True or False

You can have a great heart rate but not have a

good preload or afterload?

True

What condition has Fluid overload

Preload increased

L Afterload increased

Contractility decreased?

Congestive Heart Failure

What condition has

R preload increased

R afterload increased

Cor Pulmonale

Cor pulmonale is failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart. Symptoms: Shortness of breath or light-headedness during activity

What condition has

 L fluid decreased

L preload decreased

Right afterload increased

COPD, pulmonary hypertension

What condition has

fluid excess,

L preload high

L afterload increased

contractility decreased?

MI, poor L ventricle

What condition has

fluid deficit

preload decreased

L afterload decreased

contractility increased?

Septic Shock (hyperdynamic)

what condition has

fluid deficit

preload decreased?

hypovolemia

Where does a central line sit in the body?

In the superior vena cava or right atrium

What line goes through the right atrium into the right ventricle and out into the pulmonary artery?

Pulmonary artery cathether

What heart problem has

preload decreased

contractility decreased?

hypovolemia, L ventricular failure

Which health problem has

fluid excess

preload increased

L afterload increased

contractility decreased

L ventricular failure

(MI,  Cardiomyopathy)

Which health condition has R fluid excess,

R preload increased,

afterload increased R>L

Pumonary Hypertension

Which health problem has

fluid defecit

prelaod decreased

hypovolemia

S/S

distended jugular veins, peripheral edema, hepato-spleenmegaly, poor skin turgor, dry mucouse membranes, tachycardia, extrasystoles (S3)

What part of the heart could cause this?

CVP/RA

(Right Preload)

What S/S would be prevalent with:

weak or bounding peripheral pulses,

tachycardia,

changed level of consciousness

Cardiac output is poor

What part of the heart could cause:

cool/pale skin, flushed skin, weak or bounding peripheral pulses

SVR

Left Afterload

What part of the heart can cause:

tachycardia, peripheral pulses (poor),

and level of consciousness (poor)

ABP

 L Afterload

What part of the heart can cause:

pulmonary congestion, cool, pale skin

PCWP

L Preload

The purpose of an IABP is for what?

Augment diastole and decreased afterload

Why does a IABP augment

diastole?

to increase perfusion to

coronary arteries

After the IABP augments diastole

why does it decrease the afterload?

to promote emptying of the

ventricles by reducing

resistance

What does the PAP and ABP do and mean?

Pulmonary artery pressure (PAP)

Arterial Blood Pressure (ABP)

they measure the pulmonary resistance in the vessels following systole

What does PVR and SVP mean and do?

PVR-Pulmonary vascular resistance

SVP-Systemic vascular resistance

determine the degree of vasoconstriction or vasodilation is in the pulmonary and systemic capillary beds

What does Preload mean in terms of the Heart?

It is the volume of blood in ventricles at end of diastole

(end diastole pressure)

(immediately before systole)

If the Preload is increased

what 2 things can this mean?

Hypervolemia

Regurgitation of Cardiac Valves

What does Afterload mean to the Heart?

The resistance the ventricles must

over come to circulate blood

If the Afterload is increased what 2 things

can this mean to the heart?

HTN

Vasoconstriction

increased afterload increases cardiac workout

Cardiac output is dependent on what?

Stroke volume and Heart Rate

Stroke volume is dependent on what?

(3)

Preload, afterload, and contractility

CO is the volume of blood that is circulated in

how long?

1 minute

What is the volume of blood in ventricles at end of diastole(end diastole pressure)?

-of the heart-

Preload

What is the term for-resistance that the left ventricle must overcome to circulate blood

Afterload

If there is an increase in preload, there will be an increase in?

Cardiac Output

(until very high end diastolic volumes are reached)

Frank Starling Law

If heart chambers are filled (the ventricles) with greater preload, what will be stronger?

Contractility

CHF

If greater preload causes muscle fibers to be over stretched-what does this do to the heart next?

The heart can't contract enough to eject the contents resulting in preload not being emptied and  less volume with the next beat.

Like wise with afterload increase but still can't eject contents resulting in a decrease in preload.

Preload on the Right side is measured by:

CVP or RAP

Preload on Left Side is measured by:

PCWP or PWP

Contractility measured by?

Right Side:

Left Side:

Left Side: LVSWI (Left Ventricular Stroke Work Index)

Right Side: RVSWI (Right Ventricular Stroke Work Index)

Afterload (Resistance)

Right Side?

Left Side?

measured by:

Right Side-PAP

Left Side-ABP

Resistance and Vasoconstriction/Vasodilation

Right  Side?

 Left Side?

is measured by:

Right Side-PVR

Left Side-SVR

Advantages of Direct Monitoring?

CVP/PCP

RVSWI/LVSWI

PAP/ABP

PVR/SVR

*Continuous monitoring of critical pressures otherwise undetectable

*Most accurate information

*Allows for constant evaluation of therapeutic modalites

 *Direct Blood Sampling

*Allows detection and Tx of problems early

How many cc's does a flush line have to deliver to keep a line patent for monitoring of the heart?

1-5cc's of fluid per hour

(usu. 3-5 cc's per hour)

Where does a Central Venous Catheter

Sit in the body?

In the Superior Vena Cava or Right Atrium

The Pulmonary artery Catheter goes through what parts of the heart?

In the Right Atrium into the Right Ventricle and out into the Pulmonary Artery

How Many Ports does the Pulmonary Artery Catheter (Swan-Ganz) at least have and what are they used for?

At least (4)

Left to Right named

1-Monitor

2-Distal Pulmonary Artery Port

3-Proximal Right Atrial Port

4-Balloon port

What are the (3) things that a Central Venous Catheter is used for?

Medications

Measurements

and

Infusions

How are Left Atrial Catheters placed and why?

Can only be placed in the operating room, so not used frequently  except post-cardiac surgery

Why-for a patient whose status after surgery is particularly critical

What tool is used to monitor

venous oxygen saturation?

(2)

Sv02

and

SV02-

(newer and easier to access mixed venous blood)

What are reasons for a physician to choose to place an arterial catheter to monitor a patient's BP?

(6)

 *patients who have problems with their BP

*Decreased Perfusion

*Low CO

*Pts in Hypertensive Crisis

*Meds given with constant monitoring

*Arterial Blood gas Draws

What kind of Drugs must you have an arterial line for constant monitoring?

Vassopressors

(cause increase and/or decrease in arterial BP)

can cause drastic swing in BP

Intra-arterial lines have a diastolic, a systolic, and a mean BP

1-How do you find the Mean?

2-Where is the preferred place for an ART line?

1-Systolic pressure+(2X the Diastolic pressure)

___________________________________

3

2-Arterial line is Preferred in the Radial artery because of the palmar arch to the Ulnar artery

(ensures perfusion)

What are complications of an Arterial-line?

(3)

Hemmorage

Occlusion

Infection

What catheter is the best indicator for fluid overload or dehydration in a patient?

(fluid imbalance)

CVP Catheter

What are the (3) Indications or reasons for using a CVP catheter on a patient?

*Monitoring Fluid Balance

*Large Volume Fluid Replacements

*Administering Hypertonic Fluids or TPN

1-What complications can happen when a CVP catheter is placed?

2-Where is the CVP placed through in the body?

1-Because the catheter tip sits in the thoracic cavity it is subject to the negative pressure within the thoracic cavity(this means that the pat may be prone to an opening of air and recieve an air emboli)

2-either through the jugular vein or the subclavian vein

1-Emboli(air or throbus)

2-Hemmorage

3-Vessel trauma from Selsinger technique or blind pucture-(inserting guide wire into the vessel and then putting the cateter over the guide wire and into the vessel)

4-Infection

Why would a patient have a PA Catheter placed?

(3) Indications

1-Shock States

2-Evaluation of Myocardial Function-following surgery or after an MI

3-Evaluation of fluid status

Direct and Derived Measurements can be taken from a PA catheter

What does this mean?

A Direct measurement has no adjustment or mathematical calculation applied

(ex: temperature probe-at end of catheter will give pt's core body temperature

A Derived value has to be mathmatically solved

(ex:Mean arterial pressure from diastolic and systolic pressures)

What is the one complication that is unique with a PA Catheter from other Catheters?

How is a PA catheter placed-

What technique do we use?

Sedinger techneque(cannulating a vessel with a needle and then inserting a guide wire through the lumen of the needle)

Once the guidewire is in the vessel the needle is removed and pulmonary artery catheter is tredaded over the top of the guide wire and into the vessel.

When the PA catheter is placed in the Right atrial (RAP)

What happens before moving into the Right ventricle?

The PA catheter is balloon will float from the right atrium into the right ventricle through the ___(1)____ valve.

It's important to pass the catheter through the ventricle as quickly as possible because of high risk ____(2)____ occuring.

1-Tricupid

2-Dysrhythmias

How do you know the balloon has reach the pulmonary artery?

The pulmonary artery wave form is differentiated from the ventricular wave for by the

Dicrotic Notch

This shows the pulmonic valve has closed and this is where you can see that the catheter is indeed in the pulmonary artery

Beacause the pulmonary artery pressure is a blood pressure, the same as arterial blood pressure

It will have both ______ and _______ readings

Systolic and Diastolic

How do we obtain Left Atrial pressure from the Pulmonary Artery Catheter?

By PCWP

The balloon on the catheter is inflated and begins to float in the pumonary artery as it did when it was placed-it floats until it becomes stuck or wedged in the branch of the pulmonary artery

sensor tim transmits only pressure in front of it, not behind

(This is essentially Left Atrial Pressure)

Pulmonary Artery Catheter

*CVP/RA mean

*PAP

*PCWP

*CO

                  -thermodilution

             -continuous

CI

SVR

PVR

SV

SVI

         -RVSWI

         -LVSWI

What are the complication that can happen with

Left Atrial Catheter?

(3)

-Cardiac Tamponade

-Emboli (air or thrombi)

-Hemmorage

What can affect a true reading for the atrium (Preload)

with a PCWP?

If the patient has significant pulmonary disease

(For this reason, in some patients following cardiac surgery, a physician may choose to place a Left Atrial catheter for a direct valid measurement)

Not left in very long-not usu. more than a day, just to get patient past critical period)

Sv02, ScV02, SJV02 Catheters

1-used for patients in what state?

2-What does this measurement reflect?

1-In a Shock state to evaluate 02 supply and demand

2-reflects oxygen saturation in the venous blood

____(1)____ saturation tells us how much 02 is being sent out to the tissue.

____(2)___ saturation reflects the oxygent that is coming back to the heart on the venous side.

1-Arterial

2-Venous

By looking at these 2 numbers you can evaluate exactly how much oxygen demand there is in the tissues

What does the IABP do for the heart?

(Intra-aortic Balloon Pump)

goes through the femoral arter and sits in the aorta

 Augments Diastole

-Increases coronary artery perfusion

and

To Decrease Afterload

the balloon inflates-blood is pushed back over the aortic arch to drain into the coronary arteries

the balloon deflates-there is no resistance to ejection of blood from the left ventricle to work without straining

Acute Myocardial Infarction

Cardiogenic shock

Low cardiac output states

Transition from cardiopulmonary Bypass

Through the femoral artery into the aorta

Placed at the bedside

begins functioning almost immediately

1-Where must the IABP sit in order to do its job and not obstruct blood flow?

2-What must the IABP be synchronized to?

3-What is the timing ratio?

1-Balloon must sit above the renal artery but below the aortic arch.

This way it will not compromise renal blood flow or blood flow to the internal carotids.

2-synchronized to the ventricular contraction.

3-Sychronization timing ratio (1:2)

The balloon inflates as soon as the aortic valve closes-(this allows bllod to drain into the coronary arteries noth the left ventricle.)

The balloon deflates before the aortic valve opens-(this prevents obstruction of the aorta when the ventricle tries to eject the stroke volume).

*Aortic vessel damage

*Poor perfusion of catheterized limb

*Emboli from the balloon/catheter

*Balloon rupture

-Bridge to Recovery

-Destination Therapy

-Bridge to Transplantation

The IABP does not allow a patient to get up out of bed,

they are confined to bed and have to keep the cannulated extremity straight in order to prevent the movement of the catheter inside the aorta.

VAP's can be left in for a longer period of time

*Poor LV function

-PA Diastolic >20

-Cardiac Index <2

-Systolic ABP <90

*Maximum IABP support is insufficient

*Maximum inotropic medication is insufficient

What do Inotropics do for the heart?

What are the most common Inotropic Medications?

Intotropics are medications that increase the strength of the muscle contractions that pump blood from the heart.

Most common:  Amrinone (Inocor), Digitoxin (Crystodigin), Dogoxin (Lanoxin, Lanoxicaps), Dobutamine (Dobutrex) and Milrinone (Primacor).

One part is connected to the ventricle, the other part is connected to the vessel appropriate to the ventricle.  Blood drains directly int the ventricular assist device and it uses a pneumatic pump to put the blood back into the vessel.

(That way there is no work for the ventricle).

What are the complications for the VAD's?

(4)

-Hemmorage(pt needs to be on anticoagulation)

-Device Failure

-Emboli

-Infection