Make sure you know all of the things on this ventilator
- - evaluate health
- - guide treatment
- - evaluate effects of treatment
- Gives you regular/ continuous recording and evaluation of physiological functioning
What can be monitored?
- - general systemic observations
- - cardiovascular system
- - haemodynamics
- - respiratory system
- - CNS
- - renal/ kidney
- - other
Why do physios need to know about monitoring?
- - treating pts who are monitored
- - need to use the information from monitoring to guide management decisions
- - safety with moving pts and handling monitoring equipment (dont want to pull something out)
What are some things you generally observe?
- - Obs- frequency depends on the status of the pt
- - obs are on bed chart in general ward setting
- - obs are on flw chart in critical care setting
How does the monitoring system work?
- - monitoring involves the sensing of physiological parameters and then turning this into a displace
- - very complex but involves:
- * a sensor to pick up physiological change
- * an amplifier to increase the magnitude of the signal
- * a recording/ displace of the signal
- - transducer turn pressure changes into waveform display
- - pressure transducer- piezoeletric crystal which converts pressure canges into a voltage change then converted to a trace
- - pressure transducers need to be zeroed against the point at which the catheter tip isassume to rest- for cardiac pressures- normally 4ICS, M.A.L
- - the transducer needs to be in the right place for it to deliver an accurate reading- haemodynamic messures = RA (point of right atrium when you stand up)
What is a non invasive way to measure the CVS?
What are some invasive ways for haemodynamic monitoring?
- - CVP
- - BP
- - CO and chamber pressures
- - PAP (pulmonary artery pressure)
- - PCWP (pulmonary capillary wedge pressure)
What is the normal pressure for PCWP?
- - pulmonary capillary wedge pressure
- - 8-12mmHg
How do you work out MAP?
MAP = DBP + SBP - DBP/ 3
What is the normal value for MAP?
How do u measure BP?
How do you measure arterial blood pressure?
- - arterial blood line
- - transducer needs to be at the level of the right atrium
- - movt may compromise trace
What are the parts of an arterial waveform?
- - arterial BP
- - systolic pressure (peak)
- - dichrotic notch- need this trace to know if it is an accurate reading
- - diastolic pressure
- - pulse pressure is all of the above
- - MAP- straight line thru reading
- - for more info look at lecture
What other tests can be done via an arterial line?
What is CVP?
- central venous pressure
How is CVP measured?
- thru a venous line from the SVC (superior vena cava) (right arterial pressure)
What does a measurement of the CVP estimate?
- - intravascular volume status
- - RV preload
What is the usual range for CVP?
- - 0-5mmHg
- - 3-15cmH2O
- Note when dead CVP= 5
- - not overly useful but good for understanding fluid levels/ balance
What is a type of pulmonary artery catheter?
- swan ganz catheter
Would you mobilise someone with a Pulmonary artery catheter?
- at lot of places wont let you
What are some of the things pulmonary catheters measure?
- - pulmonary artery pressure
- - pulmonary wedge pressure
Describe the bits of a pulmonary artery catheter
- - balloon tipped, flow directed catheter
- - mulitple lumen- along tube
- - distal port PA
- - proximal part- CVP
- - indicated when precise measurements of cardiac status are neede
- - not used alot
When the balloon inflated with a pulmonary artery catheter what is it measuring?
- once it occludes the PA it is measuring the PCWP
what is the normal PCWP?
What is pulmonary capillary wedge pressure?
- - pressure in the pulmonary capillaries
- - unrestricted vascular channel thru the PA, pul vasc bed, PV, LA and LV (when mitral open)
- - reflection of the pressures in the left atrium and therefore left ventricular diastolic (LVEDP)
- - if LVEDP increases there is an increase is LVEDV - volume
- - also measure pulmonary fluid overload
What does a high PWCP mean?
- - pulmonary congestion- 18-20 (interstitual)
- -pulmonary oedema if >20-30 (fluid in arterial space)
- - if colloid osmotic pressure is decreased (albium) pulmonary oedema will occur at a lower PCWP
When is pulmonary congestion evident?
- - PCWP 18-20
- - interstitual
When is pulmonary oedema evident with PCWP?
- - fluid in arterial space
What does a low PCWP mean?
What is hypovolaemia?
is a state of decreased blood volume; more specifically, decrease in volume of blood plasma
What does it mean if you have a high PAP?
- - pulmonary disease and pulmonary vascular disease
- -increased pulmonary blood flow (left to right shunt)
- - positive pressure ventilation
How is cardiac output measured?
- - thermodilution
- - temp change
What is a normal CO?
What is the cardiac index in relation to CO?
WHat are some complications of a pulmonary artery catheter?
- - dysrythmias
- - pulmonary infection
- - balloon rupture
- - damage to PA
- - thrombolitic effects
- - infection
- - kinking or twisting of the line
- - misplacement
- These are the reasons why they are moving away from these
What is IABP?
- - intra- aortic balloon pump
- - form of cardiac support
- - used for pts waiting for heart replacements
- - helps increase pressures
What are the effects of IABP?
- - increases LVEDP
- - ↑ coronary blood flow
- - decreases LV afterload
- - increases CO
- - decreases work- decrease oxygen consumption
- - increase diasotlic pressure for blood to get around
- - guided by an ECG
Where does the IABP sit?
- - in the arch of the aorta
- - inflated balloon- on a systolic contraction
Is pulmonary artery pressure higher or lower than normal artery pressure?
What is pulmonary artery pressure more influenced by?
- - respiratory status and right heart function than PCWP
- - Not PAPD is closely related to PCWP
What do you need to be careful about with pts with IABP?
- - moving ECG lines
- - Dont do percs and vibes
- - Don't sit up past 30 degrees hip flex
What will you see with both PAP and PCWP in relation to primary cardiac disorder?
- - both will be affected
- - heart failure
What are the indications for cardiac support- IABP?
- - heart failure
- - failure to wean from CPB (cardiopulmonary bypass) eg post cardiac curgery
- - prophylatic- transplant
What are some complications of cardiac support IABP?
- - limb ischaemia
- - vascular trauma- dissection of artery
- - infection
- - balloon rupture
- - haematological complications
- - malposition- kinking
What are the different types of Cardiac support?
What is VAD cardiac support?
- - ventricular assist device
- - helps the ventricles work
- - temporary device- can be external or implantable
- - can be a continuous flow or not
How does the VAD cardiac support work?
- - blood withdrawn from the heart chamber
- - pumped through device
- - returned to outflow (aorta/PA)
What are the indications for VAD?
- - bridge transplant
- - post op heart failure
What is the cardiac support ECMO?
- - extra corporeal membrane oxygenation
- - bi- ventricular bypass
- - used recently for influenza outbreaks
- - being used more and more
- - if pt very ill place them on their belly
Things monitored with respiratory system
- - saturation
- - arterial blood gases
- - end tidal CO2
- - ventilator settings
What is measure with the CNS?
Why is ICP measured?
- - traumatic brain injury
- -trying to prevent secondary complicaitons
Where does the catheter sit to measure ICP?
- - near the site of the lesion
- - it is linked to a transducer which converts pressure to a plethymographic trace and number
What are your options when measuring ICP?
- - Epidural - not a accurate
- - subarachnoid/ subdural
- - intraventricular
What is another was CNS can be monitored?
- - CPP (MAP- ICP)
- - glascow coma scale
How do you calculate CPP?
MAP - ICP
What is ARF?
- acute renal failure
What is CRF?
- chronic renal failure
When is renal replacement therapy conducted/ indications
- - spesis
- - mulitorgan failure
- - hypoglycemic
- - if urea and creatine are rising above normal levels
What are the aims of renal therapy?
- - control fluid balance
- - control electrolyte balance
- - control acid base
- - get rid of toxins and drugs
What is dialysis based on?
- the removal of solutes and water via a semipermeable membrane- either biological or artificial
WHat are your options for renal replacement therapy?
- - arterial or venous
- - external pump or own driving pressure
- - haemofiltration or haemodialysis
WHat does conventional haemodialysis involve?
- - blood pumped through extracorporeal system, separated by a semipermeable membrane from a dialystate soution- diffusion of substances across an electrochemical gradient, fluid goes across by haemostatic pressure
- - 4-6hrs
- - poorly tolerated by critically ill pts
- -take out and clean then put back in
What is haemofiltraion (HF)?
- - removal of water and solutes by diffusion and convection
- - hydrostatic pressure drives filtrate through the membrane and solutes are taken across
- - lost liquid is replaced with plasma
- - slow- takes 24hrs
- - pressure changes affect how well it works
- - can be used continuously
What is haemofiltration also known as?
- - CVVHD- continuous, veno- venous haemofilations with dialysis
- - CAVHD- continuous, arteriovenous haemofiltration with dialysis
- - CRRT- continuous replacement therapy
What is peritoneal dialysis?
- - use the peritoneum as a semipermiable membrace
- - not as effective as HD- therefore not used in critically ill patients
What are complications with peritoneal dialysis?
- - infection
- - impair diaphragm function
- - cant walk around with it
What are some important points?
- - know what the monitors are- ask and what info u can get from them
- - the equipment itself doesnt have CI to physio- the underlying pathology might be
- - dont pull stuff out
- - alarms- know what to do if they go off
- - treating pts- make sure transducers are at the right level, monitor pt, safety, stop and check etc
- Head down tip CI for highICP