Lecture 3 - hemodynamics Flashcards

Question

central venous pressure (4)

Answer 1

1) volume that is measures on the right side of the heart 2) can be independent (hyper/hypovolemia) or dependent (backing up) on left side of heart - LV failure -> increased R pressure 3) dependent on venous return (SVC) - impedance of venous return will drop CVP - blood clots, laying on back 4) AKA: method of measurement of volume RANGE: 0-10

Answer 2

- intravascular volume - increased systemic return - mobile 3rd spacing - increase in piulmonary vascular resistance (pulmonary HTN, pulmonary stenosis, tricuspid regurgitation/lung disease)

Answer 3

- intravascular vol. loss - systemic venous dilation (neurogenic, early septic shock) - third spacing of volume (liver failure, burns)

Answer 4

- hypoxia - obstruction - decrease pulmonary compliance (pulmonary edema, ARDS, fluid overload) - vasoconstriction (acidemia, hypoxia) - pulmonary HTN

Answer 5

- vasodilators (nitric oxide, sildenafil, remodulin) - correction of hypoxemia or acidosis - normal response in exercise (physiological response to increase O2 demands to tissues -> dilation of vascular bed efficiently to provide O2)

Answer 6

1) myocardial oxygenation (hypoxia, MI) 2) electrolyte balance: - hypo-ca - hypo-mg - hyper-K - Ph balance (too acid/too alk = myocardium will be depressed) 3) positive/negative inotropic drugs - digoxin (PO), epi, dobutamine, dopamine 4) amt functional myocardium - dilated cardiomyopathy

Answer 7

1) hyperdynamic states - early septic shock (tachy -> O2 supply/demand mismatch) - hyperthyroidism 2) positive inotropes: - beta andrenergic stimulants such as epi, dobutamine 3) endogenous catecholamine release - SNS (part of ANS) - metabolic rate, exercise, stress, pain, anxiety

Answer 8

1) HYPOdynamic states - late sepsis - cardiogenic shock - MI - hypercarbia (acidosis) 2) increased preload (starling curve) 3) negative inotropes: - beta blockers, CCB 4) electrolyte imbalance: - Low Na, Ca, Mg - High K 5) decreased O2 supply: anaerobic metabolism 6) loss of functional myocardium 7) severe metabolic acidosis, <7.0 - key: treat with SODIUM BICARB (basic)

Answer 9

optimal HR: between 50 - 150/min optimal filling time optimal preload (frank starling law) - ideal amount of myocardial stretch

Answer 10

HR <50 or >150 lack of atrial kick with new onset AFIB frank starling law (less myocardial stretch) significant REduction in preload significant INcrease in afterload

Answer 11

physical assessment 1) good BP/HR 2) LOC/mentation 3) color/temp of skin (peripheral circulation, decreased CO reflects in skin) - pink/war or cold/mottled invasive monitoring: - arterial lines - pulmonary catheters

Answer 12

arterial lines pulmonary catheters central venous catheters

Answer 13

- invasive catheter - high pressure tubing with flush system - transducer to convert information to electrical energy signal - bedside monitoring - flush system: maintains patency - calibration of equipment: "stop cock" opened to atmospheric pressure @ phlebostatic axis

Answer 14

1) Phlebostatic axis - Physical reference point - 4th intercostal space, midaxillary line 2) Leveling the transducer - Aligning transducer with level of LEFT atrium 3) Patient position - Supine, head-of-bed 0 to 60 degrees - Landmarks change if patient in lateral position - Raising the transducer will drop pressures

Answer 15

Indications: - Need for multiple vasopressors to maintain BP (ex: Levophed, Epi, Vasopressin, Dopamine) - Labile BP (ie. head injuries, pre-e) - IV Vasodilators (ex: Nipride/Nitroprusside) Catheters and sites: - Location dictates size of catheter used (radial vs. femoral) - Allen’s test for collateral circulation in the hand with radial access - use pulse ox for confirmation - how: occlude radial artery + ulnar, then let go of ulnar and should turn back to pink Maintain perfusion pressure: - Use mean arterial pressure (MAP) - MAP goal is based on disease states (cardiac (wide pp) vs. neuro (narrow pp)) 60-65 - (MAP =systolic blood pressure + 2 diastolic blood pressure / 3)

Answer 16

1) Titrate medications to maintain MAP 2) Monitor Pulse pressure - Affected by the patients rhythm - You can see variation with abnormal rhythms (PVCs, afib) 3) Compare to cuff blood pressure - Normovolemic pressure little difference exists between cuff and arterial pressure - Cuff pressures help to determine if there is “under dampening” or “over dampening” - clot over tip

Answer 17

Femoral: Direct pressure, time dependent on Fr. Size ie. 7, 10, etc - 20 minute w/ increase Q5min per 10 Fr increase Radial: Hemoband for procedures, direct pressure for arterial waveform measurement

Answer 18

1) Need a central venous line - Jugular (BEST) - Brachial - Femoral 2) PICC via AC 3) Types of Catheters - Central venous system - Right atrial catheters - Pulmonary Catheters (ie. Swan-Ganz catheters)

Answer 19

1) Inserted into central venous system. - Procedure performed at bedside under sterile technique - Internal Jugular or Subclavian vein - Can use indwelling "cordis" catheter 2) Indication - Volume loss - Volume overload - Need for fluid resuscitation without hemodynamic response. 3) Complications - Air embolism if lines are open - Thrombus formation at end of catheter - Infection

Answer 20

1) Indications: - Diagnosis and evaluation of heart disease, shock states, acute respiratory distress syndrome and conditions that compromise cardiac output - Difficult to determine if central venous issue or left side of heart issue - In cardiac cath lab referred as right heart cath, used for diagnosis severity of valve disease and intra cardiac shunts 2) Can determine Cardiac output 3) Hemodynamic monitoring is used for Oxygen supply and demand evaluation (mismatch) - Preload - Afterload - Contractility

Answer 21

1) Right atrial (proximal) lumen or CVP lumen 2) Pulmonary artery (distal) lumen 3) Balloon lumen 4) Thermo lumen to determine CO and monitor core temp 5) Additional features: continuous Svo2, cardiac pacing, continuous cardiac output measurement, right ventricular ejection fraction measurement

Answer 22

Cardiac output: *4 to 6* liters per minute Cardiac index: 2.5 to 4.0 liters per minute per square meter (of body surface area) - Right atrial pressure: 2 to 5 mmHg - Pulmonary artery systolic pressure: 20 to 30 millimeters of mercury (mmHg) - Pulmonary artery mean pressure: 10 to 15 mmHg - Pulmonary diastolic pressure: 5 to 10 mmHg - Pulmonary capillary wedge pressure: 5 to 12 mmHg - Mean wedge is same as the pulmonary diastolic pressure - also same as the Left Atrial pressure

Answer 23

1) Insertion-Similar to Venous line Site- Femoral, Subclavian or Internal Jugular Veins 2) Waveform interpretation- Clinician is able to determine location type of waveform - Right atrial waveform - Right ventricular waveform - Pulmonary artery waveform - Pulmonary artery occlusion waveform (wedge pressure tip: pulmonary HTN and CHF may cause elevations in diastolic pressure

Answer 24

RA: 2-5 RV: 0-25 LA: 3-12 LV: 120/70

Answer 25

Bleeding Air Embolism Pulmonary Artery Rupture with balloon inflation Pulmonary ischemia Catheter Knotting Clot formation Ventricular Dysrhythmias Infection

Answer 26

1) Thermodilution method - Most common method used in the ICU when a swan is present - Assumes all blood is traveling uni-directionally through the heart 2) Influenced by: - Cardiac output curve - Injectate temperature - Patient position and cardiac output - Clinical conditions that alter cardiac output (Early sepsis will show hyper-dynamic state with high CO numbers)

Answer 27

1) Central Venous Catheter 2) Scvo2 port is present on PA catheter to allow for additional monitoring - Monitoring balance between oxygen supply and demand as a function of arterial oxygen saturation, cardiac output (via Fick), hemoglobin, and venous oxygen saturation - Is a good indicator of documenting response to therapy, whether oxygen or improving circulation to tissues

Answer 28

- O2 supply exceeds O2 demand - Alteration in O2 delivery: Cardiac Output elevated, See with early septic shock

Answer 29

- O2 demand exceeds O2 supply - Decrease CO - Decrease Hgb - Decrease pulse ox (SaO2)

Answer 30

Combines data from arterial lines with a specialized ScvO2 catheter Requires nurse to input patient data: height, weight, age & sex Measures Cardiac Output (CO), Stroke Volume (SV), Systemic vascular resistance (SVR) In ventilated patients, measures SVV (Stroke Volume Variation)

Answer 31

guide fluid resuscitation

Answer 32

Measuring the variation in stroke volume in patients undergoing mechanical positive pressure inhalation and exhalation (Ventilated) SVV has been proven to be a highly sensitive and specific indicator for preload responsiveness. In nursing context: predicting whether a patient will benefit from volume before the fluid is given Greater SVV=better response to fluid (variations per inhale/exhale -> give fluid to decrease variation), preload responsive tip: Breathing compresses vasculature, Preload changes.

Answer 33

Passive Leg Raising: Passive raising of the legs has been proven clinically to act like a “self volume challenge” to indicate status on the Frank-Starling curve (Augmenting Stroke Volume by increasing preload), increases SVV Situations where it is not possible to use SVV: - During arrhythmias - Patients not on control-mode of ventilation - Patients at risk of complications from fluid loading

Answer 34

- Therapeutic Hypothermia (TH) - Targeted Temperature Management (TTM) Preserving brain function and maximizing meaningful recovery in the event of an arrest - Hypoxic encephalopathy and loss of neuro function

Answer 35

Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest should be cooled to 32 (89.5F) -36 (96.8)ºC for at least 24 hours when initial rhythm was ventricular fibrillation (VF) Similar therapy may be beneficial for patients with non-VF arrest out-of-hospital or with in-hospital arrest

Answer 36

- Don’t re-warm mildly hypothermic patients - Cool early in the emergency department. - Used to use any cooling method possible. - Patients can continue to be cooled during percutaneous coronary intervention (PCI) while we look for precipitating factors - Use any pharmacologic agent necessary for primary cardiac condition (eg, aspirin, antiplatelet compounds, thrombolytics) - Treat patients as you would any critical care patient (tight glycemic control, vigilance for signs of infection, maintain perfusion, and use pressors if necessary). - Practice standard neuroprotective strategies such as placing the head of the bed at 30º and use seizure precautions. - Predict and be proactive regarding management of complications from return of spontaneous circulation and hypothermia, including: shivering, fever, hypotension or hypertension, hyperglycemia, hypokalemia or hyperkalemia, bradycardia and ongoing ischemia. - Cooling reduces cerebral metabolism (approximately 6-8% per 1ºC) -> Reduces excitatory amino acid neurotransmitters (Specifically Glutamate) key: MAP <65, 30 degree promotes Venous drainage and improves cerebral perfusion. - Norcuron and nimbex - Hypokalemia during cooling, hyperkalemia during re-warming.

Answer 37

Intubated patients with treatment initiated within a 6-hour post cardiac arrest Consistent Systolic blood pressure >90 mm Hg, with or without pressors/bolus, after cardiopulmonary resuscitation (CPR) Those not following commands - Brainstem reflexes and pathological/posturing movements are permissible. Patients with a Glasgow Coma Score (GCS) of 3 are eligible for hypothermia.

Answer 38

- Recent major surgery within 14 days - - Hypothermia may increase the risk of: infection, bleeding. Systemic infection/sepsis – not done Hypothermia may inhibit immune function and is associated with a small increase in risk of infection - Patients comatose from other causes (drug intoxication, preexisting coma prior to arrest) - Patients with a known bleeding disorders or with active ongoing bleeding – (Hypothermia may impair the clotting system). -> Check prothrombin time/partial thromboplastin time - Patients with a valid do not resuscitate order (DNR)

Answer 39

Provides consistency which follows guidelines- but also captures data for further research and extrapolation.

Answer 40

Arctic sun and other systems do this for you! - Maintain the paralytic agent and sedation until the patient’s temperature reaches 35°C (d/t shivering). - Discontinue paralytic agent first. Then sedation may be discontinued at the practitioner’s discretion. - Monitor the patient for hypotension secondary to vasodilatation related to re-warming. - Discontinue potassium infusions. - The goal after re-warming is normothermia (ie, avoidance of hyperthermia). - Await 72 hours for metabolism of sedatives before determining neurological status tip: hypothermia decreases potassium, increase in temperature will increase potassium

Answer 41

- Head of the bed at 30º - Tight glycemic control - PCO2 should be normal (35-45 mm Hg) - Skin care should be checked every 2-6 hours for thermal injury - Do not provide enteral nutrition during cooling and rewarming - MAP >80 - Paralytics to prevent shiver - Watch for arrhythmias->Bradycardia can lead to lethal arrhythmias - Monitor K+, PT/PTT & CBC during cooling & rewarm every 6 hours - Support family - Provide information of Protocol

Answer 42

1) Cardiac Arrest has extremely poor outcomes Poor prognosis: - Only 14-40% achieve ROSC - Only 20% will survive through hospital admission - Few Proven interventions: #1 CPR 2) Difficult to research: - Complex, Heterogeneity, High acuity -- Impossible to blind to Temp Treatment

Answer 43

1) Restore Cardiac output to preserve the end organ perfusion 2) Off-Load the Left Ventricle 3) Optimize balance of supply and demand 4) Allow time for recovery of injured myocardium types: - Intra-Aortic Balloon Pump (IABP), - Extra-Corporeal Membrane Oxygenation (ECMO) - Impella

Answer 44

- Pneumatic, pulsatile - Inserted retrograde via femoral artery - KEY: NOT USED TO PROVIDE CARDIAC OUTPUT- - But still may augment flow by 0.5L/min - Not much hemolysis or bleeding - Can be inserted at bedside

Answer 45

1) Inflates during diastole - Increases/Augments coronary blood flow - Increases Diastolic BP 2) Deflates in Pre-systole - Reduces afterload - Reduces SBP - MAP stays the same, sometimes improves 3) Used for STEMI, not the most effective for cardiogenic shock 4) need Daily CXR

Answer 46

Venous/Arterial Extracorporeal Membrane Oxygenation Femoral Vein from right atrium -> centrifugal pump (cardiac) -> oxygenator (lungs) -> Femoral Artery for systemic circulation - Provides full cardiac and pulmonary support - Late stage support (Survival rate relatively low) - In Babies, survival rate is much better

Answer 47

- Non-pulsatile, similar placement as the IABP - Retrograde through fem artery -> aorta - Pulls blood from left ventricle, uses impellor-contained catheter to pull blood into the aorta - Can improve CO by 5L (new approach- Axillary/Subclavian) - Used for V-tach ablation - Lots of hemolysis in the past, requires anticoagulation - Requires functional Aortic Valve - Impella runs at 33,000RPM to generate 4-5L/min