Bedside invasive procedures in ccu
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Bedside invasive procedures in ccu
- 1. www.cardiozag.com Bedside Invasive Procedures In CCU Dr.ELSayed Farag,MD Zagazig University
- 2. Agenda Arterial line Central venous line Swan Ganz catheters Periocardiocentesis Intraaortic balloon counterpulsation Bedside temporary pacemakers www.cardiozag.com
- 3. WHAT IS AN ARTERIAL LINE? An arterial line is a cannula usually positioned in a peripheral artery Such as: Radial artery Brachial artery Dorsalis pedis artery Femoral artery www.cardiozag.com
- 4. INDICATIONS FOR USING ARTERIAL LINE Ease of access Continuous monitoring of arterial blood pressure • if patient is on intropic drugs • if patient is on vasoactive drug • if patient requires frequent arterial blood sampling www.cardiozag.com
- 5. COMPLICATIONS ASSOCIATED WITH ARTERIAL LINES ACCIDENTAL INTR-ARTERIAL INJECTION OF DRUGS LOCAL DAMAGE TO ARTERY www.cardiozag.com
- 7. THE ARTERIAL WAVEFORM The arterial waveform reflects the pressure generated in the arteries following ventricular contraction and can be described as having:- • Anacrotic notch • Peak systolic pressure • Dicrotic notch • Diastolic pressure www.cardiozag.com
- 9. CVP Reasons For Inserting Central Venous Catheters Limited vascular access Administration of intropes , highly osmotic or caustic fluids or medications Frequent administration of blood and blood products Frequent blood sampling Measurement of CVP Hemodialysis www.cardiozag.com
- 10. COMMON CENTRAL LINE INSERTION SITES Right internal jugular left internal jugular right subclavian left subclavian femoral (as a last resort) Or peripherally inserted central catheters (PICC) which are inserted via the antecubital veins (basilic vein is the best) in the arm and is advanced into the central veins www.cardiozag.com
- 15. COMPLICATIONS • Carotid Artery Puncture • Pneumothorax • Air Embolism • Arrhythmia • Perforation of SVC or R. Atrium/Ventricle • Infection • Pleural Effusion • Extravasion of Infusate • Allergic reaction to catheter material www.cardiozag.com
- 17. INTERPRETATION • An increase of above normal (up to 10 cm H2O) may indicate weakening or failure of the right side of the heart, or excessive intravascular volume • A pressure below 5cm H2O usually reflects an intravascular volume deficit or drug induced excessive vasodilation • CVP measurements must not be interpreted on their own, but viewed alongside the patient's full clinical picture (BP, Respiratory Pattern, Colour, Temperature) • Several measurements are required to identify a trend www.cardiozag.com
- 18. DETERMINANTS Cardiac Competence (reduced ventricular function raises CVP) Blood Volume (increased venous return raises CVP) Intra Aortic & Intra Peritoneal Pressure (raises CVP) Systemic Vascular Resistance (raises CVP) CVP
- 20. What is a Swan? Full name: Swan-Ganz Catheter Pulmonary Artery (PA) Catheter = right heart catheter Used it to monitor a patient’s hemodynamics when we cant answer the question using noninvasive/clinical measures Useful to measure right atrial, pulmonary artery, right ventricular pressures and indirectly measure left atrial pressures, cardiac output and systemic vascular resistance www.cardiozag.com
- 21. Why use a Swan? Differentiation between causes of shock>cardiogenic, hypovolemic, septic Differentiation between causes of pulmonary edema>cardiogenic versus noncardiogenic Diagnosis of pericardial tamponade Diagnosis of intracardiac shunt Evaluation/Management of pulmonary hypertension Diagnosis of lymphangitic spread of tumor and fat embolism Management of complicated MI, HF Determine need for vasopressor/inotropic therapy Fluid Status>in GI bleed, renal failure, sepsis Ventilator management>determining the best PEEP www.cardiozag.com
- 22. Escape Trial The value of Swan-Ganz catheterization to guide tailored therapy in heart failure patients is an area of controversy. The randomized ESCAPE trial showed no benefit on a primary end point of the number of days alive and out of the hospital at six months JAMA. 2005;294:1625-1633. www.cardiozag.com
- 23. Insertion Techniques Goal: get the catheter to the pulmonary artery Right internal jugular vein or left subclavian allows easiest passage Swan should be oriented ex-vivo to approximate the course in the body Catheter goes through an introducer and into the vein. The balloon stays closed until we reach the right atrium. When we reach the right atrium (20cm), balloon should be inflated to reduce possibility of injury to the myocardium. Then the balloon should be moved quickly through the right ventricle (30cm)> and then pulmonary artery (40cm) and PCWP (50cm) FROM SUBCLAVIAN/IJ APPROACH www.cardiozag.com
- 24. How do you know you are in the Right Atrium?>>20 cm Normal right atrial presssure is 0-6mmHg. Normal oxygen content 15% Normal O2 saturation 75% www.cardiozag.com
- 25. What Elevates the Right Atrial Pressure? RV infarct Pulmonary hypertension Pulmonary stenosis Left to right shunt Tricuspid valvular disease Left heart failure www.cardiozag.com
- 26. How do you know you are in the right ventricle? RV systolic=17-30 RV diastolic=0-6 RV O2 content=15% RV O2 saturation 75% 30cm www.cardiozag.com
- 27. What Increases RV Pressures? RV failure Pulmonary hypertension Pulmonary stenosis Pulmonary Embolism Cardiomyopathy Cardiac tamponade Cardiac constriction www.cardiozag.com
- 28. How do you know you are in the pulmonary artery? Normal PA pressure, systolic 15-30 Normal PA pressure, diastolic 5-13 O2 content 15% O2 saturation 75%
- 29. What Elevates PA pressure? Volume Overload (backflow) Primary lung disease Primary pulmonary hypertension Pulmonary Embolism Left to right shunt Mitral Valve Disease www.cardiozag.com
- 30. THE WEDGE: What is the Pulmonary Artery Wedge Pressure? The measurement is obtained when the inflated balloon impacts into a slightly smaller branch of the pulmonary artery. This is where the arterial pressure exceeds the venous pressure and the venous pressure exceeds the alveolar pressure, thereby creating a continuous column of blood from the catheter tip to the left atrium when the balloon is inflated. Pulmonary venous pressure is the best indicator of left atrial pressure except when there is venoocclusive disease. AND ONLY WHEN THE PA CATHETER IS IN ZONE 3 of the lung. www.cardiozag.com
- 31. Pulmonary artery wedge 2-12 Pulmonary vein O2 content 20% Pulmonary vein O2 sat 98% PCWP tracing looks like RA tracing except that the v wave is slightly higher than the a wave (opposite of RA). Also, b/c of the time required for LA mechanical events, PAWP waveforms are further delayed when recorded by EKG Inflation of the Balloon for PCWP Tracing www.cardiozag.com
- 32. What Increases PCWP? PEEP (minimally) LV failure Cardiac tamponade Aortic Insufficiency Mitral regurgitation VSD www.cardiozag.com
- 34. •Don’t leave balloon inflated in wedge position for extended period of time>can cause pulmonary infarction • Thromboembolic events can occur with the catheter acting as a nidus for thrombus formation. Less common with heparin bonded catheters •Misinterpretation of the data •Mural thrombi can be induced by inflammation of infection of a vessel wall, seen in 33% of patients at autopsy •Sterile vegetations, seen in 90% of patients •Endocarditis of the pulmonic valve •Rupture of the catheter balloon and consequent air embolism Not Without Risks??? www.cardiozag.com
- 36. IABP PURPOSE Improves cardiac function during cardiogenic shock. 26-28 cm balloon surrounds end of centrally placed catheter (from groin) Placed into descending thoracic aorta Inflates in diastole - fills coronary arteries retrograde Deflates in systole - decreases LV afterload www.cardiozag.com
- 37. What is an IABP? The Intra-Aortic Balloon Counterpulsation system is a volume displacement device. A device used to reduce left ventricular systolic work, left ventricular end-diastolic pressure, and wall tension Decreases oxygen consumption Increases cardiac output, perfusion, pressure and volume to Coronary Artries
- 47. ECG Trigger Since triggering on the R wave of the ECG is preferred, it is very important to give the IABP a good quality ECG signal and lead www.cardiozag.com
- 48. Triggering on the Arterial Pressure Waveform Arterial pressure provides another signal to the IABP to determine where the cardiac cycle begins and ends It is used when the ECG has too much interference from patient movement or poor lead connection There are limitations to triggering on the arterial pressure curve • Therefore AP trigger should be considered a backup trigger and not the one used as the primary trigger www.cardiozag.com
- 49. The Guidelines IABP in STEMI complicated by cardiogenic shock Class 1B ACC/AHA ESC Strongly recommended Antman et al. Circulation 2004 / van de Werf et al. EHJ 2002 www.cardiozag.com
- 51. Clinical Manifestations of Tamponade SOB Tachycardia Hypotension>>Shock Elevated JVP www.cardiozag.com
- 56. Indications for Temporary Pacing Acute myocardial infarction with: CHB, Mobitz type 2 AV block, medically refractory symptomatic bradycardia, alternating BBB, new bifascicular block, new BBB with anterior MI In absence of acute MI : SSS, CHB, Mobitz type 2 AV block Treatment of tachyarrhythmias : VT www.cardiozag.com
- 58. Temporary Transvenous Pacing Unipolar Electrograms www.cardiozag.com
- 59. Invade when it is really needed but please be careful………!!!!!! www.cardiozag.com
Notas do Editor
- Thereby avoiding the discomfort of frequent punctures of the artery eg tests for blood gases, serial blood lactate levels, full blood count, u&e’s etc.
- HYPOVOLAEMIA – ACCIDENTAL DISCONNECTION OF TUBING FROM THE CANNULA CAN RESULT IN SEVERE HAEMORRHAGE AND HYPOVOLAEMIA NO DRUGS SHOULD BE ADMINISTERED THROUGH THE ARTERIAL LINE AS IT CAN CAUSE DISTAL ISCHAEMIA AND NECROSIS WITH SOMETIMES PERMANENT DAMAGE LOCAL DAMAGE TO ARTERY – THIS IS THE MOST COMMON COMPLICATION. IT IS IMPORTANT TO KEEP AN EYE ON THE DISTAL END EG FINGERS WATCH FOR SIGNS OF CHANGE IN TEMPERATURE, MOTTLING OR BLANCHING PARTICULARLY WHEN THE LINE IS FLUSHED.
- Why would the femoral vein be used as a last resort?
- Several studies show that clinicians are poor at correlating clinic status with hemodynamic assessment. In a general ICU population, clinicians could correlate correlate PCWP and cardiac index only 30-70% of the time. And 60-85% of the time in CCUs. People then argued that more frequent and accurate diagnosis of the conditions that can be treated would improve patient outcome. So in the 1970s, with Swan-Ganz, it became the standard of care in hemodynamically unstable patients. Differentiation between causes of shock>cardiogenic, hypovolemic, septic Differentiation between causes of pulmonary edema>cardiogenic versus noncardiogenic Diagnosis of pericardial tamponade Diagnosis of intracardiac shunt Evaluation/Management of pulmonary hypertension Diagnosis of lymphangitic spread of tumor and fat embolism Management of complicated MI, HF Determine need for vasopressor/inotropic therapy Fluid Status>in GI bleed, renal failure, sepsis Ventilator management>determining the best PEEP
- Average time from decision to use PA catheter until onset of catheter based treatment is 120 minutes Goal: get the catheter to the pulmonary artery Cordis into right internal jugular vein or left subclavian allows easiest passage Swan should be oriented ex-vivo to approximate the course in the body Catheter goes through an introducer and into the vein. The balloon stays closed until we reach the right atrium. When we reach the right atrium (20cm), balloon should be inflated to reduce possibility of injury to the myocardium. Then the balloon should be moved quickly through the right ventricle (30cm)> and then pulmonary artery (40cm) and PCWP (50cm) FROM SUBCLAVIAN/IJ APPROACH The balloon is inflated with air. But filtered CO2 should be used in any situation in which balloon rupture might cause air to get into arterial system>like if there is an intracardiac shunt or pulmary A-V fistula.
- a=atrial contraction. A wave peak follows the electrical p wave by about 80msec c=sudden motion of the AV ring toward the right atrium. x descent=atrial relaxation v=pressure generated by venous filling of the right atrium. The peak of the v wave occurs at the end of ventricular systole when atrium is maximally filled. This occurs near the end of the t wave y descent=rapid emptying of the RA into RV Normal right atrial presssure is 0-6mmHg. Normal oxygen content 15% Normal O2 saturation 75%
- Two pressures are measured in the RV. The peak of the RV systolic pressure and the RV end diastolic pressure, right after the a wave. The ventricular diastole is made up of early rapid filling phase (60%) and a slow phase (25%) filling and an atrial systolic phase which produces an a wave in the RV tracing.
- PA waveform is characterized by a systolic peak and diastolic trough with a dictrotic notch due to closure of the pulmonic valve. PA systolic pressure occurs within T wave of EKG similar to the systemic arterial pressures.
- The measurement is obtained when the inflated balloon impacts into a slightly smaller branch of the pulmonary artery. In this position, the balloon stop flows and catheter tip senses pressure transmitted backward through the static column of blood from the next pulmonary bed, the pulmonary veins. Pulmonary venous pressure is the best indicator of left atrial pressure except when there is venoocclusive disease The PCWP only indicates the LAP if the pressure in the surrounding capillaries exceeds the mean alveolar pressure. That is ZONE 3. This concept is based on the idea tha the lung can divided into 3 physiologic zones of blood flow which are based upon the relationship b/t alveolar pressure, PAP and pulm capillary pressure. In ZONE 1, the alveolar pressure is greater than the capillary pressure. In Zone 3, the most dependent portion of the lung, vascular pressures are the highest d/t gravity. So again PCWP is only accurately a measure of LAP IF PCP exceeds mean alveolar pressure. So how do you know you are in Zone 3? 60% of catheter insertion are only in the right place. You can look at the CXR and the catheter should be below the left atrium. If there is marked respiratory vairation in the PAWP tracing you are likely not in Zone 3 and if PAD> PCWP then you are likely not in zone 3.
- Inflation of the balloon changes the tracing of the pulmonary artery. Goes from having a dicrotic notch to having more of a,c,v wave pattern like we saw in the right atrium. This is because we are measure left atrial pressure. Pulmonary artery wedge 2-12 PCWP tracing looks like RA tracing except that the v wave is slightly higher than the a wave (opposite of RA) B/c of the time required for LA mechanical events, PAWP waveforms are further delayed when recorded by EKG. The peak of the A wave follows the the peak of the EKG p wave by 240 ms and the peak of the v wave occurs after the EKG t wave. A wave=atrial systole C wave=reflecting closure of the mitral valve V wave=represents both ventricular systole and passive atrial filling in atrial diastole. Pulmonary artery wedge 2-12 Pulmonary vein O2 content 20% Pulmonary vein O2 sat 98% Confirmation of the PCWP position is done be withdrawing blood from the distal lumen and measureing the O2 aturation. If >95% are considered satisfactory.
- The PDP/DA influences the gradient for coronary artery perfusion Irregular heart rates and irregular pulse pressures can cause the pump to not see a trigger where it expects to find one If this happens, pumping will be temporarily interrupted as the computer relearns the parameters Late deflation will also cause missed triggers and an interruption in pumping