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What's the normal value for RA?
What's the normal value for RV?
What's the normal value for PA?
What's the normal value for PA mean?
What's the normal value for PAOP?
What's the normal value for LA?
Does a swan itself improve pt outcomes?
No, but the information gained from it can be useful
What are 2 major indications for using a PA line intraop?
- 1) Does the pt have significant comorbidities that will affect response to anesthesia?
- 2) Will the surgical procedure itself have significant blood loss or fluid shifts that would make min to min assessment helpful?
If yes or either then consider if it needs to be placed pre-op or intra-op
What are some examples of indications for intraoperative invasive monitoring needed a PA line inserted pre induction?
- -Poor LV function (EF < 40)
- -Valvular heart disease
- -Recent MI
What are some examples of indications for intraoperative invasive monitoring needed a PA line inserted post induction?
- -Assessment of IV volume
- -Evaluation of response to IVF or vasoactive drugs
- -Major vascular surgery (involving cross clamping the aorta or large fluid shifts)
What are the 3 waves of the RA tracing and what do they signify?
- A- atrial contraction
- C- TC valve closes
- V- atrial filling
Why is the A wave the largest in the RA tracing?
Position of the catheter relative to the physiological event producing the pressure change
Is there an "A" wave in AF?
What changes are seen in the RA tracing with significant TR?
Large V waves
What change would be seen in the RA value with tamponade?
Elevated RA waveform
What does the first negative downslope signify on the RA tracing? What is it called?
- -Atrial relaxation
- -X wave
- -Sometimes divided into X (start of atrial diastole) which occurs after A wave and before C wave
- -and X' (downward pulling of septum during ventricular systole) which occurs after C wave and before v wave
What does the second negative downslope signify on the RA tracing? What's it called?
- Signifies opening of TC valve and emptying of RA
- Called the Y wave
What information can the RA tracing give us?
Information about intravascular volume, atrial arrhythmias, right heart valve defects, cardiac tamponade and ischemia
How is RV end diastolic pressure estimated with a PA line?
Via the CVP port, RV preload can also be estimated
How is RV systolic pressure estimated with a PA line?
How does the timing of CVP tracing compare with the EKG tracing?
Electrical activation produces contraction. So A wave follows the P wave. C and V waves occur after the beginning of the QRS.
How do the timing between the EKG and RA and PAOP compare?
There is more hysteresis (more time) between EKG activity and PAOP waveforms than with CVP.
What is a cannon a wave and when is it commonly seen?
It's a large A wave. Seen with junctional rhythm, 3rd degree AVB, PVC's, V pacing, TS or MS, diastolic dysfunction, MI, ventricular hypertrophy
What conditions can cause loss of a wave or v waves only in the CVP / PAOP tracings?
AF or ventricular pacing in the setting of asystole
What conditions can cause large v waves in the CVP or PAOP tracings?
TR or MR or acute increase in intravascular volume
If large V waves are present, when should preload be estimated?
Just before the upstroke of the V wave
Should you flush a wedged catheter?
How much is the catheter usually advanced from RA to RV?
approximately 10 cm
From RV how far is the catheter advanced to obtain a PAOP tracing?
an additional 5-10 cm
Which is normally higher, RA or LA pressures?
What produces the upstroke of the PA tracing?
Opening of the pulmonic valve
What produces the downstroke and dicrotic notch of the PA waveform?
- Downstroke= RV ejection
- Notch= sudden closure of pulmonic valve leaflets (beginning of diastole)
Why is the wedge tracing dampened?
LA pressure is significantly attenuated due to the pulmonary circulation
Where in the EKG tracing does the PA tracing occur?
Within the QT interval (RV waveform also)
When during the respiratory cycle should mean or diastolic CVP or wedge pressures be recorded?
End expiration as this is when pleural pressures are approximately equal to atm pressure
With hypovolemia what values would you expect to see with CVP and wedge?
Both decreased, PAEDP = PAOP
With LV failure what values would you expect to see with CVP and wedge?
Increased CVP and wedge, PAEDP=PAOP
With RV failure what values would you expect to see with CVP and wedge?
Increased CVP, no change in wedge; PAEDP=wedge
With PE what values would you expect to see with CVP and wedge?
Increased CVP, no change in wedge; PAEDP> wedge
With cardiac tamponade what values would you expect to see with CVP and wedge?
Increased CVP and wedge; PAEDP=wedge
When should LVEDP be measured on the wedge tracing?
Just before the v wave upstroke on the wedge tracing
When should LVEDP be measured on the PA waveform?
Just before the upstroke
In what West Zone should a PA catheter be placed in? Why?
- West Zone 3. The bulk of pulmonary blood flow lies within this region. Corresponds to a complete circuit that allows for direct communication between the right and left heart
T or F, a West Zone is an anatomic location?
F, it's a physiologic location and a West Zone 3 can turn into a West Zone 2 for example.
What factors would cause a West Zone 3 to become a Zone 1 or 2?
PEEP, diuresis, blood loss, hypovolemia, change in position (supine to sitting)
What does the PAOP waveform look like when in a West Zone 1 or 2?
a and v waves are lost and PAOP exceeds PADP.
T or F, normally the PAOP does not exceed PADP?
Other than West Zones, what other factor could cause PAOP to exceed PADP?
How does decreased ventricular compliance affect PA values (specifically PAOP and LVEDV)?
What could cause decreased ventricular compliance?
-With decreased ventricular compliance, wedge is not a reliable indicator of LVEDV.
-Decreased ventricular compliance can be caused by MI, LV hypertrophy, cardiac tamponade, or ventricular interdependence).
What is catheter whip and what can cause this?
An exaggerated oscillation of the PA tracing. Get falsely high PA numbers. Causes can be coiling of the tip of the catheter or with PH.
What factors can cause PADP to correlate poorly with PAOP?
- 1) Increased PVR (PE, COPD, ARDS, hypercarbia), PADP>PAOP
- 2) HR > 130 bpm, PADP>PAOP
- 3) Severe AR or MR, PADP<PAOP
- 4) Lung zones 1 or 2 (due to hypovolemia or PEEP), PADP<PAOP
What does CI tell you compared to CO?
Takes into account the person's size, NOT their body composition.
What value can estimate RV afterload?
How do you calculate BSA?
What value is used to guide administration of vasoconstrictors or afterload reduction?
What's the normal value for CO?
What's the normal value for CI?
What's the normal value for SVR?
What's the normal value for SVRI?
What's the normal value for PVR?
What's the normal value for SVO2?
75% or a partial pressure of 40 mmHg
Do SVR and PVR account for changes in ventricle wall size or radius
No, and these are components of afterload
What does SvO2 tell us?
An estimation of systemic O2 delivery
What is LVSWI? What does it tell us?
LV stroke work index. The amount of work performed by the LV during each contraction.
What's the normal value for LVSWI?
What are the 3 descriptors of abnormal wall motion?
- 1) hypokinesis (decreased vigor in contractility)
- 2) akinesis (no wall motion, ex: MI)
- 3) dyskinesis (paradoxical wall movement, i.e. outward during systole, MI or ventricular aneurysm)
Is EKG or TEE more sensitive for ischemia?
TEE. Hypokinesia occurs with a 50% decrease in coronary blood flow vs. a 75% decrease in coronary blood flow needed to produce ST segment changes. TEE has less hysteresis and greater sensitivity.
What information can a TEE give us?
- 1) SWMA (systolic wall motion abnormalities that can detect ischemia)
- 2) Vascular aneurysms
- 3) EF
- 4) Preload
- 5) Blood flow thru the heart