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ANPH 233

Advanced Cardio

QuestionAnswer
3 ways to maximize ventricular performance? Alter pre load, after load and contractility
How does increasing pre load volume affect PVR/SVR ? Decreases PVR/SVR AND Heart rate
How do we decreases pre load volume? Use of diuretics OR reduction of intravascular volume
What are two methods of altering ventricular afterload? Vasodilator therapy & Vasopressor therapy
When would we use vasodilator therapy? When SVR/PVR is HIGH
What is the result of vasodilator therapy? Decreased SVR/PVR, decreased afterload AND decreased preload !
The result of stimulation of vasopressors on alpha receptors is: peripheral vasoconstriction
When do we use vasopressor therapy? When SVR/PVR is LOW
What is the result of vasopressor therapy? INCREASED afterload, Increased SVR/PVR and increased preload
What are two ways we can alter Contractility? With a positive inotrope or a negative inotrope
A Positive Inotrope ___________ the force of myocardial contractility in order to ___________ cardiac output increases, increase (improve)
4 examples of Positive inotrope Dopamine, Dobutamine, Epinephrine & milrinone
What does a negative inotrope do? Decreases force of myocardial contractility and O2 requirements of the heart
Examples of negative inotropes beta blockers & calcium channel blockers
Factors(conditions) which can cause increased PVR: hypoxemia, acidosis, PPV/PEEP & vasoconstrictors
Factors which can decrease PVR: Oxygen, Nitrogen, Alkalosis & vasodilators
Factors (conditions) which INCREASE SVR? hypovolemia (aka compensatory vasoconstriction), certain shocks & vasoconstrictive drugs
Factors which DECREASE SVR? Vasodilators, morphine, certain shocks
Normal values for CVP? 2 - 6 mmHg
Normal values for RAP? 2 - 6 mmHg
Normal values for RVP? 20-30 / 0-5 mmHg
Normal values for PAP? 15-25 / 8-15
Normal values for MPAP? 10-20 mmHg
Normal values for PCWP? 5-12 mmHg
Normal values for PP? 30-50 mmHg
Normal values for MAP? 85-115 mmHg
Normal values for PVR? 155 - 255 dynes*sec/cm5
Normal values for SVR? 950 - 1300 dynes*sec/cm5
Normal EF 50 - 60%
Normal EDV? 120-180 mL
How do we increase preload volume? Infusion of I.V. Fluids
What are the indications for PAC? severe cardiogenic pulm. edema, non cardiogenic pulmo. edema (ARDS), major thoracic surgery (CABG) & Septic or cardiogenic shock
Complications of a PAC: 1. Same as CVP (pain, bleeding, infection etc.) 2.Irritation to heart (causing dysrhythmia) 3.Perforation of heart or pulm. artery 4.Pulmonary rupture from overfilling balloon
What do PAC's measure? CVP, PAP, PAWP/PCWP/PAOP, PVR, SVR & C.O.
What are the uses of a PAC? Measure cardiac output(thermodilution), route for mixed venous sampling, administration of drugs and pacing
How many lumens do PAC catheters have? 4-6
Which part of a PAC measures cardiac output The Thermistor Lumen
Which part of the PAC rests in the right atrium (for CVP measurement)? Proximal Lumen
Where does the distal lumen rest? In the pulmonary artery
Which lumen measures the PAP, PCWP and obtains mixed venous samples? Why this lumen? The distal lumen, because it is in the pulmonary artery
When inserting a PAC, when do we inflate the balloon? As it enters the right atrium
When inserting a PAC, how do we know we're in the right atrium? Pressure should read 2-6 mmHg ( CVP)
When will the CVP wave form appear, during a PAC insertion? Once the tip reaches the vena cava
How do we know when the catheter is in the right ventricle? There will be a huge pressure change/ increased wave form - and the downstroke will still come back down to zero
How do we know when we are in the pulmonary artery w/ a PAC ? Pressures increase by 6-15 mmHg and the down stoke DOES NOT come back down to zero
Once in the pulmonary artery, what does the dicrotic notch on the wave form represent? Pulmonic valve closure
When in wedge position, what pressure is being measured? The back pressure from the left ATRIUM
It takes ___________ cc's to wedge a balloon. 0.8 - 1.5 cc's
When do PAP's increasE? When PVR increases and when pulmonary blood flow increases
What pressures does PA diastolic reflect? Left atrial pressure, pulmonary venous and left VEDP
What pressure measures left ventricular filling? (Preload) PCWP
Describe optimal PCWP The pressure at which any increase shows little or no improvement in C.O. or stroke volume
Under what conditions does the PCWP reflect the LEFT ATRIAL pressure? blood flow must be uninterupted b/w the catheter tip and the let heart. this ONLY OCCURS IN ZONE 3
Which part of the breathing cycle should we measure PCWP? end expiration
What is a complication of PCWP measurements during PPV? The PCWP can be OVER ESTIMATED, b/c of transmission of pos. press. to the catheter
PCWP should be measured when pleural pressure is ___________ zero/close to zero
How does negative pressure affect the heart? It INCREASES venous return AND preload !
What can cause increased PCWP? Left ventricular failure, hypervolemia, Mitral valve stenosis, and technical causes
What would be seen on an x ray w/ a PCWP > 18 mmHg? onset of pulmonary vascular congestion
What would be seen on an x ray w/ a PCWP > 25 mmHg? Obvious pulmonary edema
What can causes decreased PCWP? Hypovolemia (blood loss) or shock !
What 3 things do CVP and PCWP BOTH reflect? Vascular volume, vascular volume to venous tone relationship, & ability of ventricles to pump blood.
What is normal JVD? < 3 cm above sternal angle
When do we use a CVP? To assess circulating blood volume & assess right Ventricular function
Possible routes of access for a CVP? Jugular vein or subclavian vein, Femoral is rare!
Which CVP insertion site has a more serious risk for a pneumo? Subclavian
Risks and Complications of a CVP? Infection, bleeding, pain, air embolism, thrombus & pneumo
What does the a wave represent on a CVP and atrial waveform? Atrial contraction ( and it follows the P wave)
What does the x descent represent on a CVP and atrial waveform? Fall in right atrial pressure as the atria relax and the ventricles fill
What does the c wave represent on a CVP and atrial waveform? Closure of the AV valve (ventricular systole)
What does the v wave represent on a CVP and atrial waveform? The filling of the atrium DURING ventricular systole ( AV valves are closed)
What does the down slope of the v wave represent on a CVP and atrial waveform? Fall in atrial pressure when AV valve opens and fills the ventricle!
Created by: emilygordon