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Monitoring/CVL/PAC

Principles (Test 3)

QuestionAnswer
Hypernatremia is Na+ >______. >145
Hypernatremia is usually related to a _________ total body water. low
What are some s/s of hypernatremia? CNS changes, mental status changes, irritability, hyperreflexia, ataxia, seizures, hypotension after induction
What are some treatments for hypernatremia? monitor volume status (CVP), replace free water (calculate H2O deficit), may need vasopressors and/or inotrops if hypovolemic, may need to adjust drug dosing (dec. vol. of dist.)
Hyponatremia is Na+ <________. <135
Hyponatremia is usually related to a _______ total body water. high
Which is more common: hyper or hyponatremia? hyponatremia
What are some s/s of hyponatremia? CNS changes, lethargy, cramps, decreased reflexes, seizures, Na+<120 associated with 50% mortality rate
What are some treatments for hyponatremia? monitor volume status (CVP), if in heart failure may need inotropic support, loop diuretics (to inc. free water excretion), avoid free water, treat acute symptoms with hypertonic saline (3% NaCl --> approx. 0.5-2mEq/L/hr
For hyponatremic patients, too rapid a correction with hypertonic saline may lead to .... demyelination of pontine neurons and a condition known as central pontine myelinolysis
Hyperkalemia is K+ >_______. >5.5
What are some causes of hyperkalemia? ESRD (cells release K when destroyed), hemolysis, DKA, drugs
What are some s/s of K+ >6.0? prolonged PR, peaked T waves; probs w/ electrical conduction system of the heart
What are some things to avoid for pts with hyperkalemia? avoid hypoventilation and high ETCO2/acidosis (for every 10mmHg change in ETCO2 the K changes 0.5mEq), avoid succinylcholine (intubating dose inc. K by 0.5mEq)
What are some treatments for hyperkalemia? hyperventilation, Lasix, D10+insulin (glucose drives K+ into cells)
Hypokalemia is K+ <______. <3.5
What are some causes of hypokalemia? diuretics, N/V, GI losses, hyperventilation/alkalosis
What are some s/s of hypokalemia? muscle weakness, cramps, PVCs, U waves, flattened T waves, low ST segment, digoxin toxicity
What are some treatments for hypokalemia? K+ replacement 20mEq KCl over 30-45 min
What are some things to avoid in pts with hypokalemia? hyperventilation/low ETCO2, NMB (watch for prolonged muscle relaxation), glucose-containing fluids
What is the normal range for serum calcium? (*extra) 8.5-10.2
What are some causes of hypercalcemia? hyperparathyroidism, cancer (esp. breast)
What are some s/s of hypercalcemia? N/V, dec. deep tendon reflexes (monitor reflexes w/ nerve stimulator), hypotonia, confusion, lethargy
What are some treatments for hypercalcemia? loop diuretics
What should you avoid in pts with hypercalcemia? thiazide diuretics (inc. calcium reabsorption)
What are some causes of hypocalcemia? dec. parathyroid hormone, dec. Mag, alkalosis (inc. pH causes Ca+ to bind to protein), massive blood tx (citrate binds Ca+), pancreatitis
What are some s/s of hypocalcemia? tetany, twitching, laryngospasm, tingling lips and fingers, spontaneous action potentials are generated
What are some treaments for hypocalcemia? IV replacement
What should you avoid in pts with hypocalcemia? hyperventilation, alkalosis
What are some causes of hypomagnesemia? poor GI absorption, dialysis, ETOH
What are some s/s of hypomagnesemia? dysrhythmias, ventricular muscle twitching/tetany
What should you avoid in pts with hypomagnesemia? diuretics (Mag follows Na), NMB
True or False: Magnesium helps treat and correct refractory hypokalemia and hypocalcemia True
What are some causes of hyermagnesemia? (RARE) infusions for preeclampsia, and pheo
What are some s/s of hypermagnesemia? lethargy, loss of deep tendon reflexes, paralysis, hypotension, heart block
What are some treatments for hypermagnesemia? temporary dialysis, loop diuretics
What are some things to avoid in pts w/ hypermagnesemia? NMB, acidosis (worsens effects)
(Obstructive or Restrictive?) pulmonary disease is more amendable to treatments? obstructive: volatile agents, etc used for bronchodilation treat obstructive dis., but not restrictive
What is FEV1 during PFT? volume forcefully exhaled in one second
What is FVC during PFT? total volume that can be forcefully exhaled (forced vital capacity)
If the FEV1/FVC ratio is <0.7, the patient is likely to have ____________ pulmonary dis. obstructive
If the FEV1/FVC ratio is 0.6-0.7, what is the severity of obstructive dis? mild
If the FEV1/FVC ratio is 0.4-0.6, that is the severity of obstructive dis? moderate
If the FEV1/FVC ratio is <0.4, what is the severity of obstructive dis? severe
If the FEV1/FVC ratio is >0.7, the patient is likely to have _______________ pulmonary dis. restrictive
How do you calculate ejection fraction? stroke volume/end diastolic volume
What is a typical ejection fraction? ~58 (SV=70/LVEDV=120)
What is an indicator of balance between oxygen delivery and consumption? SVO2
What is a normal range for SVO2? 68-80%
What is normal O2 consumption/extraction? 25%
What does American Society of Echocardiology consider a normal EF? 55% or greater
What does American Society of Echocardiology consider an EF for mild systolic dysfunction? 45-54%
What does American Society of Echocardiology consider an EF for moderate systolic dysfunction? 30-44%
What does American Society of Echocardiology consider an EF for severe systolic dysfunction? <30%
What are the 4 primary factors affecting SVO2? oxygen consumption (VO2), hemoglobin level(Hgb), cardiac output (CO), arterial oxygen saturation(SaO2)
SVO2 <30% usually indicates what kind of metabolism? anaerobic
How does the body compensate for an inc. in VO2? increasing CO
Of the SVO2 factors, SVO2 varies directly with ____________, and inversely with ______________. directly=hgb, CO, and SaO2; inversely=VO2
What can cause an increase in VO2? How does it affect SVO2? fever, hyperthermia (decreases SVO2)
What can cause a decrease in Hgb? How does it affect SVO2? anemia, hemolysis (decreases SVO2)
What can cause a decreased CO? How does it affect SVO2? MI, CHF, hypovolemic states (decreases SVO2)
How does a decreased SaO2 affect SVO2? decreases SVO2
What can cause a decreased VO2? How does it affect SVO2? cyanide toxicity, carbon monoxide poisoning, hypothermia, sepsis (increases SVO2)
What can cause an increased Hgb? How does it affect SVO2? volume depletion (increases SVO2)
What can cause an increase CO? How does it affect SVO2? burns, inotropic drugs (increases SVO2)
How does an increased SaO2 affect SVO2? increases SVO2
What types of tissues use the most O2? myocardium and skeletal muscles
What type of temperature monitoring is most accurate? bladder
How does skin temperature compare to accurate core temp? 3-4 deg lower
How does axillary temp compare to accurate core temp? 1 deg lower
What is a complication of nasopharynx temp monitoring? nosebleed
What is a complication of rectal temp monitoring? rectal perforation
What is a complication of external auditory meatus temp monitoring? eardrum perforation
What is the main indicator of venous return/preload/volume? CVP
What chamber pressure does CVP read? R atrial pressure (RAP)
True or False: RAP is an indirect determinant of RV function. True
At what anatomical point is CVP measured? junction of superior vena cava and RA
What can cause false high CVP readings? positive pressure ventilation and PEEP
What is a normal CVP? 1-8mmHg
___ waves and ____ descents make up the CVP waveform. 3 waves; 2 descents
What causes the A wave? A wave=atrial contraction produces an initial spike then descent as blood leaves the atrium and fills the ventricle
What causes the C wave? C wave=closed tricuspid elevates during isovolumic ventricular contraction
What causes the X descent? downward movement of tricuspid valve during systole and atrial relaxation when the base of the heart descends
What causes the V wave? venous return against a closed tricuspid valve during systole
What causes the Y descent? opening of the tricuspid valve during diastole as atrial pressure is higher than ventricular pressure
What can cause the absence of an A wave? a-fib (b/c no atrial contraction)
What can cause a large A wave? 1) AV asynchrony (b/c atrium contracting against a closed tricuspid); 2)pulmonary HTN (b/c more pressure); 3)decreased RV compliance (b/c more pressure); 4) tricuspid stenosis
What effect on CVP waveform does A-fib have? no A wave; prominent C-V waves
What effect on CVP waveform does AV asynchrony (d/t AV dissociation, V pacing, AV nodal rhythm, etc) have? large A wave (d/t atrium contracting against a closed tricuspid valve during ventricular systole)
What effect on CVP waveform does pulmonary HTN have? large A wave (d/t more pressure)
What effect on CVP waveform does decreased RV compliance have? large A wave (d/t more pressure)
What effect on CVP waveform does tricuspid regurg. have? broad, tall systolic C-V wave. Some call it a "regurgitant V wave"
What effect on CVP waveform does tricuspid stenosis have? tall end diastolic A wave with an early diastolic Y descent
In what order on the CVP waveform do the waves and descents come? a, c, x, v, y
What effect would LV failure have on CVP? high (d/t backpressure)
What effect would RV failure have on CVP? high (d/t backpressure)
What effect would pulmonary HTN have on CVP? high
What effect would hypovolemia have on CVP? low (dec. volume, dec. preload)
What effect would cardiac tamponade have on CVP? high
What effect would pulmonary embolism have on CVP? high
How does the CVP waveform correspond to the EKG? C wave comes at about same time as R wave on EKG (ventricular systole)
What are the 2 most important measures from a PA catheter? 1) cardiac output, 2) PAOP
What are 4 contraindications for PA catheter insertion? 1)coagulopathy, 2)thrombolytic treatment, 3)prosthetic heart valve, 4) endocardial pacemaker
What are some complications of PA catheter insertion? dysrhythmias (PVC's/RBBB), catheter knotting (in chordae tendinae or pacer wires), thromboembolism, pulmonary infarction, infection, valvular damage, pulmonary vascular injury, blood in ETT (should be addressed immediately)
At what point during insertion do you inflate the PAC balloon? when tip enters central circulation (~20cm)
Watching your PA pressures, at what point do you quit advancing the catheter? when waveform dampens and value is lower than PADP
What does PAOP measure? back pressure (LV preload) from the pulmonary venous system; gives a more accurate estimation of LAP, and therefore LV preload than CVP; estimated LVEDP
What is a normal PAOP? 8-12mmHg
In supine position, the PAC tip needs to be in lung zone ____ where a continuous full column of blood resides. 3
Describe lung zone 1. uppermost part of the lung; pulm capillaries are consistently compressed by alveoli and no blood flow occurs (no visible a and v waves); tip in zone 1 only shows alveolar pressures
Describe lung zone 2. upper third part of lung; pulmonary capillaries are open in systole and compressed by alveoli in diastole. PAC tip in zone 2 records true PA sys. pressure but PA diastolic and PWP are meaningless
What can lead to more lung areas becoming lung zones 1 or 2? PEEP or hypovolemia
Describe lung zone 3. most dependent part of lung (lower two thirds). Pulmonary capillaries are consistently patent. PA systolic and PA diastolic and PWP are valid. In supine position, most of the lung is in zone 3, and most PACs are advanced to and wedge in zone 3
How does tachycardia >130bpm affect the comparison of PAOP and LVEDP? PAOP>LVEDP (tachycardia reduces preload)
How does PEEP affect the comparison of PAOP and LVEDP? PAOP>LVEDP (5cmH2O of PEEP inc. PAOP by 1mmHg)
How does catheter tip in zone 1 or 2 affect the comparison of PAOP and LVEDP? PAOP>LVEDP (inc. pulmonary venous congestion)
How does COPD affect the comparison of PAOP and LVEDP? PAOP>LVEDP (inc. pulmonary venous congestion)
How does pulmonary venoocclusive disease affect the comparison of PAOP and LVEDP? PAOP>LVEDP
How does mitral regurg and mitral stenosis affect the comparison of PAOP and LVEDP? PAOP>LVEDP
Normally, PAP diastolic is _______ mmHg>PAOP. 1-4mmHg
If PA diastolic climbs 4-5mmHg>PAOP, it indicates a _______________. increase in pulmonary vascular resistance
What can cause an increase in PVR and therefore an increase in PA diastolic? hypoxemia, pulmonary embolism, acidosis, pulmonary vascular dis.
True or False: The greater the increase in PVR, the greater the difference between PA diastolic and PAOP. True
How does an increase in PVR affect PA systolic, PA diastolic, and PAOP? increases PA systolic and diastolic, but does not increase PAOP
How does a pulmonary embolism affect PAOP? none
How does restrictive cardiomyopathy affect PAOP? increases PAOP
How does cardiac tamponade affect PAOP? increases PAOP
How does RV failure affect PAOP? none
How does LV failure affect PAOP? increases PAOP
How does hypovolemia affect PAOP? decreases PAOP
What are some things that can skew PAOP values? balloon hyperinflation or prolonged inflation (false high), build up of intracatheter pressure from high pressure flush system, no a wave and v wave, slow progressive rise in wave then falls and rises again, values yielded are unusable
What can cause large v waves on the PAP waveform? massive mitral regurg
What is the most preferred site for a CVL? RIJ
What is the CVL site most preferred for long term use? subclavian vein
What length CVL should be used for insertion in the subclavian vein? 10cm
What length CVL should be used for insertion in the RIJ? 15cm
What length CVL should be used for insertion in the LIJ? 20cm
What length CVL should be used for insertion in the femoral vein? 40cm
What length CVL should be used for insertion in the R median basilic vein? 40cm
What length CVL should be used for insertion in the L median basilic vein? 50cm
What are 5 major CVL insertion complications? 1) vascular structure injury (carotid most common), 2)pleura injury, 3)nerve bundle injury, 4)lymphatic system injury, 5)rare spinal canal injury
What are some advantages to RIJ CVL insertion? easily identifiable landmarks, straight course to SCV, easily accessible at patient's head, high success rate (91-99%), bleeding easily recognized and controlled, reduced risk of pneumothorax
What are some disadvantages to RIJ CVL insertion? increased risk of infection (slobber), increased risk of unintentional carotid artery puncture, unable to access if patient is in cervical collar
What are the landmarks for RIJ CVL insertion? 2 heads of sternocleidomastoid and clavicle (base of triangle)
Where is the IJ found in relation to landmarks? in the groove between the 2 heads of sternocleidomastoid
How should the patient be positioned for RIJ CVL insertion? supine, mild trendelenburg, head turned slightly left
Why should you not turn pt's head more than 40deg to left when inserting RIJ CVL? >40deg can cause IJ to overlap w/ internal carotid
How do you use the carotid to help you with CVL insertion? palpate IC with L hand, IJ is lateral and anterior to IC
How do you insert the seeker needle? (22-23 gauge seeker needle); at apex of triangle, at 30deg angle toward ipsilateral nipple
What are some disadvantages to LIJ CVL site? greater risk of pneumo (pleura is higher), thoracic duct enters venous system at junction of LIJ and subclavian, smaller vessel then RIJ, catheter must traverse the innominate and enter the SVC more perpendicular leading to more vascular injuries
What are some advantages to SC CVL site? reduced risk of infection, cervical instability (c-collar patients), patient comfort, larger vessel doesn't risk collapse
What are some disadvantages to SC CVL site? increased risk of pneumo, more difficult landmarks in obese, less accessible, more difficult to ID bleeding (under drapes)
Where is seeker needle inserted for SC CVL insertion? 2-3cm caudad to mid-clavicular point
What are some advantages to EJ CVL site? closer to surface, more easily identified, preferred with patient with coagulopathy, less risk of IC puncture
What are some disadvantages to EJ CVL site? smaller vessel, more difficult to advance catheter, can be more easily kinked
What is another term for the "short axis" of the US view? transverse plane
What is another term for the "long axis" of the US view? longitudinal plane
What frequency US probe will we use to insert CVL? 7-15 mHz (high frequency)
What are 2 advantages to a higher frequency US probe? superficial structure depth, crisp, sharper images
What is the frequency of a "low" frequency US probe? 2-5 mHz
What is an advantage of the low frequency US probe? deeper structure depth
Define reflection. waves bounce and return to US probe for processing
Define refraction. waves bounce away from probe
What type of needle reflects US very well? echogenic
What are 2 ways to distinguish the IC from the IJ? compressibility (IJ decreases in size when transducer pressure applied); expandable (IJ will increase in size with valsalva maneuver or trendelenburg position)
US flow: blue=?, red=? blue=aware, red=toward
For IJ CVL insertion, you want the US probe oriented (cephalad or caudad?) caudad
You always want the US probe maker facing (right or left?) left