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Bedside invasive procedures in ccu


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Bedside invasive procedures in ccu

  1. 1. Bedside InvasiveBedside Invasive Procedures In CCUProcedures In CCU Dr.ELSayed Farag,MDDr.ELSayed Farag,MD Zagazig UniversityZagazig University
  2. 2. AgendaAgenda  Arterial lineArterial line  Central venous lineCentral venous line  Swan Ganz cathetersSwan Ganz catheters  PeriocardiocentesisPeriocardiocentesis  Intraaortic balloon counterpulsationIntraaortic balloon counterpulsation  Bedside temporary pacemakersBedside temporary pacemakers
  3. 3. WHAT IS AN ARTERIAL LINEWHAT IS AN ARTERIAL LINE?? An arterial line is a cannulaAn arterial line is a cannula usually positioned in ausually positioned in a peripheral arteryperipheral artery Such as:Such as:  Radial arteryRadial artery  Brachial arteryBrachial artery  Dorsalis pedis arteryDorsalis pedis artery  Femoral arteryFemoral artery
  4. 4. INDICATIONS FOR USINGINDICATIONS FOR USING ARTERIAL LINEARTERIAL LINE  Ease of accessEase of access  Continuous monitoring of arterialContinuous monitoring of arterial blood pressureblood pressure • if patient is on intropic drugsif patient is on intropic drugs • if patient is on vasoactive drugif patient is on vasoactive drug • if patient requiresif patient requires frequent arterialfrequent arterial blood samplingblood sampling
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  7. 7. THE ARTERIAL WAVEFORMTHE ARTERIAL WAVEFORM  The arterial waveformThe arterial waveform reflects the pressurereflects the pressure generated in the arteriesgenerated in the arteries following ventricularfollowing ventricular contraction and can becontraction and can be described as having:-described as having:- • Anacrotic notchAnacrotic notch • Peak systolic pressurePeak systolic pressure • Dicrotic notchDicrotic notch • Diastolic pressureDiastolic pressure
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  9. 9. CVPCVP Reasons For Inserting CentralReasons For Inserting Central Venous CathetersVenous Catheters  Limited vascular accessLimited vascular access  Administration of intropes , highly osmotic orAdministration of intropes , highly osmotic or caustic fluids or medicationscaustic fluids or medications  Frequent administration of blood and blood productsFrequent administration of blood and blood products  Frequent blood samplingFrequent blood sampling  Measurement of CVPMeasurement of CVP  HemodialysisHemodialysis
  10. 10. COMMON CENTRAL LINECOMMON CENTRAL LINE INSERTION SITESINSERTION SITES  Right internal jugularRight internal jugular  left internal jugularleft internal jugular  right subclavianright subclavian  left subclavianleft subclavian  femoral (as a lastfemoral (as a last resort)resort)  Or peripherallyOr peripherally inserted centralinserted central catheters (PICC)catheters (PICC) which are insertedwhich are inserted via the antecubitalvia the antecubital veins (basilic vein isveins (basilic vein is the best) in the armthe best) in the arm and is advanced intoand is advanced into the central veinsthe central veins
  11. 11. ACCESS
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  15. 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
  17. 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
  18. 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
  19. 19. The Swan-Ganz CatheterThe Swan-Ganz Catheter
  20. 20. What is a SwanWhat is a Swan??  Full name: Swan-GanzFull name: Swan-Ganz CatheterCatheter  Pulmonary Artery (PA)Pulmonary Artery (PA) Catheter = right heart catheterCatheter = right heart catheter  Used it to monitor a patient’sUsed it to monitor a patient’s hemodynamics when we canthemodynamics when we cant answer the question usinganswer the question using noninvasive/clinical measuresnoninvasive/clinical measures  Useful to measure right atrial,Useful to measure right atrial, pulmonary artery, rightpulmonary artery, right ventricular pressures andventricular pressures and indirectly measure left atrialindirectly measure left atrial pressures, cardiac output andpressures, cardiac output and systemic vascular resistancesystemic vascular resistance
  21. 21. Why use a SwanWhy use a Swan??  Differentiation between causes of shock>cardiogenic,Differentiation between causes of shock>cardiogenic, hypovolemic, septichypovolemic, septic  Differentiation between causes of pulmonaryDifferentiation between causes of pulmonary edema>cardiogenic versus noncardiogenicedema>cardiogenic versus noncardiogenic  Diagnosis of pericardial tamponadeDiagnosis of pericardial tamponade  Diagnosis of intracardiac shuntDiagnosis of intracardiac shunt  Evaluation/Management of pulmonary hypertensionEvaluation/Management of pulmonary hypertension  Diagnosis of lymphangitic spread of tumor and fatDiagnosis of lymphangitic spread of tumor and fat embolismembolism  Management of complicated MI, HFManagement of complicated MI, HF  Determine need for vasopressor/inotropic therapyDetermine need for vasopressor/inotropic therapy  Fluid Status>in GI bleed, renal failure, sepsisFluid Status>in GI bleed, renal failure, sepsis  Ventilator management>determining the best PEEPVentilator management>determining the best PEEP
  22. 22. Escape TrialEscape Trial  The value of Swan-Ganz catheterization toThe value of Swan-Ganz catheterization to guide tailored therapy in heart failure patientsguide tailored therapy in heart failure patients is an area of an area of controversy.  The randomized ESCAPE trial showed noThe randomized ESCAPE trial showed no benefit on a primary end point of the numberbenefit on a primary end point of the number of days alive and out of the hospital at sixof days alive and out of the hospital at six monthsmonths JAMA. 2005;294:1625-1633.
  23. 23. Insertion TechniquesInsertion Techniques  Goal: get the catheter to the pulmonaryGoal: get the catheter to the pulmonary arteryartery  Right internal jugular vein or leftRight internal jugular vein or left subclavian allows easiest passagesubclavian allows easiest passage  Swan should be oriented ex-vivo toSwan should be oriented ex-vivo to approximate the course in the bodyapproximate the course in the body  Catheter goes through an introducer andCatheter goes through an introducer and into the vein. The balloon stays closed untilinto the vein. The balloon stays closed until we reach the right atrium.we reach the right atrium.  When we reach the right atrium (20cm),When we reach the right atrium (20cm), balloon should be inflated to reduceballoon should be inflated to reduce possibility of injury to the myocardium.possibility of injury to the myocardium.  Then the balloon should be moved quicklyThen the balloon should be moved quickly through the right ventricle (30cm)> andthrough the right ventricle (30cm)> and then pulmonary artery (40cm) and PCWPthen pulmonary artery (40cm) and PCWP (50cm) FROM SUBCLAVIAN/IJ(50cm) FROM SUBCLAVIAN/IJ APPROACHAPPROACH
  24. 24. How do you know you are in the RightHow do you know you are in the Right Atrium?>>20 cmAtrium?>>20 cm Normal right atrial presssure is 0-6mmHg. Normal oxygen content 15% Normal O2 saturation 75%
  25. 25. What Elevates the Right Atrial PressureWhat Elevates the Right Atrial Pressure??  RV infarctRV infarct  Pulmonary hypertensionPulmonary hypertension  Pulmonary stenosisPulmonary stenosis  Left to right shuntLeft to right shunt  Tricuspid valvular diseaseTricuspid valvular disease  Left heart failureLeft heart failure
  26. 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
  27. 27. What Increases RV PressuresWhat Increases RV Pressures??  RV failureRV failure  Pulmonary hypertensionPulmonary hypertension  Pulmonary stenosisPulmonary stenosis  Pulmonary EmbolismPulmonary Embolism  CardiomyopathyCardiomyopathy  Cardiac tamponadeCardiac tamponade  Cardiac constrictionCardiac constriction
  28. 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. 29. What Elevates PA pressureWhat Elevates PA pressure??  Volume Overload (backflow)Volume Overload (backflow)  Primary lung diseasePrimary lung disease  Primary pulmonary hypertensionPrimary pulmonary hypertension  Pulmonary EmbolismPulmonary Embolism  Left to right shuntLeft to right shunt  Mitral Valve DiseaseMitral Valve Disease
  30. 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.
  31. 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
  32. 32. What Increases PCWPWhat Increases PCWP??  PEEP (minimally)PEEP (minimally)  LV failureLV failure  Cardiac tamponadeCardiac tamponade  Aortic InsufficiencyAortic Insufficiency  Mitral regurgitationMitral regurgitation  VSDVSD
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  34. 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 RisksNot Without Risks??????
  35. 35. Intra-aortic Balloon PumpIntra-aortic Balloon Pump CounterpulsationCounterpulsation
  36. 36. IABP PURPOSEIABP PURPOSE  Improves cardiac function during cardiogenicImproves cardiac function during cardiogenic shock.shock.  26-28 cm balloon surrounds end of centrally26-28 cm balloon surrounds end of centrally placed catheter (from groin)placed catheter (from groin)  Placed into descending thoracic aortaPlaced into descending thoracic aorta  Inflates in diastole - fills coronary arteriesInflates in diastole - fills coronary arteries retrograderetrograde  Deflates in systole - decreases LV afterloadDeflates in systole - decreases LV afterload
  37. 37. What is an IABPWhat is an IABP??  The Intra-Aortic BalloonThe Intra-Aortic Balloon Counterpulsation system is aCounterpulsation system is a volume displacement device.volume displacement device.  A device used to reduce leftA device used to reduce left ventricular systolic work, leftventricular systolic work, left ventricular end-diastolicventricular end-diastolic pressure, and wall tensionpressure, and wall tension  Decreases oxygenDecreases oxygen consumptionconsumption  Increases cardiac output,Increases cardiac output, perfusion, pressure andperfusion, pressure and volume to Coronary Artriesvolume to Coronary Artries
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  47. 47. ECG TriggerECG Trigger  Since triggering on the R wave of the ECG isSince triggering on the R wave of the ECG is preferred, it is very important to give the IABP apreferred, it is very important to give the IABP a good quality ECG signal and leadgood quality ECG signal and lead
  48. 48. Triggering on the Arterial PressureTriggering on the Arterial Pressure WaveformWaveform  Arterial pressure provides another signal to the IABP toArterial pressure provides another signal to the IABP to determine where the cardiac cycle begins and endsdetermine where the cardiac cycle begins and ends  It is used when the ECG has too much interference from patientIt is used when the ECG has too much interference from patient movement or poor lead connectionmovement or poor lead connection  There are limitations to triggering on the arterial pressure curveThere are limitations to triggering on the arterial pressure curve • Therefore AP trigger should be considered a backup triggerTherefore AP trigger should be considered a backup trigger and not the one used as the primary triggerand not the one used as the primary trigger
  49. 49. The GuidelinesThe 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
  50. 50. Pericardiocentesis
  51. 51. Clinical Manifestations of TamponadeClinical Manifestations of Tamponade  SOBSOB  TachycardiaTachycardia  Hypotension>>ShockHypotension>>Shock  Elevated JVPElevated JVP
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  56. 56. Indications for Temporary PacingIndications for Temporary Pacing  Acute myocardial infarction with:Acute myocardial infarction with: CHB, Mobitz type 2 AV block, medicallyCHB, Mobitz type 2 AV block, medically refractory symptomatic bradycardia, alternatingrefractory symptomatic bradycardia, alternating BBB, new bifascicular block, new BBB withBBB, new bifascicular block, new BBB with anterior MIanterior MI  In absence of acute MI : SSS, CHB, Mobitz type 2In absence of acute MI : SSS, CHB, Mobitz type 2 AV blockAV block  Treatment of tachyarrhythmias : VTTreatment of tachyarrhythmias : VT
  57. 57. Temporary Transvenous Pacing UnipolarTemporary Transvenous Pacing Unipolar ElectrogramsElectrograms
  58. 58. InvadeInvade when it is reallywhen it is really neededneeded but please bebut please be carefulcareful………!!!!!!………!!!!!!
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