W11. Life Support/Monitoring & PFTs - ML

What is the purpose of an Electrocardiogram (ECG/EKG)?

To monitor the heart's rhythm and rate using 10 electrodes to give 12 leads.

If leads fall off the monitor may look like

asystole

What vital signs are usually displayed on an ECG monitor?

Heart rate, body temperature, oxygen saturation, and respiratory rate.

Monitoring Vitals: Every Machine Is Different

Top: Ekg usually Lead 2 Or V5

O2 Saturation Wave

Respiratory Wave

On The Right:

Heart Rate

Body temp

O2 Saturation

Respiratory Rate

Which vital is not measured in real time on the monitor

BP unless it's measure by an internal line

Ekg -Watch For Indications Of Declining Status

St Segment Changes

Multiple Pvcs Or Change In Foci

Onset Of Ventricular Tachycardia Or Ventricular Fibrillation

Progression/Worsening Of Heart Block

A-fib

What does SpO2 measure?

The arterial oxygen saturation expressed as a percentage of oxygen bound to hemoglobin.

SAO2

Invasive arterial blood signal

SaO2 vs SpO2

SaO2 is the oxygen saturation via a blood gas.

SpO2 is oxygen saturation via a pulse oximeter.

What is the threshold level for SpO2 to be considered acceptable?

Above 90%.

Orders For Titrations

maintain levels above 90%

What factors can cause inaccuracies in pulse oximetry readings?

Low perfusion, anemia, nail polish, fluorescent lighting, dark skin, jaundice, and arrhythmias.

Anemia and pulse ox

Not enough RBC or regular pulse to calculate saturation

nail polish and pulse ox

Blocks light from passing through

Fluorescent Lighting and pulse ox

Interferes with infrared signal

Dark Skin and jaundice with SPO2

Melanin

Arrhythmias and pulse ox

Variations in strength and regularity of pulsatile signal making it harder to detect changes in O2 saturation

take pulse

manually

What is the normal range for heart rate (HR)?

50-100 beats per minute.

What is the normal range for SBP

85-140

What is the normal range for DBP

40-90

What is the normal range for RR`

12-20

What is the normal range for O2SAT

>95% FiO2

What is the purpose of invasive arterial lines?

To allow continuous monitoring of blood pressure and hemodynamic status in unstable patients.

What does MAP stand for and what is its normal range?

Mean Arterial Pressure; normal range is 70-110 mmHg.

MAP lower than 60

Poor perfusion

Reasons for A-Line use

Continuous SBP, DBP and MAP Management Or Hemodynamic

Monitoring (Fluid)

Frequent ABGs Taken

Drug Administration

Precautions with arterial lines

Transducers must stay level w/ R atrium

Avoid Dislodging-Large Blood Loss

Radial insertion-Limit Or Avoid WB On Wrist

Femora Insertion-Monitor Closely & Avoid Dislodging!

transducer w/ A-line

stay level at R atrium

Other Potential Arterial Line Placements

Brachial

Radial

Axillary

Ulnar

Femoral

DP Artery

Posterior Tib

What is the function of a central venous line?

To measure central venous pressure (CVP), Right atrial pressure, and provide IV access for medication administration.

What is a PICC line and where is it placed?

A Peripherally Inserted Central Catheter placed in the cephalic, basilic, or brachial vein.

PICC line is used for

long term meds and runs up to SVC

CVP or PICC Precautions

They Need To Remain Sterile.

Usually Well Covered Near Skin Insertion.

Secure Ends Well Before Mobilizing

Be Aware Of The Location And Avoid Dislodging

Use Precautions with ambulation When Femoral Picc Used

Invasive Monitoring

swan Ganz and Pulmonary Artery Catheter

What is the Swan-Ganz catheter used to measure for?

Central Venous Pressure (Cvp)

Right Atrial Pressure

Pulmonary Artery Pressure

Pulmonary Capillary Wedge Pressure

Calculation Of Vascular Resistance

SVo2 And Temporary Pacing

Right atrial pressure with swan ganz

Gives idea of venous return

Why Is The Swan Ganz Catheter So Important?

Measurement Of Left Sided Heart Function

What does pulmonary capillary wedge pressure indicate?

It provides an indirect assessment of left ventricular filling pressure.

Indirect Assessment Of Left Ventricular Function

Elevated PCWP indicates

Pulmonary Htn

Indicates Resistance To Flow Into The Left Ventricle

Uses of swan ganz

Monitoring Heart Function (Post Sx)

Diagnosing Chronic Heart Failure

Differentiating Causes Of Pulmonary Edema

Guiding Diuretic Dosing To Manage Fluid Overload

What are the potential complications of using a Swan-Ganz catheter with mobilization?

Serious Arrhythmias

Pulmonary Artery Rupture

Pulmonary Valve Damage

Infection -Heart

Newer swan ganz mobilization guidelines

Use Of A Standard Dressing And Immobilization Technique Prevents Catheter Dislodgement During Ambulation.

By Increasing Physical Activity, Patients Will Gain Strength To Help Prevent Deconditioning During Prolonged Hospitalizations

Invasive temp monitorring

Swan Ganz

Urinary Catheters

Nasopharyngeal

Rectal Probe

Rectal Probe Only When

Comatose

Intubated

Confused

What is the purpose of monitoring intracranial pressure (ICP)?

Used For Neurological Trauma

Head Injury, Brain Surgery, Hemorrhage, Tumor Meningitis

Increased Icp Causes

Decreased Perfusion Of Brain

Low Co2 Levels Can Help Control

Increased ICP

Drain Or Shunt May Be Placed To Control

ICP

What is the most common device for oxygen delivery?

Nasal cannula.

Lowest Level Of Oxygen Support

nasal cannula

Nasal cannula flow rate

1-6 L/min

Cannula humidifies when

Rate Is > 4 L/Min because mucus membrane can dry with higher flow rates

What is the FiO2 relation to oxygen flow rates?

For every 1 L/min increase in flow, FiO2 increases by 4%.

face mask flow rate

5-10 L/min

~35 To 56% Fio2

Trach mask

always worn above tracheostomy site

Always Humidified

Why Must The Trach Mask Be Humidified?

Humidification Of Air Happens In The Upper Airways, The Trach Is A Bypass of the upper airways and the nose and mouth thus reducing humidification

Venturi Mask

Venturi mask specs

Adapter allow for Much More Specific/Precise Fio2 Delivery

Gain Order For Fio2

Dictates The Liters/Min Setting On The O2 Supply

Non-rebreather mask

Bag Fills From Wall W/ (O2 >15L/Min)

Breathe In Air From Bag

Ensure bag is fully inflated

Breathe Out-Air Goes Into The Room

Due To High Flow Rate w/ non rebreather

Need To Start With Full Tank And Bring A Spare when beginning to mobilize patients

High Flow Nasal Cannula

Provides 25-60L/min of O2

Machine gets wall source of air

HFNC creates

positive pressure to splint open the airways and remove CO2

What is the function of a non-rebreather mask?

To provide up to 100% oxygen to the patient.

Non invasive ventilation

CPAP/BiPAP

invasive ventilation

- endotracheal tube

- tracheostomy

- mechanical ventilator

What does CPAP stand for and when is it used?

Constant Positive Pressure During Both Inhalation And Exhalation;

commonly used in sleep apnea.

BIPAP

2 Levels Of Pressure, One For Inhalation And One For Exhalation

Used To Wean Off Ventilator Or Prior To Invasive Ventilation

What are the two types of invasive mechanical ventilation?

Endotracheal tube and tracheostomy tube.

Causes OF INVASIVE VENTILATION

Failure To Oxygenate

Failure To Ventilate

Combination Of Both

Airway Protection

Endotracheal Tube

short-term artificial airway to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions

Tracheostomy Tube

a long-term breathing tube surgically placed through the anterior potion of the neck below the vocal chords

Ventilator Settings

-Tidal volume: amount of air given with each breath

-Rate: number of breaths per minute

-FIO2: oxygen concentration

-Peak inspiratory pressure: pressure needed to deliver set tidal volume

-PEEP: positive pressure exerted during expiration to prevent atelectasis

-Pressure support: positive pressure given during inspiration that eases workload of breathing

Mode-amount of assist

What is tidal volume in the context of ventilator settings?

The amount of air delivered per breath.

What is PEEP in mechanical ventilation?

Positive End Expiratory Pressure; it keeps the airways open at the end of exhalation.

FiO2

Percent Of O2 In Delivered Air

starts at 100% titrated down to 21% which is normal atmospheric

What is the recommended FiO2 level to prevent atelectasis?

Keep FiO2 lower than 50%.

What are the four levels of assist in ventilator settings?

Control mode, assist mode, synchronized intermittent mandatory ventilation (SIMV), and pressure support.

Control mode ventilator

Ventilator Has Complete Control

Volume & RR PRE Set, No Pt Initiation

What is Assist Control (Ac-Vc) in ventilation?

Set Number Of Breaths (Rr)

Every Breath Has Set Volume

Pt Can Initiate More Breaths-Machine Still Gives The Set Volume

What does Synchronized Intermittent Mandatory Ventilation (Simv-Vc) allow?

Set # Of Breaths W/ Set Volume Given

When Pt Takes More Breaths Than Set RR

Tidal Volume Is Not Controlled

In Spontaneous or Pressure Support ventilation, who dictates tidal volume and respiratory rate?

The patient dictates tidal volume and respiratory rate.

Set Pressure, Peep And Fio2

When pt is on a ventilator, the FiO2 is adjusted to attain an Oxygen level goal of

60 mmHg or 90%

How should adjustments be made for CO2 levels in ventilation?

Adjust the respiratory rate (RR) first then tidal volume (TV).

How should adjustments be made for O2 levels in ventilation?

Adjust FiO2 first then PEEP.

What is the purpose of a thoracotomy?

To access the thoracic cavity for surgical procedures.

What is a Posterolateral Thoracotomy used for?

It is commonly used for pulmonary thoracic procedures,

Used to access lungs for resections, pleuro and pneumothorax sx

What is a Median Sternotomy primarily used for?

It is almost exclusively used for cardiac procedures.

Anterolateral Thoracotomy aka clamshell incisions

Lateral

Subxiphoid Incision

Thoracoabdominal

What is the Anterolateral Thoracotomy incision used for?

It is used for cardiac tamponade, descending thoracic aorta repair, and left pneumonectomy.

Median Sternotomy

Initial Skin Incision Usually Begins Inferior To The Suprasternal Notch And Extends Down Midline Of The Sternum To Below The Xiphoid.

A Sternal Retractor Divides The Sternum Fully And Holds The Incision Open.

Can cause changes to the T-spine

Posterolateral Thoracotomy incision

Extends from T4 medial to scapula to anterior axilla at 5/6th intercostal space

muscles affected with posterolateral thoracotomy

Lower trap, serratus anterior and middle trap can get divided

advantage of posterolateral thoracotomy

Gives Good Visibility

disadvantage of posterolateral thoracotomy

Pain, decreased Mobility And Pulmonary Issues

Anterolateral Thoracotomy

Incision

From Sternal Edge To Midaxillary

At Level Of 4th or 5th Intercostal Space

left anterolateral thoracotomy optimal for

Cardiac Tamponade,

Descending Thoracic Aorta Repair,

Pericardial Effusion, Left Pneumonectomy

Right anterolateral thoracotomy optimal for

Right Pneumonectomy

Distal Esophageal Surgeries,

Access To The Hilum

Mitral Valve Repair/Replacement (Minimal Incision)

Anteroloateral approach can affect what muscles

pectorals, serratus and intercostals

Axillary (Lateral) Thoracotomy

Most Frequent Use:

Minimally Invasive Cardiac Procedures And Epicardial Pacemaker Placement