Hemodynamics #5

Question 1

Phosphodiesterase Inhibitors action / indication

Answer 1

Second line drug not used often. (For beta receptor down regulation)

• Beta Receptor stimulation causes ATP to be converted to cyclic AMP
• CAMP makes everything happen with cell.
• cAMP broken down w/ phosphodiesterase
• beta downregulation due to continuous beta receptor stimulation.
• beta drugs are DC, phosphodiesterase inhibitors initiated.

Question 2

Beta downregulation & steroid administration

Answer 2

Steroids tell RNA in cells to go into overdrive and create proteins which are used to create beta receptors

Question 3

Cardiogenic shock vasopressin considerations

Answer 3

Pump failure - vasopressor stick a cork in the aorta.

-dopamine & Levophed May bridge temporarily.

Question 4

Cardiogenic shock treatment

Answer 4

• Adding volume helps to a point then hurts,
• dopamine until dobutamine works
• dobutamine assists w/ decreasing afterload
• sodium Nitroprusside (nitropress) for vasodilation once BP maintained w/ dobutamine (let ventricles clear & prevent cardiomyopathies)
• IABP & LVAD therapy.

Question 5

Normal Pressures: 
CVP
CI
PA
PCWP
SVR

Answer 5

CVP: 2-6
CI: 2.5-4.2
PA: 15-25(PAS) / 8-15 (PAD)
PCWP: 4-12
SVR: 800-1200

Question 6

CVP Waveform

Answer 6

Preload for R side of heart
-hydration 1st, then RV function
Waveform: Sloppy cursive M
-A, C, V wave
-CVP range: mean average of waves

Question 7

Low CVP

Answer 7

1. Hypovolemia
2. Vasodilation / decrease preload
3. Negative pressure ventilation
   - spontaneous ventilation
   - hyperventilation

Question 8

High CVP

Answer 8

1. Hypervolemia
2. Obstruction upstream
   - RV failure or RVI
   - cardiac Tampanade
   - positive pressure ventilation (always drops preload)
   - pulmonary hypertension
   - tight lungs
   - PE
   - pulmonic valve stenosis
   - tricuspid stenosis / regurgitation

Question 9

IJ Depth of Insertion (cm)
CVP/ RA
RVP
PAP
PCWP

Answer 9

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 20
RVP: 30
PAP: 40
PCWP: 50

Question 10

Subclavian Depth of Insertion (cm)

Answer 10

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 25
RVP: 35
PAP: 45
PCWP: 55

Question 11

Femoral Depth if Insertion (cm)

Answer 11

IJ (10's) - Subclavian (+5) - Femoral (+20)
CVP/ RA: 40
RVP: 50
PAP: 60
PCWP: 70

Question 12

Positive pressure ventilation benefits and complication

Answer 12

Right heart friendly during failure (gives Chambers ability to clear)

Not left heart friendly during failure (need to improve preload on left side)

Question 13

RVP

Answer 13

-Not typically monitored
-can irritate ventricle causing VF/VT
-looks similar to VT
-Sharp upstroke and down stroke
-notching on ascending side indicates atrial kick
-Anachrotic Notch
-norm: systolic: 15-25, diastolic:0-5
(Diastolic Must be lower than CVP)

Question 14

Pressures: Single vs fractional numbers

Answer 14

Single: mean numbers (preloads)

2 numbers: arterial (after loads)

Question 15

PA waveform

Answer 15

R heart output, L heart preload

• Pulmonary compliance
• PAS: same as RVP
• PAD: higher than RVDP (pulmonic valve closes and hold pressure for backflow into RV)

Question 16

Low PAP

Answer 16

• Dehydration
• RV failure or RVI (upstream blockage)
• pulmonary stenosis (upstream blockage)

Question 17

High PAP

Answer 17

Blockage downstream

• fluid overload
• mitral stenosis or regurgitation
• left ventricular failure
• aortic stenosis/regurgitation
• high pulmonary vascular resistance / HTN (hypoxia)
• AV Communication (hole between AV chambers)
• PE, ARDS, HPVR

Question 18

PA Placement

Answer 18

• head up R Tilt position
• Cath balloon down via jugular, subclavian, femoral into vena cava.
• balloon inflated upon CVP waveform.
• RVP waveform: balloon sails toward RV septum toward PA
• PA waveform (same systolic, higher diastolic than RVP) balloon is deflated.

Question 19

PCWP Waveform

Answer 19

• balloon inflated (1.5 ml) wedges in R lung
• occluded blood from R heart, eliminating R heart pressures.
• Low amplitude rolling waveform (similar to CVP, looks like fine VF)
• diastole, mitral open. LVEDP

Question 20

High PCWP

Answer 20

• Obstruction downstream
• left ventricular failure
• high SVR
• constrictive pericarditis
• mitral stenosis and regurgitation
• fluid overload
• pulmonary hypertension
• hypoxia
• ARDS
• aortic stenosis

Question 21

Low PCWP

Answer 21

• Obstruction upstream
• RV failure
• dehydration
• vasodilation

Question 22

Inadvertent wedge troubleshooting

Answer 22

Caused by migration or balloon inflation

1. Confirm balloon is fully deflated
2. Have patient cough forcefully or roll to side and back (increases intrathoracic pressure’s and can pop back in to PA)
3. Withdraw catheter until waveform returns to PA waveform (pullback very slowly and carefully)

Question 23

Inadvertent RV waveform troubleshooting

Answer 23

Step 1: inflate balloon

• pads tip of Cath
• sail back into PA

Step 2: deflate balloon, drawback until CVP waveform obtained.

• safest technique
• confirm balloon deflated otherwise tricuspid damage will occur

Question 24

CHF Treatment (5)

Answer 24

1. Decrease preload (nitro, MS, Lasix)
2. Decrease afterload (Nitroprusside (Nipride), nesiritude (natrocor))
3. Decrease rate (beta blocker: Carvedilol (coreg) only(alpha& beta properties))
4. Inhibit RAA System (ace inhibitors (prils-analapril))
5. Improve Contractility (dobutamine B1&2 2:vasodilation(after load reduction) & phosphodiesterase inhibitors)