20160915-edwards-hemodyn

eLibrary – FREE

 

20160915-edwards-hemodyn

Build up your eLibrary starting with this gem – great hemodynamic tutorial. Hemodynamics is a huge part of our jobs as respiratory therapists and being proficient is key to being a great practitioner.

Anyone and everyone should get this booklet if you are interested in hemodynamics.

It is free to download.

Google search “edwards hemodynamics pdf” and then select the search item I have identified in the inset.

If you go to the Edwards website’s homepage, there are other good booklets for free.

There is a lot of good stuff out there for free from our vendors.

As I have opportunities, I will post them – I will use the key search words eLibrary or FREE so the references can be found.

2 min Evaluation – Urimeter – darker yellow – 10 seconds to reach a conclusion

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2 min Evaluation – Urimeter = darker yellow – 10 seconds to reach a conclusion

The quick explanation :

Situation :    urine = darker yellow.

Background :    dehydrated / intravascularly depleted.

Action :    cautious intravascular volume repletion.

Recommendation :     Alveolar recruitment technique (ART).

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The “long winded” explanation :

S-B-A-R format reporting – quick reporting format for handoff from one healthcare professional to another.

A lot of this presentation is conjecture … but time and experience has proven correct 99 out of 100 times.

Darker yellow urine is a likely indicator that your patient is intravascularly depleted to some extent.

A “passive leg raise” maneuver (MORE TO FOLLOW AT A LATER DATE) will provide additional information as to the value of  intravascular volume repletion.

If the patient’s systemic blood pressure / cardiac output improve significantly, a 500ml NSS repletion regimen is
likely going to improve outcomes.

Whenever fluid is repleted, alveolar should be protected via ART (alveolar recruitment technique) to avoid unintended
migration of NSS into the pulmonary interstitium and unintended alveolar compression (= compressive atelectasis).

 

The ICU patient – evaluating the patient in 2 minutes

 

today-icu-bed

Why would you want to evaluate a patient in 2 minutes?

>> To be able to answer anyone who asks : “How’s my patient doing?”

> answer quick and BE READY to defend your stance!

>> Why you think the patient is faring well vs. why you think the patient is decompensating.

>> if they like your answer over the course of 1 to 2 patients (and you were correct),

they will trust you for the rest of your life with anything respiratory related and

patient related as well.

How do you evaluate the patient in 2 minutes?

>> 7 zones to focus on :  2 min = 120 seconds

>> patient.  10 sec

>> patient monitor.  10 sec

>> IV pumps.  30 sec

>> ventilator.  10 sec

>> chest tube.  10 sec

>> urine collection bag.  10 sec

>> any other unusual device in room.  10 sec

>> conclusion and defense thesis.  30 sec

PATIENT :  10 seconds

cyanosis / pale / normal

MONITOR :  10 seconds

HR :  hi  /  lo  / normal
BP :  hi  /  lo  / normal

PA :  hi  /  lo  / normal

CVP :  hi  /  lo  / normal

SpO2 :  hi  /  lo  / normal

IV PUMPS :   30 seconds

Vasoactives :  constrictors  vs.  dilators

Cardiotonics :  inotropes  vs.  chronotropes

Sedation :

Analgesics :

Paralytics :

Epi  /  Levo  /  Neo  /  Vaso  /  Milrinone

Diprivan  /  Ativan  /  Versed  /  Fentanyl

VENTILATOR :   10 seconds

Type & Mode of Ventilation :   VCV  vs.  PCV  ;  AC  vs.  SIMV  vs. PSV

PEEP :    hi  /  lo  / normal

FiO2 :    hi  /  lo  / normal

P/F ratio :  hi  /  lo  / normal

Lung compliance :   hi  /  lo  / normal

CHEST TUBE :   10 seconds

Qualitative analysis :

Quantitative analysis :  hi  /  lo  / normal

URINE COLLECTION BAG :  10 seconds

Qualitative analysis :  clear  /  yellow  /  pink  /  red  / green  /  blue

Quantitaive analysis :    hi  /  lo  / normal

UNUSUAL DEVICES  :  10 seconds

EEG  /  Hypothermia Induction Device  / IAB / VAD / ECMO, CVVH, hemodialysis, wound VAC, compression stockings, external pacing device, cardio-defibrillator, video monitor, patient escape alert device.

CONCLUSION :  immediate

Rationale :  30 seconds

(MORE TO FOLLOW next week)

Starling Curve – how to “read” / use a Starling curve

 

The STARLING CURVE :

  • describes the relationship between the cardiac ventricle and its potential for ejectability of its volume.
  • describes the status of the cardiac sarcomere.

read starling 001

pictured above : the basic / generic curve.

 

read starling 002

above : how to read : draw a line from the x-axis to the curve.

(more to follow at a later date).

read starling 003

follow the line up to the curve.

read starling 004

read starling 005

read starling 006

once you reach the curve, go directly (perpendicularly) left.

read starling 007

read starling 008

keep going till you hit the y-axis.

read starling 009

read the value on the y-axis (3L/min) – for this patient at this time at this current volume status.

read starling 010

back to the x-axis, start giving 1L of IVF (intravenous fluid) challenge.

read starling 011

based on the units on the x-axis, go to 1L of IVF moreso then before fluid challenge.

read starling 012

follow the line upward … till you hit the curve.

read starling 013

read starling 014

once you hit the curve, go directly (& perpendicularly)  leftward.

read starling 015

read starling 016

read the new value on the y-axis … this is the new cardiac output after getting a 1L IVF challenge.

IABP – radio-opaque marker – close up on CXR

This is a magnification of the CXR demonstrating the IAB against the background of the heart.

The contrast & briteness were significantly altered to easily identify the inflated balloon.

cxr-iab mag

 

cxr-iab mag - marker

above : the radio-opaque marker is identified by the 2 red arrows against the background of the heart.

cxr-iab mag 002

above : the inflated balloon is outlines by the arrows.

IABP – radio-opaque marker

The IABP can be visualized in this radiograph below.

Look for the gas density (= black) in the CXR in the form of a balloon  (aligned vertically ) in the descending Ao.

In a CXR, patent alveoli = black ; atelectasis = white.

Other gas filled structures will also appear black :

> stomach, esophagus, ETT cuff.

> IABP (during inflation >> with Helium).

 

cxr-iab

 

cxr-iab radioopaque marker

pictured above, radio-opaque marker at the tip of the IAB.

Ideal position : 2cm below the top of the  Aortic arch.

 

IABP – intra-aortic balloon pump – the device

The IABP is a common device seen often in the CTICU, CCU, or not so frequently in other ICUs.

iabp-infl vs defl

Above, the balloon that is in inflated vs. deflated position.

It resides in the Descending Aorta (proper positioning to be discussed later).

iabp - dvc

Above : the IABP console.

iabp - dvc scrm

Above : the IABP control.

iabp - radiogr

IABP inserted percutaneously via femoral artery and residing in the descending Aorta.

IABP – mechanism of action (MoA)

coronary art iabp deflate 001

The heart should have an ample supply of blood for proper functioning.

Normally, the heart receives its blood supply opposite to the body’s supply.

This interesting paradox occurs because during systole, the body cannot squeeze

blood into itself via the coronary arteries.

Systole : the heart squeezes, thereby allowing :

supply of 80% of all organ systems requisite blood supply.

supply of 20% of the heart’s requisite blood supply.

Diastole : the heart relaxes, thereby allowing :

supply of 80% of the heart’s requisite blood supply.

supply of 20% of all organ systems requisite blood supply.

The day that the cardiac blood supply is compromised, is the beginning of cardiac demise.

If the insult (AMI – acute myocardial infarction) is addressed early, an IABP may allow

for recovery of the insulted myocardium.

Red = rich blood supply to the myocardium.

Pink = weak blood supply to the myocardium.

Green = blockage in the coronary arteries compromising the myocardial blood supply.

 

coronary art iabp deflate 002

Once the IABP is inserted and situated in the proper position, during systole, the heart is provided

with some of its requisite (20%) blood supply.

coronary art iabp deflate 003

Upon balloon inflation, the blood is sent cephalad (towards the head) and because the Aortic valve is closed, the blood

is forcibly driven deep into the myocardium via the  coronary arteries.

The augmented coronary blood pressure is much higher than it is normally.

Understanding cardiac physiology 001 – unravel the heart

The traditional picture does not help in understanding cardiac physiology.

cor003

The cutaway heart does not help either.

cor004

It is important to unravel the heart and its vasculature.

physio-cvcirc002

And then, line the heart up in a unidirectional flow :

pvroute001

In a nutshell : the pulmonary circuit (vasculature) is shown in the diagram above.

Blood has to traverse the route of : RA > RV > pulmonary circuit > RA > RV (and then out the Aorta).