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Principles I Test 3

CVL and PA catheters

QuestionAnswer
What chamber of the heart corresponds to CVP? CVP measures pressure in the Right Atria
What does CVP assess? the volume or preload of the right ventricle (which is a good indication of fluid volume status)
What are the indications for CVL placement? monitoring, hemodialysis, transvenous pacing, aspiration of air embolism (sitting crani), infusion of vasoactive drugs or TPN, repeated blood sampling, cannula placement (ECMO, CPB), inadequate IV access
What is the normal CVP value? 1 - 8 mmHg; this is measurement in a normovolemic patient
Right atrial pressure is an indirect determine of what? RV function
Where anatomically is CVP measured? at the junction of the SVC and RA
In healthy patients, RV function reflects what? LV function
Positive pressure ventilation and PEEP cause falsely _____ CVP readings high
What does the A wave on a CVP waveform represent? atrial contraction
What does the C wave on a CVP waveform represent? tricuspid valve closing
What does the X descent on a CVP waveform represent? atrial relaxation (downward movement of tricuspid valve during ventricular systole/atrial diastole when base of heart descends)
What does the V wave on a CVP waveform represent? venous return/passive filling of right atrium against a closed tricuspid valve during ventricular systole
What does the Y descent on a CVP waveform represent? opening of tricuspid valve during ventricular diastole
What conditions would show a large A wave on the CVP waveform? AV asynchrony, V pacing, AV dissociation, pulmonary HTN, decreased RV compliance, tricuspid stenosis, junctional rhythms, complete heart block, PVCs, myocardial ischemia, diastolic dysfunction
What conditions would cause the absence of an A wave on the CVP waveform? A-fib, ventricular pacing
What conditions would cause a large V wave on the CVP waveform? tricuspid regurgitation, acute increase in intravascular volume
What would a CVP waveform look like in a patient with tricuspid stenosis? tall end diastolic A wave with an early diastolic descent
What condition would cause a low CVP reading? hypovolemia
What conditions would cause a high CVP reading? LV failure, RV failure, pulmonary HTN, cardiac tamponade, pulmonary embolism, tricuspid stenosis or regurgitation, constrictive pericarditis, volume overload
What are the two most important measurements from a PA catheter? cardiac output and PAOP
PA catheters allow for approximation of pressure and volumes on the ______ side of the heart, and also allows for ___________ blood sampling. left; mixed venous
What are some common indications for placement of a PA catheter? hemodynamic monitoring in high-risk patients undergoing major surgery, differential diagnosis and management of shock, diagnostic eval of major cardiopulmonary disorders, titration of therapy in unstable hemodynamic conditions, PEEP titration
What are 4 contraindications for placement of a PA catheter? coagulopathy, thrombolytic treatment, prosthetic heart valve, endocardial pacemaker
What are the complications of PA catheter placement? dysrhythmias (PVCs, RBBB), catheter knotting, thromboembolism, pulmonary infarct, infection, valvular damage, endocarditis, pulmonary vascular injury
During PA catheter insertion, you should never advance the catheter unless the balloon is inflated or deflated? inflated
If a patient who is getting a PA catheter placed has a right to left intracardiac shunt, what should you use instead of air to fill the balloon and why? CO2; to prevent air embolus
What is the path that the PA catheter takes before residing in its final resting spot in the patient? from SVC into RA, through tricuspid valve, through RV, across pulmonic valve, into pulmonary artery; will continue to advance until you get a "dampened" or wedge waveform = this is where PAOP is measured
What does PAOP measure? the back pressure (LV preload) from the pulmonary venous system through estimation of left atrial pressure
PAOP and LVEDP should be ________ about equal
When patient is in a supine position, the tip of the catheter should reside in which zone of the lung to produce an accurate PAOP reading? zone 3
Why is zone 3 the part of the lung where PAOP has to be measured? because in this part of the lung, the pulmonary capillaries are consistently patient, giving you a "clear view" to the left atria
Why are PAOP measurements unreliable in zone 1? pulmonary capillaries are consistently compressed by alveoli in this area of the lung, so no "view" to the left atria
Why are PAOP measurements unreliable in zone 2? though pulmonary capillaries are open during systole, they are compressed by alveoli during diastole; again, not a clear, consistent "view" to the atria
What conditions or situations would cause PAOP to be greater than LVEDP, and is therefore not a reliable indicator of LA pressure / LV function? tachycardia > 130, PEEP, catheter tip in zone 1 or 2, COPD, pulmonary venoocclusive disease, mitral regurgitation, mitral stenosis
What would cause increased PA diastolic pressure (4 - 5 mmHg higher than PAOP), but not cause increased PAOP? increased PVR, hypoxemia, pulmonary embolism, acidosis and pulmonary vascular disease
pulmonary embolism, pulmonary HTN, and right ventricular failure will give normal or abnormal PAOP values? Normal PAOP
How would restrictive cardiomyopathy, cardiac tamponade, and left ventricular failure affect PAOP values? Higher than normal PAOP values
How would hypovolemia affect PAOP values? lower than normal PAOP values
What is over wedging? balloon hyperinflation or prolonged inflation that results in false elevation in PAOP values r/t build up of intracatheter pressure
Massive mitral regurgitation creates large ________ to appear which distort PAOP waveform V waves
Massive mitral regurgitation also causes the PA wave to be _________ notched
What is the distance to the junction of the vena cava and right atrium from the right IJ insertion site? 15 cm
What is the distance to the junction of the vena cava and right atrium from the femoral vein site? 40 cm
What is the distance to the junction of the vena cava and right atrium from the left IJ insertion site? 20 cm
What are 5 complications associated with the insertion of a CVL? vascular structure injury (CA most common), pleura injury, nerve bundle injury, lymphatic system injury, rare spinal canal injury
What are the advantages of using the right IJ for CVL access? easily identifiable landmarks, straight shot to SVC, easily accessible at pt's head, high success rate, bleeding easily recognized and controlled, reduced risk of pneumo
What are the disadvantages of using the right IJ for CVL access? increased risk of infection, increased risk of unintentional CA puncture, unable to access if pt in cervical collar
What are the landmarks for identifying the right IJ? two heads of sternocleidomastoid muscle; IJ found in groove between two heads
How should the patient be positioned for insertion of a right IJ? supine, mild trendelenberg, head turned slightly left (< 40 degrees)
If the patient's head is turned at an angle > 40 degrees when attempting to place a right IJ CVL, what will happen? the IJ overlaps with the carotid artery
What are the advantages of using the left IJ for CVL placement? easily identifiable landmarks, easily accessible at patient's head, bleeding easily recognized and controlled controlled
What are the disadvantages of using the left IJ for CVL placement? greater risk for pneumo, thoracic duct enters at junction of left IJ and subclavian, smaller vessel with more overlap of carotid, worse angles for catheter to travel = more vascular injuries
What are the advantages of using the subclavian vein for CVL placement? infection risks reduced, good for C-collar patients, patient comfort, larger vessel doesn't risk collapse
What are the disadvantages of using the subclavian vein for CVL placement? increased risk of pneumo, more difficult landmarks in obese, less assessable, more difficult to identify bleeding
What type of transducer does a CRNA use for placement of a CVL via the ultrasound guided method? linear probe with 7 - 15 mHz frequency (better view of superficial or shallow structures like veins and arteries)
When using ultrasound, why is a small angle needle preferred? more surface area for sound waves to bound off of and be displayed on screen as image
How can you tell the difference between the IJ and the carotid when using the ultrasound? IJ is compressible and will reduce in size when pressure from transducer applied; IJ is also expandable with valsalva maneuver or trendelenberg; carotid is not compressible and pulsates
The marker on the probe must always face to the ______ left
When using color flow doppler on the short axis view, how does the machine know what is red and what is blue? Blue = away; Red = toward
When using ultrasound to identify the IJ, how should you orient your probe so that the color flow will be correct? with the marker to the left, orient the probe caudad (down) so that the blood flowing away from the probe is colored blue (vein) and the blood flowing toward the probe is colored red (artery)
When using the ultrasound to view the advancement of the needle into the IJ, you swap the probe to the long axis. Where should the marker be facing? up; this ensures that the movement of the needle on the screen reflects the movement of the needle in the actual patient
Created by: Mary Beth