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1、Critical Care Monitoring,ETCO2,and Hemodynamics.By:Louise Baartz,Yazan Safi and Sunil ThomasCritical Care Monitoring1)Temperature2)Pulse3)Blood Pressure4)Respiratory Rate5)SpO26)Pain7)Level of Consiousness8)Urine OutputTemperature-Physiology Controlled by the hypothalamus-Factors Age,Infection,Medic
2、ations-Assess probs Core temp.differs b/w anatomical sitesPulse-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
3、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 adultsRespiratory Rate-Physiology Controlled by the respiratory centers in the medulla and pons-Factors Hypercapnia,hypox
4、emia,acidosis-Assessment problems Indications for measuring to establish a baseline,critical illness,a change in oxygenation,to evaluate response to treatmentLevel of Consciousness-Physiology Controlled by reticular activating system in the brain stem-Factors Cerebral perfusion-Assessment issues Inf
5、luenced by intracranial and extracranial factorsUrine Output-Physiology Produced by kidneys-Factors Renal perfusion,cardiac output-Assessment Issues Doesnt directly reflect renal function Capnography(ETCO2)What is Capnography?The term capnography refers to the noninvasive measurement of the partial
6、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 produc
7、ed by cellular system.Normal EtCO2 level is 35-45mmhgChanges 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.4 Phases of Cap
8、nographyPhases of CapnographyPhase1(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 ai
9、rway.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 en
10、d tidal CO2.This is the number that appears on the monitor display.Phase 4(D-E)represents the inspiratory cycle.Monitoring ETT Location During TransportContinuous monitoring of ETT location during transport can prevent unrecognized misplaced intubation.It can be used for both prehospital and in hosp
11、ital intubated patients.Effectiveness of CPRDuring 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 outpu
12、t,EtCO2 will rise,reflecting the increase in perfusion.An EtCO2 level 7.5mmhg is found just before return of a palpable pulse or BP.Increased ICP and Trauma PrognosisEtCO2 monitoring can help clinicians avoid inadvertent hyperventilation of patients with head injury and suspected increased intracran
13、ial 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 ce
14、rebral blood flow and increased ICP,which can harm head injuries.Sustained hyperventilation(PaCO2 30mmhg)is associated with worse neurologic outcomeClinical Applications for Spontaneously Breathing PatientsPerforming rapid assessment of critically ill or seizing patientsDetermining response to treat
15、ment in acute respiratory distressDetermining adequacy of ventilation in obtunded or unconscious patients,or in patients undergoing procedural sedation Detecting metabolic acidosis in diabetic patients and in children with gastroenteritisProviding prognostic indicators in patients with sepsis or sep
16、tic shockCritical Illness and SeizuresThe 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 wavefo
17、rm is determined entirely by respiratory activity and is not confounded by muscle activity or movement artifactAcute Respiratory DistressBy measuring EtCO2 and respiratory rate with each breath,capnography provides instantaneous feedback on the clinical status of the patient.For example,a patient wi
18、th a respiratory rate of 30 generate 150 EtCO2 readings in five minutes.This provides sufficient information to determine whether the patients ventilation is worsening despite treatment(increased EtCO2),stabilizing(stable EtCO2),or improving(decreasing EtCO2).Procedural SedationCapnography can rapid
19、ly 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
20、oximetry detects a falling oxyhemoglobin saturation.EtCO2 levels greater than 70mmhg in patients without COPD indicate respiratory failure.Prognosis in SepsisThere is an inverse relationship between EtCO2 and lactate levels in sepsis.EtCO2 performs similarly to lactate as a predictor for mortality i
21、n patients with suspected sepsis.HemodynamicsWhat is Hemodynamics?It is the movement of bloodThe measurement of the pressure that is exerted by the blood as it moves through the heart chambers during systolic and diastolic flowSome factors that control blood pressureHeartBloodVesselsKeep in mind tha
22、t without sufficient blood pressure the tissues will not receive oxygen which will lead to hypoxemiaBasic 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 gm-m/
23、m2/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/m2/beatThe normal range for end diastolic volume is 100 to 160 mL and end systolic volume is 50 to 100 mL.Coronary Artery Per
24、fusion Pressure normal range is 60 to 80 mmHg-This is calculated by taking diastolic blood pressure minus pulmonary artery wedge pressure.The heart kinda just beats and stuff!No.But seriously here is what the heart actually does in a diagram!Cardiac CycleThis refers to the pumping cycle consisting o
25、f 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 patients1)Arterial Catheter2)Central Venous Catheter3)Pulmonary Art
26、ery Catheter4)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
27、 the hearts function and blood flow.What is the arterial catheter used for?-to measure systemic artery pressure-collect arterial blood gas samplesThe insertion site consists of radial,brachial,femoral,dorsalis pedis,and umbilical(neonates)Radial artery is the site of choice because of the collateral
28、 circulation to the hand provided by the ulnar arteryArterial Catheter Waveform31:increase of BP during systole2:dicrotic notchclosure of aortic valve during diastole3:Arterial end-diastolic pressureDecrease Pulse Pressure pulse pressure=early sign of hypovolemia stroke volume(hypovolemia)blood vess
29、el compliance(shock)TachycardiaIncrease Pulse Pressure pulse pressure=early sign of vol.restoration stroke volume(hypervolemia)blood vessel compliance(arteriosclerosis)bradycardiaArterial CatheterLocated in the transducer position-To ensure accurate mesurements,the transducer,catheter,and measuremen
30、t 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 readingSome complications associated with the arterial catheter!-Ischemia-Hemorrhage-InfectionCent
31、ral Venous CatheterA multiple lumen catheter like this one allows the infusion of blood and various medications through different portsIt also permits aspiration of blood samples or injections for cardiac output measurements without the interruption of medicationsReasons to use the CVCMeasure centra
32、l venous pressureAdminister fluid,blood,or medicationsAspiration of blood samplesInsertion SitesSubclavian or internal jugular veinLocationSuperior vena cava near right atrium or within right atriumThe CVC is pressure of the blood in the-Vena Cava-Right Atrium-Right VentricleCVC AKA RAP(Right atrial
33、 Pressure)Right side preloadRight ventricular end diastolic pressureThe 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 its fluid levelsDecrease in CVP 1)Hypovol
34、emia(decreased venous return),2)Hemorrhage,3)Shock Vasodilation,4)Decreased intrathoracic pressure,and 5)Increased ability of the right heart to move bloodIncrease in CVP1)Hypervolemia(increased venouse return),2)Pneumothorax,3)Increased intrathoracic pressure,4)Pulmonary hypertension,5)Pulmonary em
35、bolism,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 catheterSo this wonderful device monitors hear
36、t 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 i
37、n 10 cm segments used to estimate catheter tip location upon insertionDistal lumen lies in the pulmonary artery and is used to inject medications,monitor SvO2,and measure pulmonary artery pressuresProximal lumen lies in the right ventricle and is used to aspirate blood samples and inject thermal bol
38、us 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
39、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 includeInfectionBleedingPneumothoraxPulmonary Artery HemorrhagePulmonary infarctionAir embolismCardiac arrhythmi
40、asPulmonary Artery Catheter:InsertionRight ventricleRight ventricleNormal pressure:Normal pressure:20-3020-30 mmHgmmHg 0-5 0-5Pulmonary ArteryPulmonary ArteryNormal Pressure:Normal Pressure:20-3020-30 mmHgmmHg 6-15 6-15Pulmonary Artery Pressure Decreases-Volume of blood ejected by the right ventricl
41、e decreases and pulmonary vasculature relaxes or dilatesPulmonary Artery Pressure Increases-Vascular resistance increases causing constriction(hypoxemia,acidosis,drugs,pulmonary hypertension)-Obstruction(pulmonary embolus)-Compression disease constricting pulmonary vasculatureInflation of Balloon-Pu
42、lmonary Artery Catheter Waveform is where the catheter will eventually be placed.-The balloon is then deflated and the catheter is stabilized in its 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
43、pulmonary capillary wedge pressure is being taken.What is the normal range for cardiac output?-(This is getting quite boring but were almost done)-4 to 8 Lpm and this depends on the body size!Ejection FractionThe ejection fraction is a measurement of the hearts efficiency and can be used to estimate
44、 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
45、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 FYIs!Pulse Pressure 40 mm HGStroke Volume 60 130 ml/beatEjaction Fraction 65 75%SVR-20 mm
46、Hg/L/minPVR-2.5 mmHg/L/minReferencesBein,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,R
47、D;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 pressu
48、re in normal,light sedation.Catheter Cardiovascular InterventionElliot,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
49、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 dayManecke,Gerard R(2005).Edwards FloTrac sensor and Vigileo monitor:easy,accurate,reliable c
50、ardiac 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.Raj