ARTERIAL LINE,CVP & SWAN GANZ

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ARTERIAL LINE, CVP & SWAN GANZ:

ARTERIAL LINE, CVP & SWAN GANZ Dr AVINASH PRAKASH GENERAL SURGERY RESIDENT KIMS

Arterial Blood Pressure:

Arterial Blood Pressure

PowerPoint Presentation:

An arterial line is nothing but an invasive method to measure BP .

So why go invasive :

Real Time BP Frequent titration of vasoactive drips Unstable blood pressures Frequent ABGs or labs (profound acidosis) Unable to obtain Non-invasive BP So why go invasive

ARTERIAL LINE:

Beat to beat measurement of B/P Upstroke of wave Related to velocity of blood ejected Slowed upstroke AS LV failure sharp vertical in hyper-dynamic states Anemia Hyperthermia Hyperthyroidism SNS Aortic regurg mlr/2007 ARTERIAL LINE

ARTERIAL LINE MONITORING SITES:

Radial Low complications Allen’s test median n damage b/o dorsiflexion Ulnar Primary source hand flow Low complications median n. damage mlr/2007 ARTERIAL LINE MONITORING SITES

ARTERIAL LINE MONITORING SITES:

Brachial Medial to biceps tendon Potential median n damage Axillary At junction pectoralis major & deltoid Safer than brachial Low thromboembolic issues mlr/2007 ARTERIAL LINE MONITORING SITES

ARTERIAL LINE MONITORING SITES:

Femoral Easy access in shock states Potential hemorrhage (local/retroperitoneal) Requires longer catheter Dorsalis Pedis Post tibial collateral circ Estimates systolic higher Contraind in DM & PVD mlr/2007 ARTERIAL LINE MONITORING SITES

ALLEN’S TEST:

OCCLUDE ulnar and radial arteries Have pt clench fist until hand blanches Release ulnar a with hand open Color return within 5 sec = adequate collateral circulation mlr/2007 ALLEN’S TEST

MODIFIED ALLEN’S TEST:

Elevate arm above heart Have pt open and close fist several times Tightly clench fist Occlude radial and ulnar a Lower hand, open fist, release ulnar a Color return within 7 sec = OK mlr/2007 MODIFIED ALLEN’S TEST

RELATIVE CONTRAINDICATIONS:

Inadequate circulation Infection at the site Recent cannulation of same artery mlr/2007 RELATIVE CONTRAINDICATIONS

ARTERIAL LINE:

SV: systolic ejection area under waveform Seen from upsweep to dicrotic notch End of systole Closure aortic valve mlr/2007 ARTERIAL LINE

Arterial Pressure Monitoring:

High- and low-pressure alarms based on patient’s status Risks Hemorrhage, infection, thrombus formation, neurovascular impairment, loss of limb (Assess 5 P’s) Arterial Pressure Monitoring

Arterial Pressure Tracing:

Arterial Pressure Tracing Fig. 66-6

ARTERIAL LINES:

mlr/2007 ARTERIAL LINES

LOSS OF WAVEFORM:

Stopcock Monitor not on correct scale Nonfunctioning monitor Nonfunctioning transducer Kinked/clotted catheter asystole mlr/2007 LOSS OF WAVEFORM

DAMPENED WAVEFORM:

Air bubble/blood in line Clot Disconnected/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing mlr/2007 DAMPENED WAVEFORM

UNDERDAMPED WAVEFORM:

Too many stopcocks Long tubing Air bubbles Defective transducer mlr/2007 UNDERDAMPED WAVEFORM

COMPLICATIONS:

Thrombosis/embolus Hematoma Infection Nerve damage/palsy Disconnect=blood loss Fistula Aneurysm Digital ischemia mlr/2007 COMPLICATIONS

CENTRAL VENOUS PRESSURE MONITORING:

CENTRAL VENOUS PRESSURE MONITORING mlr/2007

Central Venous Pressure Assesses . . .:

Central Venous Pressure Assesses . . . Intravascular volume status Right ventricular function Patient response to drugs &/or fluids 25

CENTRAL VENOUS PRESSURE MONITORING:

CENTRAL VENOUS PRESSURE MONITORING Indirect measure of volume RAP reflects RVEDP CVP INDICATIONS Cardiac disease Expected volume shifts Hypovolemia Shock states Massive trauma mlr/2007

CVP ACCESS:

CVP ACCESS RIJ EJ Subclavian Antecubital Femoral mlr/2007

CVP PLACEMENT:

CVP PLACEMENT RIJ benefits Access Landmarks Risks Carotid Brachial plexus trauma pneumothorax mlr/2007

CVP PLACEMENT:

CVP PLACEMENT EJ benefits Superficial Safe Risks Low success rate Sheath kinking at SC v. Subclavian trauma mlr/2007

CVP PLACEMENT:

CVP PLACEMENT Subclavian benefits Accessible Good landmarks Risks Pneumo Hemothorax Chylothorax Pleural effusion mlr/2007

CVP PLACEMENT:

CVP PLACEMENT Antecubital benefits Low complication rate Risks Lowest success Thrombosis/thrombophlebitis Catheter shearing mlr/2007

CVP PLACEMENT:

CVP PLACEMENT Femoral advantages High success Risks Sepsis thrombophlebitis mlr/2007

CVP PLACEMENT:

CVP PLACEMENT mlr/2007

CVP WAVEFORMS:

CVP WAVEFORMS A=RA contraction After P wave of EKG C=closure tricuspid Near end QRS V=atrial filling/tricuspid v closed Early T-P interval mlr/2007

COMPLICATIONS:

COMPLICATIONS Arterial puncture Hematoma False aneurysm Fistula Catheter position during placement Wall perf / tamponade Dysrhythmias Catheter shear Brachial plexus injury Thoracic duct injury mlr/2007

READING THE CVP:

READING THE CVP 5 cm below sternum 4 ICS, mid axillary End expiration Supine PPV adds 8-12 cm to reading! mlr/2007

HIGH READINGS:

HIGH READINGS Ventricular failure (R/L) SVC obstruction Tricuspid regurg Tamponade Pulmonary HTN Overload glomerulonephritis mlr/2007

LOW READINGS:

LOW READINGS Vasodilation hemorrhage hypovolemia Addisonian crisis Sepsis Regional anesthesia Polyuria Sympathetic dysfunct mlr/2007

SWAN-GANZ CATHETER:

SWAN-GANZ CATHETER mlr/2007

PowerPoint Presentation:

SWAN GANZ CATHETER a. Distal Lumen: the PA (pulmonary artery) b. Proximal Lumen: (CVP port) c. Inflation Balloon d. Thermostat Lumen e. Additional Lumens * VIP - venous infusion port * Pacing Port- 5/5/2013 48 pulmonary artery catheterization

PowerPoint Presentation:

5/5/2013 49

pulmonary artery catheterization:

pulmonary artery catheterization Indications Establish diagnosis of shock and/or respiratory failure Guide therapy of shock and/or respiratory failure Measure RAP (Right Atrial Pressure) Same as CVP Assess blood volume; reflects preload to the right side of the heart Assess RV function Infusion site for large fluid volume Infusion site for hypertonic solutions

Information derived:

Information derived Directly measured CVP Pulmonary artery pressure SvO2 Cardiac output (CO) PCWP (Wedge pressure) Calculated Systemic vascular resistance (SVR) Pulmonary vascular resistance( PVR) Stroke volume (SV) Oxygen delivery pulmonary artery catheterization

PLACEMENT:

PLACEMENT mlr/2007

PowerPoint Presentation:

pulmonary artery catheterization

Equalization of pressures:

Equalization of pressures RAP = RVed = PCWP Cardiac tamponade Constrictive pericardial disease Restrictive cardiomyopathies

SWAN-GANZ RELATIVE CONTRAINDICATIONS:

SWAN-GANZ RELATIVE CONTRAINDICATIONS LBBB WPW syndrome Ebstein’s malformation Tachyarrythmias Hypercoagulation Sepsis Site of infection mlr/2007

Complications:

Complications Pneumothorax Hemothorax Hemorrhage Cardiac tamponade Vessel, RA, or RV perforation Arrhythmias Air embolism Pulmonary embolism Thromboembolism Infection

Nevertheless…:

Nevertheless… PAC can be occasionally useful in the carefully selected patient

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