Monitoring the CV Patient - Quiz 2 Flashcards by Donny Le

Why are A-Lines used?

Real time BP
Frequent Blood Draws
Bypass, IABP, Vasoactive Drugs, Deliberate Hypotension
Cant do NIBP d/t burns, obesity
Pulse Contour Analysis: SPV, SV
Easy to place
Hand has good collateral circulation

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What are the complications to placing a Radial Art Line?

Vasospastic Disease

Prolonged Shock

High-Dose Pressors

Prolonged Cannulation

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Why is a Brachial Art Line NOT preferred over a Radial Art Line?

Needs longer catheter to get around elbow

Arm needs to stay extended

Collateral circulation not as good as hand

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What technique should be used for placing a Femoral Arterial Line?

Guide-Wire Technique

Poke Fem artery below Inguinal Ligament

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What amount of Systolic Pressure Variation indicates Hypovolemia?

> 15 mmHg or Δdown 15 mmHg

(Δdown 5 mmHg = ↓venous return)

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What does the PulseCO system do?

Predicts increase in stroke volume from fluids and helps identify Hypovolemia

Similar to Echo preload numbers

Needs mech. vent & limited by arrythmias

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When is a Central Line indicated?

CVP

Advanced CV Disease

Major Operation

Secure Vascular Access

Craniotomy Air Aspiration

Cant get Peripheral

Swanz, Pacer

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Where is the Internal Jugular Vein located?

Between Sternal & Clavicular heads of Sternocleidomastoid muscle, Anterior to the Carotid

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What is used in the Seldinger Method of inserting a CVC?

22G Finder

18G Needle

Guidewire

Scalpel

Dilator

Catheter

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Where should the needle be inserted when placing a CVC?

Towards Ipsilateral Nipple

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When placing a CVC, why is the Subclavian sometimes placed instead of an IJ?

C-Spine Precautions

Better Patient Comfort

2% Pneumo Risk

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What is are the advantages of gaining an External Jugular access?

Easy & No Pneumo Risk

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What are the complications of Double cannulating the same vein?

Vein Avulsion

Tangled Catheter

Catheter Fracture

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When should CVP be measured?

End-Expiration

(Zero @ Mid-Axillary)

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What can a Pulmonary Artery Catheter measure?

PAP

PCWP

CVP

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What are complications associated w/ Pulmonary Artery Catheters?

Serious: Knotting, Pulm. Infarction, PA Rupture d/t overwedge, Endocarditis

Transient RBBB

Dont Place with LBBB

Death

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Cardiac Output from a Pulm. Artery Catheter allows for calculation of ____________

Cardiac Output from a Pulm. Artery Catheter allows for calculation of Oxygen Delivery (DO₂)

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How is Thermodilution done?

Inject 10cc of room temp/iced D5W into CVP port at End Expiration
Measure change in blood temp at thermistor
Average of 3 Measures

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With Thermodilution, Cardiac Output is _______ proportional to area under curve

With Thermodilution, Cardiac Output is Inversely proportional to area under curve

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What are some problems with measuring Cardiac Output w/ a PA Cath?

Inaccurate temps d/t:

Thermistor Blood Clot

Shunts

Tricuspid Regurg

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What can be used as an Indirect Cardiac Output indicator?

SvO₂ if O₂, VO₂ & Hg are constant

Normal SvO₂ 60-75%

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What can cause and Increased SvO₂?

Wedged PAC - LAP Saturation

Low VO₂ d/t Hypothermia, General Anesthesia, NMB

Carbon Monoxide poisoning

High CO d/t Sepsis, Burn, L-to-R Shunt, AV Fistulas

What can cause a Decreased SvO₂?

Decreased CO

↓Hgb

↓SaO₂

↑VO₂
(Fever, Agitation, Thyrotoxic, Shivering)

What does the dicrotic notch on an A Line tracing signify?

Aortic Valve Closure

How does an Overdamped A - Line affect the reading?

Understimated SBP & Overestimated DBP

What does and Underdamped A - Line mean?

Overestimated SBP & Underestimated DBP

In regards to Square Testing an A-Line, what indicates Optimal Dampening, Overdampening, and Underdampening?

Optimal: 1-2 oscillations after square Underdamped: \> 2 oscillations Overdamped: \< 1.5 oscillations

What factors might cause an Overdampened A-Line?

Bubbles or Clots in Tubing Vasospasm Friction Long, Narrow Tubing Extension Compliant tubing

What factors cause an Under Dampened A-Line?

Catheter Whip Artifact Stiff Non-Compliant Tubing Hypothermia Tachycardia Dysrhythmia

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Subclavian?

10 cm

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Right IJ?

15 cm

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Left IJ?

20 cm

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Femoral Vein?

40 cm

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Right Median Basilic Vein?

40 cm

What is the distance to the Vena Cava / RA Junction when placing a CVC from the Left Median Basilic Vein?

50 cm

When inserting a PA Cath from the RIJ, what is the distance the cathether traveled when it is in the Right Atrium?

15 -25 cm

When inserting a PA Cath from the RIJ, what is the distance the cathether traveled when it is in the Right Ventricle?

25 - 35 cm

When inserting a PA Cath from the RIJ, what is the distance the cathether traveled when it is in the Pulmonary Artery?

35 - 45 cm

When inserting a PA Cath from the RIJ, what is the distance the cathether traveled when it is in the Pulmonary Artery Wedge Position?

40 - 50 cm

What do the A, C, and V waves represent on a CVP tracing?

A Wave: Right Atrial Contraction C Wave: Closure of Tricuspid V Wave: Right Atrial Filling

When would you see only V Waves on a CVP tracing?

A-Fib & Asystolic Ventricular Pacing

What would cause Large A Waves on a CVP tracing?

Tricuspid/Mitral Regurg & Acute Intravascular Volume Increase

When would you see Giant, "Cannon" A Waves on a CVP tracing?

Junctional Rhythm Complete Block PVCs Ventricular Pacing Tricuspid/Mitral Stenosis Diastolic Dysfunction Myocaradial Ischemia Ventricular Hypertrophy

What can cause a High variation in CVP?

RV Failure Tricuspid Stenosis/Regurg Cardiac Tamponade Pericarditis Volume Overload Pulmonary HTN

What can cause Low CVP Variations?

Hypovolemia & ARDS

What can cause Overestimates w/ Thermodilution?

Low Injectate Volume Injectate too warm Thombus on Thermistor Wedged PA Cath

What can cause Underestimates w/ Thermodilution?

Excessive Injectate Volume & Injectate to Cold

What is the PA Wedge Pressure used for?

Estimate Left Ventricular End Diastolic Pressure (LVEDP) Normal: 8 - 12 mmHg

List where the PA Catheter is (1-4)

1. Right Atrium: 0-8mmHg 2. Right Venticule: 20-30/0-8mmHg 3. Pulm. Artery: 20-30/8-15mmHg 4. PA Wedge: 8-12mmHg

What can cause High PA Pressures?

LV Failure Mitra Stenosis/Regurg L-R Shunt Atrial / Ventricular Septal Defect Pulm. HTN Catheter Whip/coil

What can cause Low PA Pressures?

Hypovolemia RV Failure Tricuspid Regurg/Stenosis

What can cause Low PA Wedge Pressures?

Hypovolemia RV Failure Tricuspid Regurg/Stenosis Pulmonary Embolism

What can cause High PA Wedge Pressures?

LV Failure Mitral Stenosis/Regurg Cardiac Tamponade Constrictive Pericarditis Volume Overload Ischemia