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Life Support # 3
Direct Pressure Monitoring
| Question | Answer |
|---|---|
| What 2 types of catheters are inserted into central veins for direct pressure monitoring of central circulation? | Central venous catheter(CVP), and Pulmonary artery cath (BTFDC) |
| What is BTFDC? | Balloon tipped flow directed catheter |
| Central venous catheters have how many lumens? | they can have single, double or triple lumens |
| Central venous catheters sit at what junction in the body? | at the SVC and RA junction |
| What are the indications for central venous caths? | RAP monitoring, drug/fluid/nutrition/electrolyte infusion, blood and blood product admin, phlebotomy access, and lack of accessible veins |
| What can cause a lack of accessible veins? | trauma, sclerosis, thrombosis, or inflamed peripheral veins |
| The site of insertion for a CVC is dependent upon what? | physician preference, regional trauma, or burns |
| Specific circumstances of insertion sites are? | anticoagulation, coagulation abnormalities, presence of lung hyperinflation secondary to airway obstruction |
| What are the 3 main insertion sites for a CVC? | internal jugular, subclavian, and femoral veins |
| What are the advantages of inserting a CVC into the subclavian vein? | easy to access, maintain sterility and intact dressing, unrestricted movement and less likely to develop thrombus d/t rapid venous blood flow |
| What are the disadvantages of subclavian central venous access? | Risks of air emboli, pneumothorax, hemothorax, nerve injury, tracheal puncture, ETT cuff puncture and puncture or laceration of subclavian artery |
| Advantages of Internal jugular central venous access | short, direct pathway; reliable site, unlikely to be displaced, less likely to develop thrombus d/t rapid blood flow, and lower risk of art puncture and pneumo than subclavian site |
| Disadvantages of Internal jugular central venous access | risk of air emboli, puncture of common carotid artery, pneumothorax (more common in left), and thoracic duct injury (left IJ only) |
| Advantages of femoral vein central venous access | readily accessible, familiar site (used for central access longer than any other site), greater ease of insertion, no risk of pneumo and minimal risk of air emboli |
| Disadvantages of femoral central venous access | inadvertent cannulation of smaller veins, increased risk of infection, difficult to maintain intact dressing, difficult to locate in obese patients, high risk of thrombus and PE, and difficulty immobilizing |
| What is a PICC line? | peripherally inserted central catheter used for long periods of time |
| What are PICC lines used for? | ABT regimen, chemotherapy |
| 5 Complications of PICC lines | catheter occlusion, phlebitis, infection, hemorrhage, and thrombus |
| What is the main reason for a Pulmonary Artery Cath? | measure PA pressure |
| What is a Swan-Ganz or BTFDC? | multi lumen catheter inserted through central vein and passively directed into a brach of the PA |
| The PAC is __-__cm in length | 60-110cm |
| The PAC is marked in __cm increments | 10cm |
| A PAC, Swan-Ganz or BTFDC usually has how many lumens/ports? | 5 |
| What are the 5 ports of the PAC? | Proximal infusion port, Proximal injectate port, Distal port, Balloon inflation port and Thermistor connector |
| The proximal injectate and infusion ports open to a lumen that terminates how far from the tip? | 30cm |
| The opening of the lumen for the injectate and infusion ports lies where within the body? | RA when the tip is in the PA |
| What pressure can you measure through the proximal ports? | RAP(CVP) |
| What can you administer through the proximal ports of the PAC? | medications, fluid, electrolytes, blood and blood products |
| What can you take samples of therough the proximal ports of a PAC? | RA blood |
| This opening of the proximal ports inside the RA receive the injectable solution for what measurement? | CO |
| What does the distal port of the PAC open to? | a lumen that runs the length of the catheter abd ebds at the cath tip |
| What pressures can you measure at the opening of the distal port within the body? | PAP and PCWP (upon inflation of the balloon) |
| The distal port samples what type of blood? | mixed venous |
| What cant you use the distal port of a PAC for and why? | admin of meds d/t PA segment rupture, vascular and tissue reaction and damage |
| What is the thermistor? | temp sensitive wire that terminates 4-6cm from tip of PAC and measures core temp |
| What does the thermistor allow for determination of and how? | CO using thermodilution technique |
| Describe thermodilution technique | Inject 10cc of solution less than body temp into proximal port then measure the magnitude of temp change over time to predict CO |
| An average of __ injections that produce a CO of no more than __% difference | 3 injections; < 10% diff |
| When do you Inflate the balloon on a Pulm Artery Cath? | for insertion from RA-PA and to measure the PCWP |
| What is the safety feature on the balloon inflation port? | special syringe to only allow 1.5cc air and port lock to prevent inadvertent inflation |
| Overinflation of the ballon on a PAC can cause what 3 things? | PA segment rupture, balloon herniation over cath tip resulting in erroneous pressure reading, and balloon rupture |
| What does it indicate if you have a PCWP wave w/o inflation of the balloon and how do you fix it | cath too far into PA segment, withdraw until PAP appears |
| What does it mean if you don't get a PCWP with inflation and how do you fix it | cath not in far enough or balloon not intact, floar cath or advance in unless rupture suspected |
| How does CCO work | thermal filament warms surrounding blood causing a washout curve, the area under curve is proportional to CO |
| How does a PAC help assess pulmonary status | It allows you to see changes in PASP/PADP to assess for COPD, ARDS, Pulm Htn, Pulm emboli, Pulm edema |
| PAC indications for use | Peripoperative monitor, fluid and drug admin, lack of peripheral veins, emergency placement of transvenous pacemaker |
| Large veins used for PAC allow what to occur that doesnt in peripheral veins | dilution of caustic or hypertonic soultions (KCL, Levophend, hyperalimentation, Chemo) |
| What type of heart block called for emergency placement of transvenous pacemaker thru PAC | third degree |
| Contraindications for PAC use | severe coagulation defects, Prosthetic right heart valve, pacemaker, severe peripheral vascular disease, high pneumo risk, and pulm htn |
| What causes a high rick of pneumothorax to happen on PAC insertion | increased PEEP, emphysema, air-trapping and subclavian insertion |
| What happens during Pulmonary Htn that makes it a contraindicaiton for PAC | PA is distended causing an increased risk of rupture |
| What port is located at the 30cm mark and what does it do | proximal port in RA, monitors fluid volume status, CVP/RAP/ Preload of RV, estimates venous return, intravascular volume |
| What 5 problems can we monitor for/ or progression of with the proximal port | trauma, burns, hypovolemia, sepsis, renal failure |
| CVP estimates ______ and cannot be used as an estimate in what disorders | RVEDP; tricuspid valve disorders |
| Formula for PVR and normals | PVR=(MPAP-PCWP)/CO x 80 Norms: 20-120 dynes/sec/cm-5 |
| Formula for SVR and Normal range | SVP=(MAP-CVP)/CO x80 Norm:770-1500 dynes/sec/cm-5 |
| PVR is an indications of what | RV afterload and myocardial work |
| CVP=RVEDP= Formula | RVEDP= (LVEDP-2mmHg)/2 |
| LEVDP formula | (RVEDPx2)+2 |
| How do you assess and treat for hemorrhage from PAC | oozing at site, bruising, swelling treat with pressure and decrease number of attempts |
| What is the most common bacteria for nosocomial infection of PAC | Staph aureus |
| How do you assess and treat for nosocomial infection of PAC | fever, redness, swelling, increased WBC, treat with proper sterile/aseptic technique, keep dressing and line dry, ABT and culture tip |
| How do you assess for and treat a pneumothorax d/t PAC | dyspnea, elevated HR and RR, decreased BP and SpO2, increased PIP, decreased Vt and BS, treat with chest tube |
| How can a PAC cause arrhythmia and how do you assess and treat | irritation of endocardium d/t migration into RV or during insertion. assess:presusre tracing, ecg, loc. Treat:reposition PAC, and antiarrythmics |
| What can cause a thromboembolism to form?# | kinks in PAC tubing and decreased pressuree in bag |
| Assess and treat for thromboembolism | chest pain, dyspnea, tachy, dampened waveform, poor med infusion, inability to aspirate from port. Trea:heparin therapy, removal of cath |
| How can you prevent a thromboembolism if port not used for continuous med infusion | aspirate and flush port QS |
| What is one way to decreased risk of air embolism during PAC insertions | place pt in trendelenburg |
| AIr embolism treatment | place pt left side down to prevent air from moving into pulm circulation, aspirate air from RA into cath, PPV 100% hyperbaric to enhance air reabsorption |
| How do you assess for balloon rupture | absence of normal resistance felt during inflation, blood in balloon lumer, failure to wedge, syringe does not fill with air when released |
| Tx for balloon rupture | label cath port, notify MD and use PADP to estimate PCWP |
| Where is knotting or looping most likely to occur | RV |
| What causes knotting or looping of PAC | repeated advances and withdraws, dilated cardiac chambers, excessively long cath |
| Assess for knotting or looping | ventricular arrythmias, dampened waveform, PA distal reads CVP wave, difficulty aspirating or flushing, CXR |
| Treatment for knotting or looping PAC | undo under fluoroscopy, surgical removal |
| What causes Rupture of PA segment | advancing PAC with balloon deflaated, rapid or forceful ballon inflation, spontaneous migration of cath |
| How do you assess for and treat PA segment rupture | hemoptysis(blood in ETT), treat by pulling cath back, control airway, O2, place effected side down to prevent blood from entering other lung, PEEP to compress hemorrhage and surgery |
| What can cause pulmonary infarct or ischemic injury in relation to PAC | PA occlusion by clot or persistently wedged cath |
| What is the RT job when assisting physician with insertion of PAC | set up bag, zero, check ports, inflate balloon, deflate balloon |
| Describe the Seldinger technique | constant, negative pressure on syringe so that a flash of blood will be observed upon vein entry. |
| After entrance into the vein and intravenous position of needle confirmed what happens | a guide wire is passed thru needle and threaded to a distance of no more than 20cm |
| MPAP formula and normal value | MPAP=[(PADPx2)+PASP]/3 norm:10-15mmHg |
| Cardiac index formula and norm | CI=(CO/BSA) Norm: 2.5-4.2 LPM/m2 |
| 4 things to remember when measuring hemodynamic pressures with PAC | HOB no greater than 30 degrees, remain consistent, level and zero QS, and measure at end-exhalation |
| CVP measureswhat 3 things | intravascular volume, venous return and RV preload |
| CVP reflects ____ in the absence of ___ ____ disorders | RVEDP; Tricuspid valve disorders |
| PAC waveform: This wave indicates late ventricular diastole, RA contraction; atrial kick; and occurs after P wave | A |
| PAC waveform: This indicates waveform descent; atrial relaxation | X wave |
| __ wave= small crest that distorts descent; upward bulging of the AV valves during early systole | C wave |
| Whay is the C wave not usually visibile? | due to damping |
| __wave= atrila filling during ventricular systole; occurs after QRS | V wave |
| __ wave= atrium emptying; filling ventricle with pressure gradient | Y wave |
| What causes increased CVP? | fluid overload, RV failure, Right sided valve disorders, cardiac tamponade/ effusion, and Obstructive RA tumor |
| What causes decreased CVP? | hypovolemia and shock |
| What test can you perform to determine true volume status in response to fluid therapy? | fluid challenge |
| Fluid challege = ___-___ml bolus | 300-500 |
| CVP response to fluid challene in normovolemic patient is | CVP increased 2-4mmHg and returns to baseline within 10-15 mins |
| CVP response to fluid challenge in hypervolemic patient | cvp rapidly increases but does not return to baseline within 10 mins |
| CVP response to fluid challene in hypovolemic patient | CVP fails to increase |
| This pressure is normally only measured on insertion of PAC | RVP |
| What does the RVP waveform look like? | no dicrotic notch, lg ventricular wave, sharply contrasted to small RA waveform |
| What is the anacrotic rise | early systol, inotropic component |
| What is the anacrotic nothc? | volume displacement curve= indicator of SV; mid systole |
| Waht is the sloping descent? | late systole, diastole |
| What is the dicrotic nothc? | end systole, begin diastol, closure of aortic valve |
| What causes increased PAP? | lung dysfunction, LH failure, hypervolemia |
| PCWP is an indication of what? | LV preload/ LVEDP |
| PCWP>18= | pulmonary vascular congestion |
| PCWP>30= | pulmonary edema |
| When can PADP be used as an estimate of PCWP? | in the absence of pulmonary disease and with a normal PVR |
| When is the balloon inflated to measure PCWP? | exhalation |
| Wha causes increased PCWP? | LH failure, intravascular volume overlaod, cardiac tamponade/effusion, Obstructive LA tumor |
| Anytime PADP is higher than PCWP it indicates what? | increased PVR |
| High PCWP with normal PADP= | LV problem not yet affecting lungs |
| High PCWP and PADP= | LV causing lung dysfunction |
| High PADP with normal PCPW= | lung dysfunction |
| A wide PADP, PCWP gradient = | lung dysfunction and increased SVR |
| Where do you get mixed venous blood sample? | Distal port of PAC |
| Normal Mixed venous Blood gas is | 7.3-7.4/41-50/40/65-75% |
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