7.26. 2014 online version hemodynamic monitoring · pulmonary artery catheter swan insertion...
Post on 26-Sep-2019
7 Views
Preview:
TRANSCRIPT
8/1/14
1
Cardiovascular and Hemodynamic
Assessment Essentials
Al Quinones, DHA, MA, RRT-NPS, RPFT, RPSGT, CCT, A-EC, FACHE
Circulatory Path Cardiac Auscultation
Systole - S1: Closure of AV valves at the onset of systole - Systolic murmur: Regurgitation through AV valve; Forward flow through
stenotic semilunar valve Diastole - S2: Closure of semilunar valves at the onset of diastole - Diastolic murmur: Regurgitation through semilunar valve; Forward flow
through stenotic AV valves
Heart Sounds
" Normal S1 S2
" https://www.youtube.com/watch?v=X0p9GqvaKDw
" Aortic Murmur " https://www.youtube.com/watch?
v=HtDzHWNYKQM " Mitral Valve Murmur " https://www.youtube.com/watch?
v=OQ9xrxDg3uc
Definition of Hemodynamic terms
" Preload – amount of blood in the ventricle before contraction: End diastolic volume – EDV determines the amount of ‘stretch’ that is
placed on the myocardial muscle – That ‘stretch’ determines the strength of the next
contraction – The strength of the contraction determines how
much blood is pumped out of the ventricle during the next systole ‘stroke volume’
– The stroke volume determines the blood pressure
" Afterload - resistance to blood flow from the ventricle; work that must be done to pump blood from the ventricle to the circulation
" Resistance determined by size of valve opening, blood viscosity and blood pressure in pulmonary or systemic circulation
" Work – is the oxygen consumed by the myocardium to overcome the resistance to flow
Alveolar Capillary
Membrane
Lets Talk More About: Normal Alveolar Capillary Membrane
8/1/14
2
Early Pulmonary Edema Interstitial Edema Late Pulmonary Edema
Flow-directed pulmonary artery catheters
Swan-Ganz catheters can perform many functions including: 1. Direct measurement of the right atrial pressure, right
ventricular pressure, and pulmonary arterial pressure 2. Indirect assessment of the left atrial pressure via
measurement of the pulmonary artery occlusion pressure (also called the pulmonary capillary wedge pressure)
3. Sampling of mixed venous blood 4. Thermodilution analysis, which is used to calculate
hemodynamic variables such as cardiac output, pulmonary vascular resistance, and systemic vascular resistance.
Pulmonary Artery Catheter Swan Insertion " The potential sites for
insertion of Swan-Ganz catheters include:
1. internal jugular vein 2. subclavian vein 3. femoral vein 4. right or left brachial
veins.
Pulmonary Artery Catheter in Wedge Position Normal Chest x-ray
8/1/14
3
MV: Cardiovascular Affects Ø Cardiovascular-Lung relationships
– Spontaneous breathing
MV: Cardiovascular Affects Ø Cardiovascular-Lung relationships
– Positive pressure ventilation
Pulmonary artery catheters for adult patients in intensive care.
Rajaram SS1, Desai NK, Kalra A, Gajera M, Cavanaugh SK, Brampton W, Young D, Harvey S, Rowan K.
" PAC is a diagnostic and haemodynamic monitoring tool but
not a therapeutic intervention. Our review concluded that use of a PAC did not alter the mortality, general ICU or hospital LOS, or cost for adult patients in intensive care. The quality of evidence was high for mortality and LOS but low for cost analysis. Efficacy studies are needed to determine if there are optimal PAC-guided management protocols, which when applied to specific patient groups in ICUs could result in benefits such as shock reversal, improved organ function and less vasopressor use. Newer, less-invasive haemodynamic monitoring tools need to be validated against PAC prior to clinical use in critically ill patients.
Left-Sided Heart Failure " Pulmonary congestion occurs
when left ventricle cannot pump well
" Dyspnea upon exertion, orthopnea, and paroxysmal nocturnal dyspnea
" Oliguria
Right-Sided Heart Failure
" Congestion of viscera and peripheral tissues when right ventricle fails
" Jugular vein distention " Dependent edema " Hepatomegaly " Ascites " Weakness, anorexia, and nausea " Weight gain
Coronary Artery Disease (CAD)
Assessment " Presentation: Unstable
angina, SOB, N/V, Diaphoresis, Lightheadedness, Syncope
" Elevated cardiac enzymes
" ST or T wave changes on 12 lead
Plan of Care " Supplemental 02
" Pain management " Antiplatelet therapy " Dysrhythmia
management " Reperfusion decision
Percutaneous coronary intervention (angioplasty) Stenting
Percutaneous coronary intervention (angioplasty) Stenting
" http://www.bing.com/videos/search?q=Percutaneous+coronary+intervention+VIDEO&FORM=VIRE1#view=detail&mid=5FC075889623DE04DC4C5FC075889623DE04DC4C
CAD, MI
STEMI " Rapid decision
regarding reperfusion strategy
" Cardiac catheterization " Fibrinolysis " Percutaneous
angioplasty/stenting " CABG
NSTEMI " Thorough examination
and risk stratification. " Search for non-coronary
causes " Stress testing if negative
cardiac enzymes " Consider adjunctive
treatment (NTG, Beta blockers, Heparin)
8/1/14
4
Cardiac Cath
http://www.bing.com/videos/search?q=cardiac+catheterization+video+youtube&FORM=VIRE9#view=detail&mid=2D962259B9369708A3A12D962259B9369708A3A1
Where is the MI? Where is the MI? CHF
Assessments " Pleural effusion:
Increased hydrostatic pressure
" Pulmonary Edema: Productive cough with pink frothy secretions
" Dyspnea " Increased L heart preload,
decreased contractility, increased afterload
Plan of Care " Supplemental oxygen (if
hypoxemic), NPPV (refractory hypoxemia, acidosis)
" Intubation, PEEP (failed NPPV)
" Diuretic, Vasodilator, Inotrope
PHTN Assessments
" Dyspnea " Angina " Loud S2 (AV valve closure) " ECG: RV hypertrophy (R in V1 + S in V5 (or V6) 10 mm)
" CXR: Kerley B lines " Echo: RV dilation, tricuspid
regurgitation " Increased R heart preload,
JVD
Plan of Care
" Prevent hypoxemia! " Oxygen " PEEP/ CPAP " Inhaled pulmonary
Vasodilators " Lung Transplant
Kerley B Lines linear opacities seen on the chest radiograph. They are 1-2 cm long
horizontal lines which meet the pleura at right angles. They are typically seen as a ladder up the side of the lungs beginning at the costophrenic
Shock
" Hypovolemic " Cardiogenic " Distributive
- Septic - Neurogenic - Anaphylatic
8/1/14
5
Shock
Assessments " Tachycardia,
hypotension " Dyspnea " Mental status change " Diaphoresis " Metabolic acidosis " Oliguria
Plan of Care " Avoid PPV " Adequate
oxygenation " Appropriate
intravascular volume
" Judicious PEEP
top related