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Types of lines we transport...
- 1. Arterial (A-lines, Art-Line)
- 2. Central Venous Presure (CVP)
- 3. Pulmonary Artery Catheter (PA, Swan-Ganz)
- (These lines should be transduced and monitored in most cases.)
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General Principles
- 1. The pressure bag is inflated ro 300mm/Hg ("green zone")
- 2. monitor invasive line
- 3. Whenever possible get rid of extra stuff
- 4. Must appropriately position, zero and scale
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What to monitor with invasive lines?
- 1. distal perfusion and sensation
- 2. infection
- 3. hemorrhage
- 4. occlusion
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Arterial Lines Facts
- 1. catheter is in an artery opposing flow
- 2. monitors real time BP
- 3. very helpful for patients with multiple vasoactive infusions or if critically unstable
- 4. can be used for serial arterial sampling
- 5. usually the RED readout on a monitor
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Common arterial line sites
- 1. radial
- 2. brachial
- 3. femoral
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Zeroing Arterial Line
- When initiating monitoring, switching monitors or any disconnection the system must be zeroed.
- 1. open the transducer to ambient pressure (open to air, closed to patient)
- 2. Assure the transducer is at the phlebostatic axis
- 3. remove the cap
- 4. select "Zero" on the monitor
- 5. may need to "scale" the waveform
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Phlebostatic Axis
4th ICS mid axillary line
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Performing the Square Wave Test
- (also called the Fast Flush or Sine Wave Test)
- 1. pull the tail to flush the system and produce a square sine wave
- 2. evaluate for dampening
- Generally one or two oscillations prior to return to baseline
- under-dampened: > 1
- over-dampened: no oscillation
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Arterial Line Complications
- 1. dampened waveforms
- 2. loss of vibrating energy due to resistance in the transducer system
- - Under-dampened (exaggerated response) causes false high systolic and false low systolic readings
- - Over-dampened (blunted response) causes false low systolic and false high diastolic readings
- o clots
- o positional catheters
- o dislodged catheters
- o low BP/high BP
- o loose connections
- o air in system
- o poor tubing compliance
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Central Venous Pressure (CVP)
- 1. potentially a measurement of preload
- - high = fluid overload or right sided disease (pulmonary pHTN, stenosis, high PEEP, etc)
- - normal is variable but generally 0-6 cm/H2O
- 2. Usually verified placement by x-ray in the SVC 2cm distal to the RA
- 3. generally the BLUE waveform on a monitor
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Pulmonary Artery Catheter (PA)
- Measures numerous parameters in the ICU (we can only measure PA pressures in transport)
- - at Temple, generally used to guide therapy in the first 25 hours and the DC'd
- - should get a "set of numbers" prior to transport
- - generally the PURPLE waveform on the monitor
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"Normal" Hemodynamic Values
CO/CI
2.5 - 4.2 L/Min
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"Normal" Hemodynamic Values
SVR/SVI
900 - 1300 dynes/sec/cm
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"Normal" Hemodynamic Values
LVEF
50-70%
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"Normal" Hemodynamic Values
SV/SVI
50-100ml
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"Normal" Hemodynamic Values
PVR
155-255 dynes/sec/cm
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"Normal" Hemodynamic Values
PCWP
4-12 mm/Hg
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Right Heart Failure
⇧ CVP ⇩ CI ⇧ PVR
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Left Heart Failure
⇧ PCWP ⇩ CI ⇧ SVR
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Pericardial Tamponade
⇧ PWCP ⇧ SVR ⇩ CI
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Hypovolemia
⇩ CVP ⇩ PCWP ⇩ CI ⇧ SVR
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Cardiogenic Shock
⇧ PCWP ⇩ CI ⇧ SVR
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Septic Shock
⇩ PCWP ⇧ CI ⇩ SVR
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Care for a PA Catheter
- Generally same as an ART Line but...
- 1. check for the balloon status - open vs wedged
- 2. monitor for the ectopy, dysrhythmia or a change in the waveform
- 3. Monitor the depth of the catheter
- 4. Observe for "catheter whip" (excessive movement of the catheter tip caused by cardiac contractions - use PAP)
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Ventriculostomy
- - not a frequent transport
- - needs to be fairly aseptic
- - NEVER infuse a ventric
- - transducer system is leveled at the Foramen of Monroe (tragus of the ear/auditory meatus) and corresponds to the 3rd cerebral ventrile
- - Normal ICP 0-15, establish a threshold ICP
- - CPP (MAP - ICP) >60 mm/Hg
- (neurosurgical procedure that involves creating a hole ("stomy") within a cerebral ventricle for drainage. It is done by surgically penetrating the skull, dura mater, and brain such that the ventricle of the brain is accessed.)
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Ventriculostomy
Drainage and Monitoring
- 1. can not monitor and drain simultaneously
- 2. typically we monitor or drain as clinically indicated or as ordered
- 3. clamp during coughing, vomiting, movement or suctioning
- 4. Drainage system will be ordered at a specific level above zero point (+5 cm, +10 cm, etc)
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Ventriculostomy
Drainage and Monitoring
- 1.
- 2. assess ICP for drainage every 15 minutes
- 3. for herniation drain 10 ml and reassess
- 4. maintain adequate, CPP, sedation/pain management, positioning
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