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When supine where should the transducer be leveled to?
Midaxillary at the level of the RA
When sitting where should the transducer be leveled to?
Circle of Willis
Lowering the transducer has what affect on blood pressure?
Lowering the transducer by 1 cm will decrease BP by 0.75 mmHg
What catheter size is used for radial artery cannulation?
What catheter size is used for femoral artery cannulation?
18-20g long catheter
Does raising or lowering the patients arm affect the BP reading?
What do the A line upstroke and downstroke represent?
- Upstroke- contractility
- Downstroke- PVR
How could use of an A line while a pt is mechanically ventilated alert us that a pt is hypovolemic?
Systolic pressure variation of >8 mm during the respiratory cycle
If a distal artery (like the foot) is cannulated, how would SBP and DBP be altered?
- -SBP and pulse pressure would be falsely elevated
- -DBP and MAP would be falsely lowered
Underdampening of an A line
-what is it?
-what can cause it?
- -SBP is OVERestimated by 15-30 mmHg
- -artifact is amplified
causes: very small tubing (<1.5 mm diameter), long connection line, stiff tubing, large catheters
Overdampening of an A line
-what is it?
-what can cause it?
-SBP is UNDERestimated
causes: high viscosity, soft tubing, air bubbles, blood clots, kinked catheters
How can dampening problems be eliminated?
- -tube length < 120 cm
- -avoid extraneous stop cocks
- -remove air bubbles
- -use low compliance system with an internal diameter of 1.5 - 3 mm
- -use a continuous flushing system
A line complications
- -vascular insufficiency and vasospasm
- -blood loss
- -arterial thrombosis
- -nerve damage
- -intra-arterial drug administration
How can A line complications be minimized?
- -smaller catheters
- -continuous infusion of NS at a rate of 2-3 mls/ hr
- -aseptic insertion
- -use pulse ox to continually assess perfusion
- -minimize flushing
In what patients is PA preferred over CVP to estimate IV volume and preload?
- -Severe mitral disease
- -pulmonary hypertension
- -significant reduction in LV compliance (EF< 40%)
For CVP placement, is L or R IJ preferred and why?
RIJ is preferred as LIJ cannulation is associated with pneumothorax and pleural effusion (due to injury of nearby thoracic duct)
Where is the IJ located in relation to the carotid artery?
What should be done if the carotid artery is punctured?
- -remove the catheter and apply direct pressure for 10 mins
- -if pt is anticoagulated leave the catheter in place until the coagulation status is normal or repair can be performed
In what position should be pt be in for central line insertion?
Trendelenburg- prevents air entrainment and distends the neck veins
Where should the CVP catheter tip lie?
At or superior to the junction of the SVC and the RA
What landmarks are used to locate the IJ?
The triangle formed by the clavicle, and lateral and medial heads of the SCM (sternocleidomastoid muscle)
Central line complications
- -thrombus formation
- -atrial / ventricle perforation
- -air embolism
- -vascular erosion
What are indications for PAC use in cardiac surgery?
- -EF < 40%
- -severe aortic or mitral valve disorder
- -recent MI or severe angina
- -moderate or severe PH
Relative contraindications to use of a PA line
- -mechanical heart valve
- -LBBB (placement can induce RBBB)
- -hypercoagulable state
- -recent transvenous pacing wire placement