Download Left ventricular pressure systolic is 100 to 140 mmHg

Critical Care Monitoring, ETCO2, and Hemodynamics.
By: Louise Baartz, Yazan Safi and Sunil Thomas
Critical Care Monitoring
1) Temperature
2) Pulse
3) Blood Pressure
4) Respiratory Rate
5) SpO2
6) Pain
7) Level of Consiousness
8) Urine Output
Temperature
- Physiology – Controlled by the hypothalamus
- Factors – Age, Infection, Medications
- Assess probs – Core temp. differs b/w anatomical sites
Pulse
- Physiology – Reflects circulating volume and strength of contractility
- Factors – Intravascular volume contractility, oxygen demand
- Assessment problems – Should be counted for at least 30 seconds.
Regularity, strength, and equality should also be assessed.
Blood Pressure
- Physiology – Regulated by vasomotor center in the medulla
- Factors – Intravascular volume, vascular tone
- 90 to 120 mmHg over 60 to 80 mmHg is ideal for most HWP adults
Respiratory Rate
- Physiology – Controlled by the respiratory centers in the medulla and pons
- Factors – Hypercapnia, hypoxemia, acidosis
- Assessment problems – Indications for measuring to establish a baseline,
critical illness, a change in oxygenation, to evaluate response to treatment
SpO2
- Physiology – Reflects the peripheral saturation of hemoglobin by O2
- Factors – Cardiac output, hemoglobin level, FiO2
- Assessment issues – Doesn't reflect respiratory function overall
Pain
- Physiology – Detected by peripheral nerve fibers, interpreted by thalamus
and cerebral cortex
- Factors – Patients response
- Assessment problems – often under-assessed and treated in hospital
Level of Consciousness
- Physiology – Controlled by reticular activating system in the brain stem
- Factors – Cerebral perfusion
- Assessment issues – Influenced by intracranial and extracranial factors
Urine Output
- Physiology – Produced by kidneys
- Factors – Renal perfusion, cardiac output
- Assessment Issues – Doesn't directly reflect renal function
Capnography (ETCO2)
What is Capnography?
The term capnography refers to the noninvasive
measurement of the partial pressure of CO2 concentration
over time.
Capnography provides instantaneous information about
ventilation (how effectively CO2 is being eliminated by the
pulmonary system), perfusion(how effectively CO2 is being
transported through the vascular system), and metabolism(how
effectively CO2 is being produced by cellular system.
Normal EtCO2 level is 35-45mmhg
Changes in the shape of the capnogram are diagnostic of
disease conditions, while changes in end tidal CO2, the
maximumCO2 concentration at the end of each tidal breath,
can be used to assess disease severity and response to
treatment.
Capnography - Physiology
4 Phases of Capnography
Phases of Capnography
•
•
•
•
Phase1 (dead space ventilation, A-B) represents the beginning of
exhalation where the dead space is cleared from the upper airway.
Phase 2(ascending phase, B-C) represents the rapid rise in CO2
concentration in the breath stream as the CO2 from the alveoli
reaches the upper airway.
Phase 3(alveolar plateau, C-D) represents the CO2 concentration
reaching a uniform level in the entire breath stream from alveolus
to nose. Point D, occurring at the end of the alveolar plateau,
represents the maximum CO2 concentration at the end of the tidal
breath and is approximately named the end tidal CO2 . This is the
number that appears on the monitor display.
Phase 4(D-E) represents the inspiratory cycle.
Clinical Applications for Intubated Patients
Verification of ETT placement
Continuous monitoring of tube location during transport
Gauging effectiveness of resuscitation and prognosis during
cardiac arrest
Indicator of ROSC during chest compressions
Titrating EtCO2 levels in patients with suspected increase in
intracranial pressure
Determining prognosis in trauma
Determining adequacy of ventilation
Verification of ETT Placement
–
Capnography is highly accurate in determining ETT
location.
–
A normal wave form can occur when the tube has been placed in
the right main stem bronchus.
–
A flat line wave form can occur in several situations,
–
Esophageal placement or tracheal placement with circulatory
failure
–
Prolonged cardiac arrest with diffuse cellular death (in
which no CO2 is produced because of an absence of cellular
respiration and CO2 exchange in the pulmonary bed is
severely compromised)
–
ETT obstruction
–
Complete airway obstruction distal to ETT (foreign body)
Monitoring ETT Location During
Transport
Continuous monitoring of ETT location
during transport can prevent unrecognized
misplaced intubation. It can be used for both
prehospital and in hospital intubated
patients.
Effectiveness of CPR
During cardiac arrest, when alveolar ventilation and
metabolism are essentially constant, EtCO2 reflects
pulmonary blood flow. Therefore, EtCO2 can be used as a
gauge of the effectiveness of cardiac compressions. As
effective CPR leads to a higher cardiac output, EtCO2
will rise, reflecting the increase in perfusion. An EtCO2
level <3mmhg is found immediately after cardiac arrest
and higher level generated during cardiac compressions
and a mean peak > 7.5mmhg is found just before return of
a palpable pulse or BP.
Return of Spontaneous Circulation
Capnographic waveform monitoring virtually eliminates the need
to stop chest compressions to check for pulses. Reestablishment of
a perfusing rhythm is accompanied immediately by a dramatic
increase in EtCO2 . Once this rise in EtCO2 is noted , chest
compressions can be safely stopped while cardiac rhythm and BP
are assessed.
Increased ICP and Trauma Prognosis
EtCO2 monitoring can help clinicians avoid inadvertent
hyperventilation of patients with head injury and suspected
increased intracranial pressure (ICP). It may also help
determine the prognosis of trauma victims.
Arterial CO2 tension affects blood flow to the brain. High CO2
levels result in cerebral vasodilation , while low levels result in
cerebral vasoconstriction. Sustained hypoventilation (PaCO2
levels >50mmHg results in increased cerebral blood flow and
increased ICP, which can harm head injuries. Sustained
hyperventilation (PaCO2 <30mmhg) is associated with worse
neurologic outcome
Clinical Applications for Spontaneously Breathing Patients
Performing rapid assessment of critically ill or seizing patients
Determining response to treatment in acute respiratory distress
Determining adequacy of ventilation in obtunded or unconscious
patients , or in patients undergoing procedural sedation
Detecting metabolic acidosis in diabetic patients and in children
with gastroenteritis
Providing prognostic indicators in patients with sepsis or septic
shock
Critical Illness and Seizures
The airway, breathing, and circulation of critically
ill patients can be rapidly assessed using the
capnography wave form and EtCO2 values.
Capnography is the only monitoring that is
accurate and reliable in actively seizing patients
because the capnographic waveform is determined
entirely by respiratory activity and is not
confounded by muscle activity or movement
artifact
Acute Respiratory Distress
By measuring EtCO2 and respiratory rate with each breath ,
capnography provides instantaneous feedback on the clinical status
of the patient. For example, a patient with a respiratory rate of 30
generate 150 EtCO2 readings in five minutes. This provides
sufficient information to determine whether the patient’s ventilation
is worsening despite treatment (increased EtCO2), stabilizing (stable
EtCO2), or improving (decreasing EtCO2).
•
Procedural Sedation
Capnography can rapidly detect the common adverse airway and
respiratory events associated with procedural sedation,
including: apnea, upper airway obstruction , laryngospasm,
bronchospasm, and respiratory depression. Respiratory
depression caused by over sedation will manifest an
abnormally high or low EtCO2 well before pulse oximetry
detects a falling oxyhemoglobin saturation. EtCO2 levels
greater than 70mmhg in patients without COPD indicate
respiratory failure.
Detecting Metabolic Acidosis
As the patient becomes acidotic, HCO3 decreases , causing an
increase in minute volume, which results in a compensatory
respiratory alkalosis. This process results in a decrease in EtCO2.
Prognosis in Sepsis
There is an inverse relationship between EtCO2 and lactate
levels in sepsis.EtCO2 performs similarly to lactate as a
predictor for mortality in patients with suspected sepsis.
Hemodynamics
More problems that an increase or decrease in
hemodynamis may cause!!!!
What is Hemodynamics?
It is the movement of blood
•
The measurement of the pressure that is exerted by
the blood as it moves through the heart chambers
during systolic and diastolic flow
Some factors that control blood pressure
•
Heart
•
Blood
•
Vessels
Keep in mind that without sufficient blood pressure the tissues will not
receive oxygen which will lead to hypoxemia
Basic Anatomical Features of the Heart
(Stroke Volume Index * (MAP – PAWP) * 0.0136)
1) Left Ventricle relates to the systemic arteries
- The normal range for left ventricular stroke work index is 50 to 62 gmm/m^2/beat
(Stroke Volume Index * (MPAP -RAP) * 0.0136)
2) Right Ventricle relates to the pulmonary arteries
- The normal range for the right ventricular stroke work index is 5 to 10
gm-m/m^2/beat
The normal range for end diastolic volume is 100 to 160 mL and end
systolic volume is 50 to 100 mL.
Coronary Artery Perfusion Pressure normal range is 60 to 80 mmHg
- This is calculated by taking diastolic blood pressure minus pulmonary
artery wedge pressure.
Basic Anatomical Features of the Heart
3) Left Atrium relates to the pulmonary veins
4) Right Atrium relates to the systemic veins
- Some Normal Pressures to Keep in mind
•
Central venous pressure is 3 to 8 mmHg
•
Right ventricular pressure systolic is 15 to 30 mmHg
•
Right ventricular pressure diastolic is 3 to 8 mmHg
•
Pulmonary artery pressure systolic is 15 to 30 mmHg
•
Pulmonary artery pressure diastolic is 4 to 12 mmHg
•
Pulmonary capillary wedge pressure is 2 to 15 mmHg
•
Left ventricular pressure systolic is 100 to 140
mmHg
•
Left ventricular pressure diastolic is 3 to 12 mmHg.
The heart kinda just beats and stuff!!!!
No.... But seriously here is what the heart actually
does in a diagram!!!!
Cardiac Cycle
This refers to the pumping cycle consisting of systole and diastole!
Preload is the stretch of ventricle muscle fibers before contraction, created by
end diastolic volume.
Afterload is the resistance to ejection of blood during systole.
So what can improve hemodynamically unstable patients
1) Arterial Catheter
2) Central Venous Catheter
3) Pulmonary Artery Catheter
4) Drugs (beta blockers calcium channel blockers, atropine, dopamine, and
dobutamine)
(Drugs explained in a picture in about 16 slides!!!! I think.... Maybe-ish)
Swan Ganz
is the passing of a thin tube (catheter) into the right side of the heart
and the arteries leading to the lungs. It is done to monitor the heart's
function and blood flow.
What is the arterial catheter used for?
- to measure systemic artery pressure
- collect arterial blood gas samples
The insertion site consists of radial, brachial, femoral, dorsalis pedis, and umbilical
(neonates)
Radial artery is the site of choice because of the collateral circulation to the hand
provided by the ulnar artery
Arterial Catheter Waveform
3→1: increase of BP during systole
2: dicrotic notch
closure of aortic valve during diastole
3: Arterial end-diastolic pressure
Decrease Pulse Pressure
↓ pulse pressure = early sign of hypovolemia
↓ stroke volume (hypovolemia)
↑blood vessel compliance (shock)
Tachycardia
Increase Pulse Pressure
↑ pulse pressure = early sign of vol. restoration
↑ stroke volume (hypervolemia)
↓ blood vessel compliance (arteriosclerosis)
bradycardia
Arterial Catheter
Located in the transducer position
- To ensure accurate mesurements, the
transducer, catheter, and measurement site
should all be at the same level
- Transducer or catheter higher than side will
give a false decreasing pressure reading
- Transducer or catheter lower than site will give
a false increasing pressure reading
Some complications associated with the arterial catheter!
- Ischemia
- Hemorrhage
- Infection
Central Venous Catheter
A multiple lumen catheter like this one allows the infusion of blood
and various medications through different ports
It also permits aspiration of blood samples or injections for cardiac
output measurements without the interruption of medications
Reasons to use the CVC
Measure central venous pressure
Administer fluid, blood, or medications
Aspiration of blood samples
Insertion Sites
Subclavian or internal jugular vein
Location
Superior vena cava near right atrium or within right atrium
The CVC is pressure of the blood in the
- Vena Cava
- Right Atrium
- Right Ventricle
•
CVC AKA RAP (Right atrial Pressure)
•
Right side preload
•
Right ventricular end diastolic pressure
The CVC is located above the right atrium.
Normal pressures are 2-6 mmHg by the transducer and a running pressure of
4-12 cmH2O by the water manometer.
It measures the right heart function and it's fluid levels
Decrease in CVP
1) Hypovolemia (decreased venous return), 2) Hemorrhage, 3) Shock
Vasodilation, 4) Decreased intrathoracic pressure, and 5) Increased ability
of the right heart to move blood
Increase in CVP
1) Hypervolemia (increased venouse return), 2) Pneumothorax, 3) Increased
intrathoracic pressure, 4) Pulmonary hypertension, 5) Pulmonary embolism,
6) Constrictive preicarditis, and 7) Cardiomyopathy
(Obviously there are some more problems if there is an increase or decrease in pressure for the
central venous catheter, but these are some of the major issues)
Pulmonary Artery Catheter AKA Swan Ganz catheter
So this wonderful device monitors heart rate, blood pressure, and cardiopulmonary
problems.
But, what could that possibly mean.... It monitors the right and left sides of the heart.
The pulmonary artery catheter has a number of modes (like our vents) but most
come in about 110 cm in length with 3 lumens.
The exterior of the catheter is marked off in 10 cm segments used to estimate
catheter tip location upon insertion
Distal lumen lies in the pulmonary artery and is used to inject medications, monitor
SvO2, and measure pulmonary artery pressures
Proximal lumen lies in the right ventricle and is used to aspirate blood samples and
inject thermal bolus for thermal dilution cardiac output measurements.
The thermistor on the pulmonary artery catheter is what it sounds like = measures
temperature.
Pulmonary artery catheter used to measure central venous pressure,
pulmonary artery mean pressure, collect mixed venous blood samples,
monitor mixed venous O2 saturation, measure cardiac output, and
provide cardiac pacing.
This PAV is inserted at the subclavian or internal jugular vein.
Some complications pertaining to the pulmonary artery catheter include
•
Infection
•
Bleeding
•
Pneumothorax
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Pulmonary Artery Hemorrhage
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Pulmonary infarction
•
Air embolism
•
Cardiac arrhythmias
Pulmonary Artery Catheter:
Insertion
Right ventricle
Normal pressure: 20-30 mmHg
0-5
Pulmonary Artery
Normal Pressure: 20-30 mmHg
6-15
Pulmonary Artery Pressure Decreases
- Volume of blood ejected by the right
ventricle decreases and pulmonary vasculature
relaxes or dilates
Pulmonary Artery Pressure Increases
-Vascular resistance increases causing
constriction (hypoxemia, acidosis, drugs,
pulmonary hypertension)
- Obstruction (pulmonary embolus)
- Compression – disease constricting
pulmonary vasculature
Inflation of Balloon
- Pulmonary Artery Catheter Waveform is where the catheter will
eventually be placed.
- The balloon is then deflated and the catheter is stabilized in it's place,
the balloon remains deflated and the pulmonary artery pressure tracing
remains on the monitor at all time.
- The balloon is inflated only when the pulmonary capillary wedge
pressure is being taken.
What is the normal range for cardiac output????
- (This is getting quite boring but we're almost done)
- 4 to 8 Lpm and this depends on the body size!
Ejection Fraction
The ejection fraction is a measurement of the heart's
efficiency and can be used to estimate the function of
the left ventricle, which pumps blood to the rest of
the body. The left ventricle pumps only a fraction of
the blood it contains. The ejection fraction is the
amount of blood pumped divided by the amount of
blood the ventricle contains. A normal ejection
fraction is more than 55% of the blood volume. If the
heart becomes enlarged, even if the amount of blood
being pumped by the left ventricle remains the same,
the relative fraction of blood being ejected decreases.
Lets just give you a couple more FYI's!!!!
Pulse Pressure – 40 mm HG
Stroke Volume – 60 – 130 ml/beat
Ejaction Fraction – 65 – 75%
SVR - < 20 mmHg/L/min
PVR - < 2.5 mmHg/L/min
References
Bein, Berthold; Meybohm, Patrick; Cavus, Erol; Renner, Jochen; Tonner, Peter H.; Steinfath, Markus; Scholz, Jens; Doerges, Volker (2007). "The Reliability of
Pulse Contour-Derived Cardiac Output During Hemorrhage and After Vasopressor Administration". Anesthesia & Analgesia 105
Bland, RD; Shoemaker, WC; Abraham, E; Cobo, JC (1985). "Hemodynamic and oxygen transport patterns in surviving and non-surviving postoperative
patients".
Chaliki HP, Hurrell DG, Nishimura RA, Reinke RA, Appleton CP (July 2012). "Pulmonary venous pressure: relationship to pulmonary artery, pulmonary
wedge, and left atrial pressure in normal, light sedation". Catheter Cardiovascular Intervention
Elliot, M. (2012, May 1). Critical care: The eight vital signs of patient monitoring.
Goers, Trudi A.; Washington University School of Medicine Department of Surgery; Klingensmith, Mary E; Li Ern Chen; Sean C Glasgow (2008). The
Washington manual of surgery. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Jaffe MB (September 2008). "Infrared measurement of carbon dioxide in the human breath: "breathe-through" devices from Tyndall to the present day"
Manecke, Gerard R (2005). "Edwards FloTrac™ sensor and Vigileo™ monitor: easy, accurate, reliable cardiac output assessment using the arterial pulse
wave". Expert Review of Medical Devices 2
Peacock, Andrew J.; Lewis J. Rubin (2009). Pulmonary Circulation: Diseases and their treatment.
Potter, Patricia Ann, and Anne Griffin Perry. "Nutrition." Essentials for nursing practice. Eighth ed. St. Louis: Elsevier, 2015.
Rajaram, SS; Desai, NK; Kalra, A; Gajera, M; et al. (2013). "Pulmonary artery catheters for adult patients in intensive care". Cochrane Anaesthesia Group.
Sandham, JD; Hull, RD; Brant, RF; Knox, L; et al. (January 2, 2003). "A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk
surgical patients".
Shah, MR; Hasselblad, V; Stevenson, LW; Binanay, C; et al. (October 5, 2005). "Impact of the pulmonary artery catheter in critically ill patients: Meta-analysis
of randomized clinical trials".
Uzun M, Erinc K, Kirilmaz A, et al. (November 2014). "A novel method to estimate pulmonary artery wedge pressure using the downslope of the Doppler
mitral regurgitant velocity profile". Echocardiography.
Mike's website helped us with the catheters!
Silly boys and girls.... We are still not finished
It is time to review what we learned this semester because we are
officially the last group to present the group project.
So does anyone want to take a break before we present another 15 or so
slides? (Future information does not include citations and the credible
sources come from our classmates and there wonderful work)
Now that Yazan, Louise, and Sunil finished rambling on and on
about these topics, we are officially half way done with 5/6ths or
2/3rds (Josh, Raj, Zee) of the respiratory therapy courses.
(Pending a Traci course takeover and Mike Haines final exam :/)