Hemodynamic Monitoring

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Author:
Merrittk
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223240
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Hemodynamic Monitoring
Updated:
2013-06-11 17:51:08
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BC CRNA
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NU494
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  1. True or False: PA Line's have reduced mortality and morbidity. (Explain your answer)
    False. PA Catheter's are NOT a therapeutic intervention, but can guide therapeutic interventions.

    There is research stating that experienced practitioners can misinterpret waveforms- causing the PA line to be more harmful than helpful.
  2. What is the range and mean of the pressure when the PA Catheter is in the Right Atrium?
    • Range: 1-10 mmHg
    • Mean: 5 mmHg
  3. What is the range and mean of the pressure when the PA catheter is in the Right Ventricle (Systolic/Diastolic) ?
    • Range: 15-30/0-8mmHg
    • Mean: 25/5mmHg
  4. What is the range and mean of the pressure when the PA catheter is in the Pulmonary Artery (systolic/diastolic)?
    • Range: 15-30/5-15mmHg
    • Mean: 25/10mmHg
  5. What is the range and mean of the pressure when the PA catheter is in the Pulmonary Artery (mean)?
    • Range: 10-20mmHg
    • Mean: 15mmHg
  6. What is the range and mean of the pressure when the PA catheter is in the Wedge Position?
    • Range: 5-15mmHg
    • Mean: 10mmHg
  7. What is the range and mean of the pressure when the PA catheter is representing the Left Atrial Pressure (mean)?
    • Range: 4-12mmHg
    • Mean: 8mmHg
  8. What is the range and mean of the pressure when the PA catheter is representing the Left Ventricular End Diastolic Pressure?
    • Range: 4-12mmHg
    • Mean: 8mmHg
  9. What do the waveforms look like as the PA catheter is put through the:
    a) Right Atrium 
    b) Right Ventricle
    c) Pulmonary Artery
    d) Pulmonary Artery Wedge
  10. Which of the following patients would need lines prior to induction (per Sue)?

    -Poor LV function
    -Assessment of Intravascular Volume
    -Evaluation of the response to IV fluids or vasoactive drugs
    -Valvular Heart Disease
    -Recent MI
    -ARDS
    -Massive Trauma with Blood Loss
    -Major Vascular Fluid Surgery (ie Aortic cross clamping, large fluid shifts)
    • -Poor LV function
    • -Assessment of Intravascular Volume
    • -Evaluation of the response to IV fluids or vasoactive drugs
    • -Valvular Heart Disease
    • -Recent MI
    • -ARDS
    • -Massive Trauma with Blood Loss
    • -Major Vascular Fluid Surgery (ie Aortic cross clamping, large fluid shifts)
  11. Which of the following patients could have lines placed post to induction (per Sue)?

    -Poor LV function
    -Assessment of Intravascular Volume
    -Evaluation of the response to IV fluids or vasoactive drugs
    -Valvular Heart Disease
    -Recent MI
    -ARDS
    -Massive Trauma with Blood Loss
    -Major Vascular Fluid Surgery (ie Aortic cross clamping, large fluid shifts)
    • -Poor LV function
    • -Assessment of Intravascular Volume
    • -Evaluation of the response to IV fluids or vasoactive drugs
    • -Valvular Heart Disease
    • -Recent MI
    • -ARDS
    • -Massive Trauma with Blood Loss
    • -Major Vascular Fluid Surgery (ie Aortic cross clamping, large fluid shifts)
  12. What quantifies poor LV function?
    • EF < 40%
    • Cardiac Index < 2
  13. What's important to keep in mind when deciding whether or not to place lines in a patient with massive trauma and blood loss?
    Priority is to STOP THE BLEEDING! This takes precedence over line placement.
  14. If the patient has significant comorbidities and the surgery will result in significant fluid loss, what are some other placement considerations?
    • 1. Presence of significant comorbidities (want to monitory the response to anesthesia)
    • 2. Whether surgical procedure itself will result in significant blood/fluid loss (That makes minute to minute followup essential)
  15. If the patient has significant comorbidities and the surgery will result in significant fluid loss, what are some other placement considerations?
    -Whether or not the patient needs monitoring during induction or post induction

    Timing is important due to ease and efficiency of the placement procedure- may not want to wait to place post-induction because the surgeon is ready to go, while you're fumbling under drapes to place the lines
  16. Describe the CVP trace... as in what it looks like and what each wave/dissent represents.


    • a wave: contraction of the RA
    • c wave: closure of the tricuspid valve
    • v wave: passive filling of RA
    • x dissent (not pictured- between a&c waves): start of atrial diastole
    • xI dissent (x pictured): downward pulling of septum during ventricular systole
    • y dissent: opening of tricuspid valve
  17. The CVP tracing consists of three positive waves, they are:
    a, c, and v waves
  18. The CVP tracing consists of two negative waves (dissents), they are:
    x and y dissents/depressions
  19. What tracing can be helpful when assessing intravascular fluid status?
    CVP
  20. What tracing can be helpful when assessing atrial arrythmias, R sided cardiac valve defects, cardiac tamponade, and myocardial ischemia?
    CVP
  21. If a patient is atrially fibrillating how will the CVP tracing be affected?
    The a wave will disappear since the atria don't contract you get fibrillatory waves
  22. Considering the CVP tracing, how will the tracing change in tricuspid regurgitation?
    The c/v waves will be prominent, because the tricuspid valve sort of closes but then atria fill secondary to regurgitation
  23. Considering the CVP tracing, how will the tracing change in cardiac tamponade?
    The CVP pressures will be ELEVATED and there will be a loss of Y dissent
  24. Compare the timing of the EKG and the corresponding CVP tracing.
  25. The wedge tracing is reflective of the: 
    (A) RAP
    (B) RVP
    (C) LAP
    (C) LAP
    (this multiple choice question has been scrambled)
  26. True or False: there is a greater hysteresis between the EKG and the waveform of the wedge tracing.
    TRUE. 

    Means that there is a greater distance in time between the electrical activity and the pressure waveform.
  27. In what situations would there be a loss of the  a wave or only v waves.
    • Atrial Fibrillation
    • Ventricular pacing in the setting of asystole
  28. In what situations would there be giant a waves (Cannon a waves)?
    • Junction Rhythm*
    • Complete AV Block*
    • V pacing
    • PVC's
    • V pacing
    • Tricuspid or mitral stenosis
    • Diastolic dysfunction
    • Myocardial ischemia
    • Ventricular hypertrophy

    *cause atria to contact against a closed tricuspid valve- produces large a waves (aka cannon waves)
  29. In what situations would there be large v waves?
    • Tricuspid or mitral regurgitation
    • Acute increase in intravascular volume

    -Valve defects can affect CVP and wedge tracing by increasing the amplitude of v wave with regurgitation
  30. Tricuspid regurgitation makes the CVP look like the __________ tracing.
    RV
  31. Mitral regurgitation makes the wedge tracing look like the _________ tracing.
    Pulmonary Artery
  32. If you want to flush the catheter but suspect it is in the wedge position, how do you proceed?
    DO NOT FLUSH IT!!

    -similar to effect of an overinflated balloon, can cause vascular damage (anywhere from endobronchial hemorrhage to massive hemoptysis)
  33. True or False: True PA rupture incidence is low with overinflated balloons.
    True.
  34. In tricuspid regurgitation, the v waves are super imposed on the __ waves.
    a waves
  35. In what volemic status will significant tricuspid and mitral regurgitation be associated with normal RA and wedge tracings?
    hypovolemic (and more compliant atria)
  36. True or False: There is a STRONG correlation between the size of the v wave and the degree of regurgitation.
    False.

    There is a weak correlation between the size of the v wave and the degree of regurgitation.
  37. In acute increase in preload that decreases atrial and pulmonary compliance, large ___ waves can be seen.
    large v waves can be seen
  38. If large v waves are seen, when is the best (most accurate) time to estimate preload?
    Just before the upstroke of the v wave (this moment will equate with end diastolic pressure)
  39. How many cm would you advance the PA catheter into the heart to move from the RA to the RV?
    10 cm
  40. The RV trace shows initial, brisk upstrokes representing:
    isovolumetric contraction
  41. Following RV systole, the steep down slope of the RV tracing represents:
    isovolumetric relaxation (reduced ejection)
  42. PA Catheter with the balloon inflated at the end placed in the RV can cause:
    Ventricular ectopy or a conduction block (Bundle Branch)
  43. Pressures generated during RV systole and RV diastole are assessed indirectly via the: (2 things)
    • 1. CVP port
    • 2. Distal tip of the PA catheter
  44. Why is it less common to detect a c wave on a wedge pressure tracing?
    It is less common to detect a c wave on a wedge pressure tracing because retrograde transmission of LAP (produced by closure of the mitral valve) is significantly attenuated (dampened) within the pulmonary circulation.
  45. How do you know when the PA catheter has entered the pulmonary artery (from the RV)?
    The diastolic pressure will increase acutely (with little change in the systolic P)
  46. The upstroke of the PA tracing is produced by the:
    opening of the pulmonic valve
  47. The downstroke of the PA tracing contains the:
    dichrotic notch
  48. What produces the dichrotic notch in the downstroke of the PA pressure tracing?
    the dichrotic notch is caused by sudden closure of the pulmonic valve leaflets (the beginning of diastole)
  49. The PA wedge pressure tracing is similar to what other PA line tracing?
    the CVP

    • EXCEPT: the pressure values are higher!
    • (and the waves are caused by different things- ie. a wave: produced by LA systole, c wave: closure of mitral valve, v wave: filling of the LA as well as upward displacement of the mitral valve during LV systole)
  50. Hypovolemia will do what to the CVP, PAOP, and Pulmonary Artery End Diastolic Pressure?
    • CVP: ↓
    • PAOP:↓
    • PAEDP: PAEDP=PAOP
  51. LV failure will do what to the CVP, PAOP, and Pulmonary Artery End Diastolic Pressure?
    • CVP: ↑
    • PAOP:↑
    • PAEDP: PAEDP=PAOP
  52. RV Failure will do what to the CVP, PAOP, and Pulmonary Artery End Diastolic Pressure?
    • CVP: ↑
    • PAOP: NO CHANGE
    • PAEDP: PAEDP=PAOP
  53. Pulmonary Embolism will do what to the CVP, PAOP, and Pulmonary Artery End Diastolic Pressure?
    • CVP: ↑
    • PAOP: NO CHANGE
    • PAEDP: PAEDP>PAOP
  54. Cardiac tamponade will do what to the CVP, PAOP, and Pulmonary Artery End Diastolic Pressure?
    • CVP: ↑
    • PAOP:↑
    • PAEDP: PAEDP=PAOP
  55. List causes of ↑ CVP... please :)
    • RV Failure
    • Tricuspid Stenosis/Regurgitation
    • Cardiac Tamponade
    • Constrictive Pericarditis
    • Volume Overload
    • Pulmonary Hypertension
    • LV Failure (chronic)
  56. List causes of ↑ RV Values
    • Pulmonary Hypertension
    • VSD
    • RV Failure
    • Constrictive Pericarditis
    • Tamponade
    • Pulmonary Stenosis
  57. List causes of ↑ PAP
    • LV Failure
    • Mitral Stenosis/Regurgitation
    • L-R Shunt
    • ASD or VSD
    • Volume Overload
    • Pulmonary Hypertension
    • Catheter Whip
  58. List causes of ↑ PAOP
    • LV Failure
    • Mitral Stenosis/Regurgitation
    • Cardiac Tamponade
    • Constrictive Pericarditis
    • Volume Overload
    • Ischemia
  59. What is catheter whip? What patients does it occur in?
    Catheter whip is a false high PAOP. It is a phenomenon due to excess coiling of the PA near the pulmonic valve

    Occurs in patients with dilated pulmonary arteries with pulmonary hypertension
  60. What is the most valuable PA catheter recording (per sue)?
    The wedge pressure! because it indirectly assesses LV function
  61. During what part of the respiratory cycle should mean pressure be recorded?
    end expiration

    *(whether spontaneously breathing OR on ventilator- because this is the time that pleural pressures are approximately equal to atmospheric pressures EXCEPT when PEEP is in use)
  62. When is Left Ventricular End Diastolic Pressure (preload) best measured? (as in before the upstroke of what wave)
    LVEDP best measured before upstroke of v wave
  63. What is ventricular interdependence?
    refers to the fact that there are forces transmitted from one ventricle to the other through the myocardium/pericardium that are independent of neural/humoral circulatory effects (these effects are immediate and a consequence of the closeness anatomically of ventricles- since they're encircled by the same pericardium)
  64. True or False: It is important to remember that patients who require a pulmonary artery catheter/CVP typically have several pathological processes going on that will skew values and relationships between approximations of pressure to volume.
    TRUE
  65. What pathophysiologic processes occur that cause the CVP to no longer accurately (indirectly) represent the pulmonary artery diastolic pressure?
    • change in RV compliance (pulmonic stenosis)
    • Tricuspid valvular disease
  66. What pathophysiologic processes occur that cause the pulmonary artery diatolic pressure to NO longer accurately (indirectly) represent the wedge pressure?
    • Pulmonary HTN
    • Mitral Regurgitation
    • Aortic Regurgitation
    • Lung zone I/II
    • Tachycardia
    • ARDS
    • Right Bundle Branch Block
  67. What pathophysiologic processes occur that cause the mean left arterial pressue to NO longer (indirectly) represent left ventricular end diastolic pressure?
    • Juxtacardiac pressure (PEEP)
    • Mitral Valve Disease
    • Change in LV compliance (Aortic Stenosis)
  68. What pathophysiologic processes occur that cause the left ventricular end diatolic pressure to NO longer (indirectly) represent the left ventricular end diastolic volume?
    • Juxtacardiac pressure (PEEP)
    • Ventricular Interdependence
    • Change in LV compliance (MI)
  69. What is the goal for placement of the PA Catheter (as far as what zone to have it in)? Why?
    To have the PA catheter reside in a West Zone III of the lung because the bulk of pulmonary blood flood lies within this region of the lung
  70. Lung Zones are defined:
    (a) physiologically
    (b) anatomically
    (a) Physiologically!
  71. What factors contribute to a dynamic state of Zone III?
    • Application of PEEP
    • Significant Diuresis
    • Hemorrhage
    • Change in Patient Position
  72. Normally <____% of PEEP is transmitted to the microvasculature- even if pulmonary compliance is poor (ie ARDS).
    <50%
  73. Patients with hypovolemia (CVP <5 mmHg) with PEEP can have:
    collapse of the pulmonary capillaries which distorts the wedge pressure
  74. A pulmonary artery catheter in West Zone I/II will produce what type of waveform?
    1. a waveform with marked variations in the wedge waveform during respirations
  75. What happens to the a & v waves in a tracing of a PA cath in a West Zone I/II?
    a & v waves are lost
  76. What is the relationship between the wedge pressure and Pulmonary artery diastolic pressure in a patient who's pulmonary catheter is place in West Zone I/II?
    Wedge P>PADP
  77. How will tachycardia affect wedge pressure and  left ventricular end diastolic pressure?
    An increased heart rate causes a decreased time spent in diastole. A rapid heart rate can increase PADP and decrease LVEDP which reduces the amount of blood being transported from the pulmonary circulation to the LV
  78. True or False: As the heart rate increases, the LA begins to contract against a closed mitral valve.
    True
  79. A HIGH wedge pressure can exist in patients with an elevated preload with poor ventricular compliance.

    Give examples of patients with these characteristics.
    • MI
    • LV Hypertrophy
    • Tamponade
    • Ventricular Interdependence
  80. In an open heart patient, high wedge pressures exist >___% of the time in conjunction with a low volume status.
    50% of the time

    HOWEVER... the patients respond favorably to an increase in intravascular volume despite the elevated wedge pressure
  81. In what clinical situations does PADP correlate poorly with wedge pressure?

    Give examples of when PADP>Wedge P
    • (1) PVR is increased (COPD, HPV, Pulmonary Embolism, ARDS, hypercarbia)
    • (2) Tachycardic (>130)

    (1)+(2)= PADP>wedge
  82. In what clinical situations does PADP correlate poorly with wedge pressure?

    Give examples of when PADP<Wedge P
    • (1) Severe mitral regurgitation
    • (2) West Zone III changes to Zone I/II (hypovolemia/PEEP)

    (1)+(2)= PADP<Wedge P
  83. Explain how to find cardiac output using thermodilation, including why it works :)
    Most common technique for determining CO is thermodiltion, whereby an analog computer calculates the CO by using the modified Stewart-Hamilton equation. 

    It entails the injection as a known quantity of an indicator solution (D5 in H20 or NS) through a proximal port of a thermodilution pulmonary artery catheter

    The injected solution is considered a thermal indicator because it is cold relative to body temperature. It rapidly mixes with incoming blood and is carried through the RV until it is detected by the thermistor near the end of the PA catheter.

    The computer plots a time-temperature curve with the area under the curve being inversely proportional to the CO
  84. What factors can influence the recorded values of the computation constant (during thermodilation CO calculations)?
    • Catheter Size
    • Injectate Volume
    • Temperature
    • Speed of Injection
  85. ___ is important in determining the adequacy of tissue perfusion, which is linked to maintenance of arterial blood pressure, the delivery of O2, and removal of wastes.
    CARDIAC OUTPUT!
  86. Normal CO is qualified by considering:
    • Age
    • Metabolic activity
    • Temperature
    • Patient Size
  87. Metabolic activity is ↑/↓ under anesthesia?
    Metabolic activity is  under anesthesia.
  88. Cardiac output ↑/↓ with hyperthermia?
    Cardiac output ↑ with hyperthermia.
  89. How is patient size adjusted for when calculating CO?
    By converting the CO into the CIndex!
  90. Cardiac Index adjusts for what two patient variables?
    • Height
    • Weight
  91. What is a limitation of cardiac index?
    • It does not address the lack of uniformity of predicted basal O2 consumption and metabolic rates resulting from differences in sex, age, body surface area, and blood flow
  92. What value is used to provide guidance in the use of vasoconstrictors (phenylephrine) or afterload reduction drugs (nitroglycerin, nitroprusside)?
    SVR
  93. What value is used as an estimate of Right Ventricular afterload?
    PVR
  94. What does SVR and PVR NOT account for?
    Changes in ventricular wall thickness or radius
  95. What is the formula for CO?
    Stroke Volume X Heart Rate
  96. What is the normal value for CO?
    5-6 L/min
  97. What is the formula for cardiac index?
  98. What is the normal value for cardiac index?
    2.8-3.6 L/min x m2
  99. What is the formula for SVR?
  100. What is the normal value for SVR?
    700-1600 dyne sec/ cm5
  101. What is the formula for SVRI?
  102. What is the normal value for SVRI?
    1760-2600 dyne sec/cm5  (or m2)
  103. What is the formula for PVR?
  104. What is the normal value for PVR?
    20-130 dynes sec/cm5
  105. What is the formula for PVRI?
  106. What is the normal value for PVRI?
    45-225 dyne sec/ cm5 (or m2)
  107. What is the formula for SvO2?
  108. What is the normal value of SvO2?
    75%
  109. What is the formula for Stroke Volume?
  110. What is the normal value for stroke volume?
    60-90 mL
  111. What is the formula for Stroke Index?
  112. What's the normal value for stroke index?
    20-60 ml/beat
  113. What's the formula for Left Ventricular Stroke Work Index?
    0.0136 (MAP-PCWP) x SI
  114. What's normal value for Left Ventricular Stroke Work Index?
    50-60 gm/m2/beat
  115. What is the left ventricular stroke work index represent?
    amount of work the LV does during each contraction- best measurement of contractility
  116. What are the advantages of TEE?
    • safe
    • non-invasive
  117. How does TEE work?
    uses ultrasound waves that are emitted by a piezoelectric crystal

    as sound energy strikes various tissue planes it gets reflected back to the crystal and is used to determine distance, velocity, and density
  118. What state should the patient be in during placement of the TEE?
    either under sedation or post anesthesia induction
  119. During a TEE what can be seen, assessed, diagnosed?
    • Cardiac anatomy can be assessed
    • MI can be diagnosed via presence of a SWMA
    • Blood flow through the heart chambers and across valves can be observed
  120. What does SWMA stand for?
    Systemic wall motion abnormalities- can be seen with TEE
  121. Abnormal motion of the walls of the heart can be described with 3 terms:
    • 1. Hypokinesia
    • 2. Akinesia
    • 3. Dyskinesia
  122. In terms of abnormal wall movement, what does hypokinesia mean?
    contraction that is less than vigorous than normal (likely meaning wall thickening is decreased)
  123. In terms of abnormal wall movement, what does akinesia mean?
    absence of wall motion (MI)
  124. In terms of abnormal wall movement, what does dyskinesia mean?
    correlates with paradoxical movement (outward motion during systole)
  125. Of the three abnormal wall movement descriptors, which one is a hallmark of an MI or ventricular wall aneurysm?
    Dyskinesia
  126. True or False: Asynchronous ventricular depolarization can occur and lead to an erroneous diagnosis of an SWMA.
    True.

    Can occur in a right bundle branch block
  127. True or False: The presence of an SWMA can persist long after coronary perfusion has been restored.
    True. Up to 6 hours- indicating a stunned myocardium
  128. A ___% decrease in coronary blood flow will show hypokinesia in a TEE; whereas a ___% decrease is required to produce ST segment deviation.
    50%;75%

    meaning TEE is more sensitive

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