Advanced Critical Care Series
                Module I: Hemodynamics


                                                   ...
Advanced
 Critical Care
    Series
       Module1:
Advanced Hemodynamics




  Advanced
Hemodynamics
  Elizabeth Scruth, R...
Outline
 Normal hemodynamic values
 Hemodynamic goals for critically ill patients
 Insertion sites for invasive
 hemodynam...
Review of Selected
Hemodynamic Principles

 Cardiac output (CO) is the amount of
 blood ejected over 1 minute
   Normal CO...
Review of Selected
Hemodynamic Principles

 Stroke volume (SV) is amount of blood
 ejected with each heart beat
   SV = CO...
Preload
 RV preload (RVEDP) measured by CVP
   Normal CVP 2-6 mmHg or 3-8 cmH20


 LV preload (LVEDP) measured by
 PAOP, P...
Contractility
 RVSWI & LVSWI are most useful &
 sensitive measures of contractility
   RVSWI measures RV contractility
   ...
Hemodynamic Goals
  for Critically Ill
      Patients
      Eugene Y Cheng, MD, FCCM




Indication for Invasive
Hemodynam...
Therapeutic Hemodynamic Goals
 Pressure
   Peripheral     65 mmHg
   Cerebral       70 mmHg
   Coronary       70 mmHg
   R...
Indications for
Arterial Catheterization

 Unstable cardiovascular state
 Continuous assessment of blood pressure
 respons...
Arterial Circulation of the Hand
                      Radial artery
                      first choice for
              ...
Arterial Circulation of the Arm
                    Axillary artery
                    third choice
                    N...
Complications of
Arterial Catheterization

 Hematoma
 Thrombosis
 Embolism
 Hemorrhage
 Infection




Indications for Cent...
Additional Hemodynamic
Information from Pulmonary
Artery Catheterization
 Pulmonary artery pressure
 Right ventricular pre...
Pulmonary Artery Catheters
 Standard thermodilution cardiac output
 Continuous cardiac output
 Right ventricular function
...
Central Venous
Catheterization Complications

 Hematoma
 Arrhythmias
 Hemorrhage
 Embolization
 Pneumothorax




Complicat...
Subclavian Vein Site for CVC
                      Lowest rate
                      of infection
                      Mo...
Femoral Vein Site for CVC
                  Site of last choice
                  for elective
                  placement...
Care and
 Maintenance of
 Hemodynamic
   Catheters




The Institute of Healthcare Improvement
has recommended as a bundle...
A hemodynamic monitoring system
 contains 2 compartments: the electronic
 system and the fluid-filled tubing system.




1...
Leveling and Zeroing

 Leveling and zeroing


 Dynamic response testing




                   21
Leveling and Zeroing
  Level of the transducer must be at the
  level of the left atrium- 4th ICS –lateral
  aspect
  Zero...
General care of invasive lines
 Alarms are never to be turned off-this is
 not only a safety requirement, but also a
 requ...
Pressure bag to be inflated at 300 mm Hg
at all times
Dressing changes
Bag changes




                   24
Interpretation of
   hemodynamic
     waveforms




A C V WAVES- CVP waveform
 A wave- occurs after the P wave
 C wave occ...
Measuring CVP
 The peak of the “a” wave coincides with
 the point of maximal filling of the right
 ventricle
 Therefore, t...
Reading Pressure Waveforms –
       CVP Practice Waveform



              Patient is on ventilator




5-15




       Re...
Causes of large V waves in the CVP
tracing- tricuspid valve regurgitation




What does it mean when the RA port from
a PA...
It means the following:
1) If the patient has cardiomyopathy
   the CVP port is sitting in the RV
2) The PA catheter needs...
PAOP
Pulmonary arterial occlusion pressure :
  Pulmonary arterial occlusion pressure
 (PAOP) is measured when the balloon ...
Instances where PAOP overestimates
LVED pressure include those
which create an interfering pressure
gradient, but do not r...
Reading Pressure Waveforms - CVP/PAOP




   P wave represents atrial contraction




Reading Pressure Waveforms - CVP/PAO...
Tricuspid and
Mitral Valve Pathology

 Tricuspid and MITRAL VALVE STENOSIS:
    Look for presence of large A waves on
    ...
Reading Pressure Waveforms –
PAOP Practice Waveform Answer




Relationship between
Pulmonary Artery Diastolic
(PAD) and P...
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP

 PA mean (PAM) pressure must always be
 high enough to pus...
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP

 PAD is also usually higher than PAOP.


 If PAOP equals P...
Relationship between
Pulmonary Artery Diastolic
(PAD) and PAOP




Discrepancy seen between        Relationship seen betwe...
Effects of Lung Zones
on a PAOP Tracing
Zone III




Effects of Lung Zones
on a PAOP Tracing

  When PA catheter is below ...
Insertion and
Confirmation of Proper
   Central Venous
 Catheter Placement

   Eugene Y Cheng, MD, FCCM




CXR Landmarks
...
CVC “In Good Position”




CVC in the R-Atrium




            40
PA Catheter Position Confirmation




It’s All About Me




               41
Oxygen Delivery
 Cardiac Output
 SvO2 (ScvO2)
 Lactate
 Gastric tonometry




Cardiac Output Monitors
 Invasive Techniques...
Cardiac Output Monitors
 Semi-Invasive Techniques
   Lithium dilution curve with arterial
   waveform analysis (LIDCO™)
  ...
Oxygen Supply and Demand

      O2 delivery = CO ∗ CaO2

O2 consumption = CO ∗ (CaO2 − CvO2 )

               O2 content =...
ScvO2 Measurements
 Normal                   65-70%
 Mild global ischemia     <60%
 Severe global ischemia   <50%




    ...
Case Study
 63 y/o 100 kg male arrives to the ED
 obtunded and tachypneic.
 T 38.3oC                  RR 38/min;
 HR 120/m...
Assessment and Plan (1h)
 Hct 31%          lactate 7.3 mmol/L
 Na+ 138 mEq/L    K+ 4.9 mEq/L
 Scr 1.8 mg/dL    pH 7.2
 pCO...
Assessment and Plan (3h)
 3 L NS given; maintenance iv 200 ml/h
 T 37.1oC      RR 28/min
 ScvO2 55%
 HR 117/min    SpO2 97...
Assessment and Plan (6h)
 5 L of NS (1 L bolus) given, iv rate 200 mL/h
    NE gtt 30 mcg/min
    Dobutamine 5 mcg/kg/min
...
Assessment and Plan (8h)
 Continue current treatment plan




                   50
ORDER FORM
                                 CLINICAL VIDEOCONFERENCING NETWORK TAPES


             Fields marked with an ...
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  1. 1. Advanced Critical Care Series Module I: Hemodynamics March 4th, 2008 8:30 AM - 10:00 AM Presented by: Elizabeth Scruth, RN, MN, CCRN Eugene Cheng, MD, FCCM - 1 -Copyright 2005-2006. Kaiser Permanente. All rights reserved for all countries. Except for personal (noncommercial) or nonprofit educational use, no part of this document may be reproduced in any form or by any means without written permission from Kaiser Permanente. Disclaimer: The information in this document is provided by Kaiser Permanente. While we try to keep the information as accurate as possible, we disclaim any implied warranty or representation about its accuracy or completeness, or appropriateness for a particular purpose. You assume full responsibility for using the information at this site, and you understand and agree that Kaiser Permanente is neither responsible nor liable for any claim, loss, or damage resulting from its use. The mention of specific products or services at this site does not constitute or imply a recommendation or endorsement by Kaiser Permanente unless it is explicitly stated. Information on this Web site may be changed or updated without notice. Information may be out of date at any given time since Kaiser Permanente has no obligation to update information presented on this Web site. Kaiser Permanente may also make improvements and/or changes in products and/or services described in this information at any time without notice. 1
  2. 2. Advanced Critical Care Series Module1: Advanced Hemodynamics Advanced Hemodynamics Elizabeth Scruth, RN, MN, MPH, CCNS, CCRN Eugene Y Cheng, MD, FCCM 2
  3. 3. Outline Normal hemodynamic values Hemodynamic goals for critically ill patients Insertion sites for invasive hemodynamic catheters Care and maintenance Interpretation of hemodynamic wave forms Insertion and confirmation of proper catheter placement Tissue perfusion and oxygen delivery Case study Cardiovascular Physiology Cardiac output Preload Afterload Contractility Conduction pathways 3
  4. 4. Review of Selected Hemodynamic Principles Cardiac output (CO) is the amount of blood ejected over 1 minute Normal CO in resting adult is 4-6 L/min Review of Selected Hemodynamic Principles CO indexed to pt’s BSA is cardiac index (CI) Normal CI in resting adult is 2.2-4.0 L/min/m2 4
  5. 5. Review of Selected Hemodynamic Principles Stroke volume (SV) is amount of blood ejected with each heart beat SV = CO ÷ HR Example: 4.0L/min ÷ 100 = 40mL/beat Normal range for SV is 60-100 ml Determinants of Cardiac Output Cardiac Output Stroke Volume Heart Rate Preload Afterload Contractility 5
  6. 6. Preload RV preload (RVEDP) measured by CVP Normal CVP 2-6 mmHg or 3-8 cmH20 LV preload (LVEDP) measured by PAOP, PAD & LAP Normal PAOP 5-12 mmHg Presence of COPD, ARDS, pulmonary embolism, pulmonary HTN, mitral stenosis/regurgitation alters PAOP accuracy Afterload RV afterload: Caused by resistance of pulmonary arteries and arterioles Measured by PVR (normal PVR 100-250 dynes/sec/cm-5) LV afterload Caused by systemic arteries and arterioles Measured by SVR (normal SVR 800-1400 dynes/sec/cm-5 6
  7. 7. Contractility RVSWI & LVSWI are most useful & sensitive measures of contractility RVSWI measures RV contractility (normal 7.9-9.7g-m/m2) LVSWI measures LV contractility (normal 50-62g-m/m2) 7
  8. 8. Hemodynamic Goals for Critically Ill Patients Eugene Y Cheng, MD, FCCM Indication for Invasive Hemodynamic Monitoring Cardiac Complicated MI CHF Pulmonary HTN ARDS Perioperative care Shock Acute renal failure 8
  9. 9. Therapeutic Hemodynamic Goals Pressure Peripheral 65 mmHg Cerebral 70 mmHg Coronary 70 mmHg Renal 65 mmHg Afterload Systemic 600-800 dyne·sec/cm-5 Pulmonary 180-220 dyne·sec/cm-5 Therapeutic Hemodynamic Goals Flow Cardiac output >4-6 L/min Cardiac index >2-3 L/min Volume PAOP 8-12 mmHg LV stroke volume 60-80 mL/beat Tissue perfusion ScvO2 65-70% 9
  10. 10. Indications for Arterial Catheterization Unstable cardiovascular state Continuous assessment of blood pressure response to therapy Need for multiple arterial samples Indicator dilution CO determination Seldinger Technique 10
  11. 11. Arterial Circulation of the Hand Radial artery first choice for catheterization Allen test no longer needed prior to catheter insertion Use 20g needle or smaller Femoral Vasculature Femoral artery catheterization if radial artery not available Must use longer catheter to prevent dislodgement 11
  12. 12. Arterial Circulation of the Arm Axillary artery third choice Not for coagulopathic patients Avoid using brachial artery Arterial Waveform 12
  13. 13. Complications of Arterial Catheterization Hematoma Thrombosis Embolism Hemorrhage Infection Indications for Central Venous Catheterization Secure venous access Assessment of intravascular volume CO measurement Assessment of tissue oxygenation Titration of fluids and medications 13
  14. 14. Additional Hemodynamic Information from Pulmonary Artery Catheterization Pulmonary artery pressure Right ventricular pressure Pulmonary artery occlusion pressure PVR CVC Options Length Lumens Coating 15 cm Single lumen Heparin 20 cm Double lumen Antiseptic 25 cm Triple lumen Antimicrobial Quadruple lumen Antimetabolic 14
  15. 15. Pulmonary Artery Catheters Standard thermodilution cardiac output Continuous cardiac output Right ventricular function Pacing PA catheter Paceport PA catheter CVC Insertion Sites Subclavian/Axillary vein Internal/external jugular vein Femoral vein Basilic/Cephalic vein 15
  16. 16. Central Venous Catheterization Complications Hematoma Arrhythmias Hemorrhage Embolization Pneumothorax Complications of Right Heart Catheterization RBBB Pulmonary artery rupture Right ventricular perforation Catheter knotting 16
  17. 17. Subclavian Vein Site for CVC Lowest rate of infection Most comfortable for patientes Highest placement risks Internal Jugular Site for CVC Second best choice for CVC Lower insertion risk of pneumothorax 17
  18. 18. Femoral Vein Site for CVC Site of last choice for elective placement of CVC Highest infection rate Cannot monitor CVP or ScvO2 Good choice if patient has coagulapathy or during CPR Basilic Site for CVC Low risk Poor flow rates Questionable accuracy of CVP 18
  19. 19. Care and Maintenance of Hemodynamic Catheters The Institute of Healthcare Improvement has recommended as a bundle to implement the following: Hand hygiene Maximal sterile barriers Chlorhexidine for skin asepsis Avoid femoral lines Avoid/remove unnecessary lines 19
  20. 20. A hemodynamic monitoring system contains 2 compartments: the electronic system and the fluid-filled tubing system. 1. Steps should always be followed when setting up for pressure monitoring. 2. Correct setup and maintenance of the tubing setup and the pressure transducer are crucial to avoid errors. 20
  21. 21. Leveling and Zeroing Leveling and zeroing Dynamic response testing 21
  22. 22. Leveling and Zeroing Level of the transducer must be at the level of the left atrium- 4th ICS –lateral aspect Zeroing must be done at time of insertion and then once per day and as needed if numbers seem inaccurate A dynamic response test is done to determine if a hemodynamic monitoring system can adequately reproduce a patient’s cardiovascular pressures Test should produce two oscillations- otherwise overdamped or underdamped waveforms appear 22
  23. 23. General care of invasive lines Alarms are never to be turned off-this is not only a safety requirement, but also a requirement by Joint Commission Label all lines Document the waveform characteristics Document the level of the PA catheter at the site of insertion Accurate interpretation of waveforms 23
  24. 24. Pressure bag to be inflated at 300 mm Hg at all times Dressing changes Bag changes 24
  25. 25. Interpretation of hemodynamic waveforms A C V WAVES- CVP waveform A wave- occurs after the P wave C wave occurs at the end of the QRS complex in the RST junction V wave occurs after the T wave Final filling of the ventricle occurs during atrial contraction- A wave, therefore, to assess final ventricular filling pressures: -average the a wave of the CVP waveform 25
  26. 26. Measuring CVP The peak of the “a” wave coincides with the point of maximal filling of the right ventricle Therefore, this is the value which should be used for measurement of RVEDP Machines just “average” the measurement Should be measured at end-expiration 26
  27. 27. Reading Pressure Waveforms – CVP Practice Waveform Patient is on ventilator 5-15 Reading Pressure Waveforms – CVP Practice Waveform Answer 27
  28. 28. Causes of large V waves in the CVP tracing- tricuspid valve regurgitation What does it mean when the RA port from a PA catheter is in the RV so you see an RV tracing on the monitor instead of a CVP tracing? 28
  29. 29. It means the following: 1) If the patient has cardiomyopathy the CVP port is sitting in the RV 2) The PA catheter needs to pulled back 29
  30. 30. PAOP Pulmonary arterial occlusion pressure : Pulmonary arterial occlusion pressure (PAOP) is measured when the balloon on the tip of the PAC is inflated within a pulmonary artery. This enables the catheter to obtain an indirect measurement of left ventricular end diastolic pressure (normal range 6-12 mmHg) 30
  31. 31. Instances where PAOP overestimates LVED pressure include those which create an interfering pressure gradient, but do not represent the function of the left ventricle: Chronic Mitral Stenosis PEEP (Positive end expiration pressure ventilation) Left atrial myxoma Pulmonary Hypertension Instances where PAOP underestimates LVED pressure include those that increase the pressure in the left ventricle which the catheter tip cannot detect: Stiff Left Ventricle LVED pressure > 25mmHg Aortic Insufficiency 31
  32. 32. Reading Pressure Waveforms - CVP/PAOP P wave represents atrial contraction Reading Pressure Waveforms - CVP/PAOP Wave CVP PAOP a wave In the P-R interval End of QRS c wave End of QRS S-T segment v wave Near end of T wave In T-P interval The mean of the peak of the a wave and the bottom of the x descent is the numerical value obtained for CVP/PAOP readings 32
  33. 33. Tricuspid and Mitral Valve Pathology Tricuspid and MITRAL VALVE STENOSIS: Look for presence of large A waves on CVP and PAOP tracings Tricuspid and MITRAL VALVE REGURGITATION: Look for large V waves Reading Pressure Waveforms – PAOP Practice Waveform Patient is breathing spontaneously E9-9.5 33
  34. 34. Reading Pressure Waveforms – PAOP Practice Waveform Answer Relationship between Pulmonary Artery Diastolic (PAD) and PAOP Blood always moves from a higher to a lower pressure 34
  35. 35. Relationship between Pulmonary Artery Diastolic (PAD) and PAOP PA mean (PAM) pressure must always be high enough to push blood into LA Therefore, atrial pressures should never exceed mean arterial pressures Relationship between Pulmonary Artery Diastolic (PAD) and PAOP This means PAOP must be lower than PAM pressure If PAOP is higher than PAM, recheck waveform-make sure correct points are being identified 35
  36. 36. Relationship between Pulmonary Artery Diastolic (PAD) and PAOP PAD is also usually higher than PAOP. If PAOP equals PAD, the difference needed to move blood forward is very small Relationship between Pulmonary Artery Diastolic (PAD) and PAOP Normally, PAD is 1-4 mmHg higher than PAOP This relationship occurs only in normal situations or passive pulmonary HTN (PAP increase in response to increased LV pressures seen in heart failure) 36
  37. 37. Relationship between Pulmonary Artery Diastolic (PAD) and PAOP Discrepancy seen between Relationship seen between PAD and PAOP in PAD and PAOP in patients pulmonary HTN caused by with LV failure (PAOP obstruction or loss of correlated with PAD) vasculature Effects of Lung Zones on a PAOP Tracing Obtaining an PAOP tracing is only possible if an uninterrupted pathway exists from tip of PA catheter and LA Theoretically, the lung has 3 perfusion zones 37
  38. 38. Effects of Lung Zones on a PAOP Tracing Zone III Effects of Lung Zones on a PAOP Tracing When PA catheter is below the level of the LA, a zone III condition is likely to exist A lateral chest x-ray is needed to confirm whether the PA line is below the LA 38
  39. 39. Insertion and Confirmation of Proper Central Venous Catheter Placement Eugene Y Cheng, MD, FCCM CXR Landmarks 39
  40. 40. CVC “In Good Position” CVC in the R-Atrium 40
  41. 41. PA Catheter Position Confirmation It’s All About Me 41
  42. 42. Oxygen Delivery Cardiac Output SvO2 (ScvO2) Lactate Gastric tonometry Cardiac Output Monitors Invasive Techniques PA catheter and thermodilution Direct Fick calculation Transpulmonary TD with arterial pulse contour analysis (PiCCO™) 42
  43. 43. Cardiac Output Monitors Semi-Invasive Techniques Lithium dilution curve with arterial waveform analysis (LIDCO™) Trans-esophageal/gastric doppler ultrasound Indirect Fick calculation with partial CO2 rebreathing Cardiac Output Monitors Noninvasive Techniques Electrical bio-impedance cardiography 43
  44. 44. Oxygen Supply and Demand O2 delivery = CO ∗ CaO2 O2 consumption = CO ∗ (CaO2 − CvO2 ) O2 content = ( Hb ∗1.39) × (0.0031∗ pO2 ) Factors Influencing SvO2 (ScvO2) Cardiac output Oxygen consumption Hemoglobin concentration Arterial oxygen content Venous oxygen content 44
  45. 45. ScvO2 Measurements Normal 65-70% Mild global ischemia <60% Severe global ischemia <50% 45
  46. 46. Case Study 63 y/o 100 kg male arrives to the ED obtunded and tachypneic. T 38.3oC RR 38/min; HR 120/min SpO2 81% BP 85/30 mmHg Recommendations? Assessment and Plan (1h) Patient intubated; 20g L-anticubital iv; NS 500 ml fluid bolus and maintenance infusion NS 100 ml/h ECG—t wave inversion V2-6; CXR—basilar atelectasis 46
  47. 47. Assessment and Plan (1h) Hct 31% lactate 7.3 mmol/L Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.8 mg/dL pH 7.2 pCO2 45 mmHg pO2 165 mmHg HCO3 20 mmol/L T 38.1oC HR 126/min RR 28/min BP 80/39 mmHg SpO2 99% Recommendations? Assessment and Plan (2h) ScvO2 triple lumen CVC inserted 1000 ml NS bolus T 37.5oC RR 28/min HR 121/min SpO2 99% BP 85/39 mmHg CVP 5 mmHg Recommendations? 47
  48. 48. Assessment and Plan (3h) 3 L NS given; maintenance iv 200 ml/h T 37.1oC RR 28/min ScvO2 55% HR 117/min SpO2 97% BP 87/39 mmHg CVP 9 mmHg Recommendations? Assessment and Plan (4h) 4 L NS given, iv rate 200 mL/h NE gtt 30 mcg/min T 37.1oC RR 28/min ScvO2 62% HR 117/min SpO2 97% BP 92/35 mmHg CVP 9 mmHg Hct 30% lactate 6.3 mmol/L Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.6 mg/dL pH 7.21 pCO2 42 mmHg pO2 133 mmHg HCO3 20 mmol/L Recommendations? 48
  49. 49. Assessment and Plan (6h) 5 L of NS (1 L bolus) given, iv rate 200 mL/h NE gtt 30 mcg/min Dobutamine 5 mcg/kg/min T 37.1oC RR 28/min ScvO2 60% HR 117/min SpO2 97% BP 97/39 mmHg CVP 7 mmHg Hct 26% lactate 4.3 mmol/L Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5 mg/dL pH 7.19 pCO2 42 mmHg pO2 133 mmHg HCO3 20 mmol/L Recommendations? Assessment and Plan (8h) 6 L of NS (1 L bolus) given, iv rate 200 mL/h NE gtt 30 mcg/min Dobutamine 8 mcg/kg/min 2 u PRBCs T 35.1oC RR 28/min ScvO2 65% HR 126/min SpO2 97% BP 93/39 mmHg CVP 10 mmHg Hct 31% lactate 3.3 mmol/L Na+ 138 mEq/L K+ 4.9 mEq/L Scr 1.5mg/dL pH 7.25 pCO2 39 pO2 133 HCO3 20 mmol/L Recommendations? 49
  50. 50. Assessment and Plan (8h) Continue current treatment plan 50
  51. 51. ORDER FORM CLINICAL VIDEOCONFERENCING NETWORK TAPES Fields marked with an * are required PLEASE PRINT CLEARLY AND FILL OUT COMPLETEY * Full Name: PROGRAM TITLE: Advanced Critical Care * Home Series Module I: Hemodynamics Address: * City/State/Zip BROADCAST DATE: March 4th, 2008 (Tuesday) * Home Ph: ( ) NOTE: orders will be sent via interoffice mail to CHECK ONE: Kaiser Permanente employee in California I would like to borrow the DVD: * KP Location NCAL Employees Only Code I would like to purchase _______DVD(s): * Facility/Org: My Recharge Number for purchase is: * Department: No abbreviations * Street recharge Address: entity location cost center code * City/State/Zip * Work #: ( ) RETURN BY: inter-office mail | US mail | or fax Kaiser Permanente Multimedia Library * E-mail: 1950 Franklin Street, 3rd Floor | Oakland, CA 94612 * KP NUID fax: (510) 873-5034 / 8-427-5034 tel: (510) 987-4991 / 8-427-4991 *Supervisor: Want easier ordering? Try ONLINE: kpmmlibrary.org *Shift: * Date: • Clinical E-Learning Find more D I S T A N C E L E A R N I N G programs at: • Clinical Video Conference Network http://nursingpathways.kp.org/national/learning/distance.html • Web Video • Satellite Programs 11/15/07

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