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When supine where should the transducer be leveled to?
Midaxillary at the level of the RA
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When sitting where should the transducer be leveled to?
Circle of Willis
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Lowering the transducer has what affect on blood pressure?
Lowering the transducer by 1 cm will decrease BP by 0.75 mmHg
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What catheter size is used for radial artery cannulation?
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What catheter size is used for femoral artery cannulation?
18-20g long catheter
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Does raising or lowering the patients arm affect the BP reading?
NO
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What do the A line upstroke and downstroke represent?
- Upstroke- contractility
- Downstroke- PVR
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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
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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
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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
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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
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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
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A line complications
- -vascular insufficiency and vasospasm
- -hematoma
- -blood loss
- -arterial thrombosis
- -nerve damage
- -infection
- -intra-arterial drug administration
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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
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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%)
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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)
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Where is the IJ located in relation to the carotid artery?
lateral
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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
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In what position should be pt be in for central line insertion?
Trendelenburg- prevents air entrainment and distends the neck veins
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Where should the CVP catheter tip lie?
At or superior to the junction of the SVC and the RA
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What landmarks are used to locate the IJ?
The triangle formed by the clavicle, and lateral and medial heads of the SCM (sternocleidomastoid muscle)
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Central line complications
- -pneumothorax
- -thrombus formation
- -infection
- -chylothorax
- -arrhythmias
- -atrial / ventricle perforation
- -air embolism
- -vascular erosion
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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
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Relative contraindications to use of a PA line
- -WPW
- -mechanical heart valve
- -LBBB (placement can induce RBBB)
- -hypercoagulable state
- -bacteremia
- -recent transvenous pacing wire placement
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