveform

Answer 28

morphology similar to PA waveform | dicrotic notch due to Aortic valve closing

Question 29

Atrial pressure waveform analysis: 5 components, 3 waves

Answer 29

- A wave: atrial contraction - C wave: closure of tricuspid valve and isovolumetric contraction - V wave: venous filling in atria

Question 30

Normal RAP

Answer 30

1-8 torr

Question 31

3 causes of increased CVP

Answer 31

1- pulmonary HTN 2- right heart failure 3- left heart failure

Question 32

cause of decreased CVP

Answer 32

hypovolemia

Question 33

EARLY clinical signs of increased CVP

Answer 33

- distended peripheral veins - increased right sided filling pressures - increased HR - bounding pulses

Question 34

LATE signs of increased CVP

Answer 34

- systemic edema - decreased pulmonary compliance - S3 gallop

Question 35

PAOP - normal LAP____ | PAOP _____

Answer 35

2-12 torr LAP | 5-15 torr PAOP

Question 36

Cardiac output

Answer 36

SV x HR

Question 37

CO thermodilution

Answer 37

the change in temp of blood is inversely proportional to blood flow - if erroneously low volume of injectate will have false high CO

Question 38

CO- regurgitation of tricuspid or pulmonic valve or septal defect may lead to....

Answer 38

falsely high TD CO readings

Question 39

_____ can cause interference with TD CO

Answer 39

electrocautery

Question 40

CO accuracy can be increased by...

Answer 40

1- averaging at least 3 measurements 2- measure at end inspiration or expiration 3- injecting identical volume and rate of NS

Question 41

Cardiac index

Answer 41

CO/BSA (m2) | normal - 2.5- 4.0L/min/m2

Question 42

SVI

Answer 42

SV/BSA | normal = 40-60

Question 43

normal SV for 70kg male

Answer 43

60-90ml

Question 44

EF

Answer 44

SV/EDV normal 55-75% EF <40 = LV failure

Question 45

PAOP > LVEDP

Answer 45

- mitral stenosis - left atrial myxoma (tumor) - pulm venous obstruction - elevated alveolar pressure

Question 46

PAOP

Answer 46

- decreased LV compliance | - aortic insufficiency