This document provides an overview of cardiac monitoring techniques including stethoscopy, electrocardiography, pulse rate monitoring, arterial blood pressure monitoring, central venous pressure monitoring, and pulmonary artery catheterization. Key points include: stethoscopy was introduced in 1818 but is not used for continuous monitoring; electrocardiography is the most common method to detect heart rate; differences exist between heart rate and pulse rate; noninvasive and invasive blood pressure monitoring methods are described along with their complications; central venous pressure monitoring provides information on right atrial pressure; and pulmonary artery catheters allow direct measurement of pressures and cardiac output in critically ill patients.
Comprehensive presentation on intra arterial blood pressure with a good insight into the the basic physics and brief look into the risks and complications.
Comprehensive presentation on intra arterial blood pressure with a good insight into the the basic physics and brief look into the risks and complications.
This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.
The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. Normal CVP is 2-6 mm Hg. CVP is elevated by : overhydration which increases venous return.
Hemodynamic monitoring- Hemodynamic monitoring refers to the measurement of pressure, flow and oxygenation within the cardiovascular system. Hemodynamic monitoring is amandatory process in all the critical care units to assess the patients progress. This presentation is aimed to create an insight on Hemodynamic monitoring.
This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.
The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. Normal CVP is 2-6 mm Hg. CVP is elevated by : overhydration which increases venous return.
Hemodynamic monitoring- Hemodynamic monitoring refers to the measurement of pressure, flow and oxygenation within the cardiovascular system. Hemodynamic monitoring is amandatory process in all the critical care units to assess the patients progress. This presentation is aimed to create an insight on Hemodynamic monitoring.
Handout for Inhalational Anaesthesia CME held in 2013 by the Department of Anaesthesiology, JNMC, Belagavi. Authors have been credited in each chapter.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. Stethoscopy
• Laennec introduced in 1818
• During surgery by Harvey Cushing
• Precordial and Esophageal stethoscopy
• Now a days not used for continuous monitoring because for introduction of
other methods.{ except for peads and remote location].
3. Heart Rate monitoring
• “Finger on pulse” is the easiest and quickest method to assess heart rate.
• ECG is most common method to detect heart rate in ot, by measurement of
r-r interval.
• ECG can get confounded by electrosurgical instruments, power line noises,
twitchings and fasciculations, lithotripsy machine, cardiopul bypass, and fluid
warmers.
• Direct ECG monitoring is better than monitoring of derived heart rate.
4. Picture shows HR of 49 but direct observation shows dangerous bradyarrythmia
it may be a asystole that cannot be assessed by digitally displayed HR.
Arrow shows correction of baseline by ECG filters.
5. Pulse Rate monitoring
• Difference between pulse rate and heart rate is the difference between
electrical depolarization and mechanical contraction of heart.
• Pulse deficit arises in conditions such as AF , PEA( in Cardiac tamponade,
extreme hypovolemia, and conditions where electrical activity is present but
not capable of producing pulse).
• Pulse oxymetery gives PR. Although it seems redundant to measure both HR
and PR but its important to avoid error.
6. Arteial blood pressure monitoring
• Sphygmomanometer use for systolic blood pressure first described by Riva and
Rocci in 1896(palpatory method). Korotkoff in 1905 described measurement of
diastolic as well.(auscultatory method).
• Any condition causing decrease in blood flow below the level of detection, or
conditions needing excessive pressure to occlude artery.
• Size of cuff 40% and 80%of circumference and length of arm. Too large can still
be accepted but too small will give spuriously high reading. Pressure should be
released slowly to assess korotkofs sounds properly. Rapid deflation results in
falsely low readings.
7. Automated NIBP
• Intermittent based on oscillometery method, first described by marey 1876.
• Assess MAP most accurately and SBP and DBP are derived. DBP is least reliable by this
method.
• This method is although highly unrelialable, its still most used in critical care settings but its
use other than upper arm is not validated.
• Complications may occur due to continuous use and use in patients with coagulopathies,
arterial and venous insufficiency, thrombolytic therapy and peripheral neuropathies.
• Automated continuous techniqes(eg:finger BP by arterial volume clamp method) are also
available but with several disadvantages.
8.
9. Complications of Noninvasive Blood Pressure Measurement
• Pain
• Petechiae and ecchymoses
• Limb edema
• Venous stasis and thrombophlebitis
• Peripheral neuropathy
• Compartment syndrome
10. IBP/ Direct blood pressure monitoring
• Despite various complications and need of expertise IBP monitoring is ideal
reference standard for BP monitoring ,which provide timely and crucial
information.
• Arterial cannulation can be done in radial, ulnar, brachial, axillary or femoral artery.
• More central the artery is more are the chances of embolism. Axillary and femoral
arterial cannulation results waveforms that resembles change in pressure in aortic
arch more closely.
• In radial artery cannulation hyperextension is avoided to prevent median nerve
injury and in femoral artery cannulation must be done below the inguinal ligament.
17. A, Normal ART and pulmonary artery pressure (PAP) wave, B, In aortic stenosis, the ART waveform is distorted and demonstrates a
slurred upstroke and delayed systolic peak.. See text for greater detail. C, Aortic regurgitation produces a bisferiens pulse and a wide
pulse pressure. D, The arterial pressure waveform in hypertrophic cardiomyopathy shows a peculiar “spike-and-dome” configuration.
The pressure waveform assumes a more normal morphology after surgical correction of this condition
18. Central venous Pressure monitoring
• Central vein is catheterized for various purposes.
• Measurement of CVP is often necessary in heamodynamically unstable and
patietns undergoing major surgeries.
• Rt IJV is most commonly catheterised central vein. Others are left IJV , right
and left subclavian, femoral, external jugulars and axillary.
• Most commonly used size is 7 French , 20 cm catheter with a 18 g introducer
needle and guide wire.
19. Indications for Central Venous Cannulation
• Central venous pressure monitoring
• Pulmonary artery catheterization and monitoring
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration -Concentrated vasoactive drugs
• Hyperalimentation
• Chemotherapy
• Agents irritating to peripheral veins
• Prolonged antibiotic therapy (e.g., endocarditis)
• Rapid infusion of fluids (via large cannulas) Trauma
• Major surgery
• Aspiration of air emboli
• Inadequate peripheral intravenous access
• Sampling site for repeated blood testing
20. Complications of CVP:
• Mechanical Vascular injury Arterial
Venous
Hemothorax
Cardiac tamponade
• Respiratory compromise
Airway compression from hematoma
Tracheal, laryngeal injury
Pneumothorax
• Nerve injury
• Arrhythmias
• Subcutaneous/mediastinal emphysema
• Thromboembolic
Venous thrombosis
Pulmonary embolism
Arterial thrombosis and embolism (air, clot)
Catheter or guidewire embolism
• Infectious Insertion site infection
Catheter infection
Bloodstream infection
Endocarditis
• Misinterpretation of data
• Misuse of equipment
21. Central Venous Pressure Waveform Components
• a wave End diastole Atrial contraction
• c wave Early systole Isovolumic ventricular contraction,
tricuspid motion toward the right atrium
• v wave Late systole Systolic filling of the atrium
• h wave Mid to late diastole Diastolic plateau
• x descent Mid systole Atrial relaxation, descent of the base,
systolic collapse
• y descent Early diastole Early ventricular filling, diastolic
collapse
22.
23. JVP's - Appearance and Interpretation
Introduction
The JVP (jugular venous pressure) is a manometer of pressure in the right atrium; when pressure in the
atrium is high the JVP will be raised and when right atrial pressure is low the JVP will drop.
Features of the JVP
A venous pulse is not usually palpable.
Pressing at the base of the vein will make the vein visible as it continues to fill and distend above the
point of pressure NB do not do this in exams.
Hepatojugular reflex aids identfication of JVP - probably by forcing blood out of liver into IVC and
therefore into right atrium increasing its pressure.
JVP alters with changes in posture.
24. How to find the JVP
Sit patient at 45° and turn head slightly away from you.
• Look for JVP in internal jugular vein (not external jugular vein)
medial to the clavicular head of sternocleidomastoid; the vein
passes behind the angle of the jaw in direction of earlobe.
• Measure JVP in cm above the sternal notch - a vertical not
diagonal distance - if larger than 3cm the JVP is raised.
Abnormalities of the JVP
1) Raised JVP with normal waveform
•right heart failure
•fluid overload
•bradycardia
26. Abnormalities of the JVP
1) Raised JVP with normal waveform
•right heart failure
•fluid overload
•bradycardia
2) Raised JVP with absent pulsation
•SVC obstruction - full dilated jugular veins, no pulsation,
oedematous face and neck
3) Large a wave
•tricuspid stenosis - atria contracts against stiff tricuspid and so
pressure in atria rises higher than normal
•pulmonary hypertension - there are generally higher pressures on
the right side of the heart
•pulmonary stenosis
4) Extra-large a wave = Cannon wave
27. 5) Absent a wave
•atrial fibrillation
6) Systolic waves = combined c-v waves = big v waves
•tricuspid regurgitation (c-v wave because the pressure in the right atrium is raised
throughout ventricular systole - tip is to watch for earlobe movement!)
7) The slow y descent occurs in tricuspid stenosis (if the HR is so low as to allow the
length of descent to be appreciated!)8) Paradoxical JVP = Kussmaul's sign
Normally the JVP should rise on expiration and fall on inspiration.
When the JVP rises on inspiration it indicates
•pericardial effusion
•constrictive pericarditis
•pericardial tamponade
29. Introduction
• Pulmonary artery catheters (also called as Swan-Ganz catheter) are used for
evaluation of a range of condition
Although their routine use is not common, they are still occasionally placed
for management of critically ill patients
30. Physiological Measurements
• Direct measurements of the following can be obtained from an accurately placed
pulmonary artery catheter(PAC)
• Central Venous Pressure(CVP)
• Right sided intracardiac pressures(RA/V)
• Pulmonary artery pressure(Pap)
• Pulmonary artery occlusion pressure (PAOP)
• Cardiac Output
• Mixed Venous Oxygen Saturation(SvO2)
31. • Indirect measurements that are possible:
• Systemic Vascular Resistance
• Pulmonary Vascular Resistance
• Cardiac Index
• Stroke volume index
• Oxygen delivery
• Oxygen uptake
32. Indications
• Diagnostic:
• Differentiation among causes of shock
• Differentiation between mechanisms of pulmonary edema
• Evaluation of pulmonary hypertension
• Diagnosis of pericardial tamponade
• Diagnosis of right to left intracardiac shunts
• Unexplained dyspnea
33. • Therapeutic:
• Management of perioperative patients with unstable cardiac status
• Management of complicated myocardial infarction
• Management of patients following cardiac surgery/high risk surgery
• Management of severe preecclampsia
• Guide to pharmacologic therapy
• Burns/ Renal Failure/ Heart failure/Sepsis/ Decompensated cirrhosis
• Assess response to pulmonary hypertension specific therapy
34. Contraindications
• Absolute:
• Infection at insertion site
• Presence of RV assist device
• Insertion during CPB
• Lack of consent
• Relative:
• Coagulopathy
• Thrombocytopenia
• Electrolyte disturbances
(K/Mg/Na/Ca)
• Severe Pulmonary HTN
35. Making decision to place pulmonary artery
catheter
In critically ill or perioperative patients
decision to place a pulmonary artery catheter should be based
on patient’s hemodynamic status or diagnosis
that cannot be answered satisfactory by clinical or non-invasive
assessment
36. Preparation
• Patient has to be monitored with continuous ECG throughout the
procedure, in supine position regardless of the approach
• Aseptic precautions must be employed
• Cautions should be taken while cannulating via IJV/ Subclavian vein
40. 1. Aseptic precautions undertaken
2. Local infiltration done
3. Check balloon integrity by inflating with 1.5ml of air
4. Check lumens patency by flushing with saline 0.9%
5. Cover catheter with sterile sleeve provided
6. Cannulate vein with Seldinger technique
7. Place sheath
8. Pass catheter through sheath with tip curved towards the heart
Technique:
41. 9. Once tip of catheter passed through introducer sheath inflate balloon at
level of right ventricle
10. The progress of the catheter through right atrium and ventricle into
pulmonary artery and wedge position can be monitored by changes in
pressure trace
11. After acquiring wedge pressure deflate balloon
42.
43.
44. • Important tip:
• When advancing catheter- always inflate tip
• When withdrawing catheter- always deflate
• Once in pulmonary artery - NEVER INFLATE AGAINST RESISTANCE - RISK
OF PULMONARY ARTERY RUPTURE.
45. Interpretation of hemodynamic values and
waveforms
• Ensuring accurate measurements:
• Zeroing and Referencing
• Correct placement
• Fast flush test
46. • Zeroing and Referencing:
• PAC must be appropriately zeroed and referenced to obtain accurate readings in
supine position/30 degrees semi-recumbent position
• Correct placement :
• By either pressure waveform/ fluoroscopic guidance
48. Catheter waveforms and pressures
• Pressure waveforms can be obtained from
• Right atrium
• Right ventricle
• Pulmonary artery
49. • Right atrium:
• In presence of a competent tricuspid valve, RA pressure waveform reflect both
• Venous return to RA during ventricular systole
• RV End Diastolic Pressure
• Normal RA pressure: 0-7 mmHg
50.
51. • Elevated RA pressure:
• Diseases of RV( infarction/ cardiomyopathy)
• Pulmonary hypertension
• Pulmonic stenosis
• Left to right shunts
• Pericardial diseases
• LV systolic failure
• Hypervolemia
52. • Differentiating among etiologies depends on
• Clinical
• Radiographical
• Echocardiographic features
+
PAC findings
Eg: Increased RA Pressure and Mean pulmonary Pressure PAH
Increased RAP and Normal Pa pressures RV disease/ Pulmonary stenosis
53. • Abnormal RA waveforms:
• Tall v waves: Tricuspid Regurgitation
• Giant/ cannon a waves:
• Ventricular tachycardia
• Ventricular pacing
• Complete heart block
• Tricuspid stenosis
• Loss of a waves:
• Atrial fibrillation/ Atrial flutter
54.
55.
56. • Right Ventricle:
• Transitioning from SVC or RA to RV:
• Once balloon is inflated in the SVC/RA the catheter is slowly advanced
When catheter tip is across tricuspid valve pressure waveform changes and systolic
pressure increases
57. • 2 pressures are typically measured in right ventricular pressure waveform
• Peak RV systolic pressure 15-25mmHg
• Peak RV diastolic pressure 3-12 mmHg
58.
59. • As a general rule elevations in RV pressure:
• Diseases increasing pulmonary artery pressure
• Pulmonic valve disorders
• Diseases affecting right ventricle
• Pulmonary vascular and pulmonary valve disorders a/w increased RV systolic pressures
• RV disorders – ischemia/infarction/failure – a/w increased RV End diastolic pressure
60. • Pulmonary artery:
• The risk of arrhythmias is greatest while catheter tip is in RV
Thus, catheter should be advanced from RV to PA without delay
• When catheter tip passes pulmonary valve Diastolic pressure increases and
characteristic dichrotic notch appears in waveform
61. • Normal pulmonary artery pressures:
• Systolic 15-25mmHg
• Diastolic 8-15 mmHg
• Mean 16 (10-22mmHg)
• Main components of PA tracing:
• Systolic and Diastolic pressure
• Dichrotic notch(due to closure of pulmonic valve)
62.
63. • Increase in mean pulmonary pressure:
• Acute:
• Venous Thromboembolism
• Hypoxemia induced Pulmonary Vasoconstriction
• Acute on Chronic:
• Hypoxemia induced pulm VC in patient with chronic cardiopulmonary disease
• Chronic:
• Pulmonary hypertension
64. • Types of PHT:
• Primary
• Due to Heart Disease
• Due to Lung Disease
• Due to chronic venous thromboembolism
• Miscellaneous ( Sickle Cell Anemia)
65. Pulmonary arterial occlusion pressure
• Once catheter tip has reached PA, it should be advanced until PAOP is
identified by decrease in pressure and change in waveform
The balloon should then be deflated and PA tracing should reappear
If PCOP tracing persists catheter should be withdrawn with definitive PA
tracing obtained
66. • Final position of the catheter within PA must be such that PCOP
tracing is obtained whenever 75-100% of 1.5ml maximum
volume of balloon is insufflated
• If < 1ml of air is injected and PAOP is seen then it is overwedged
needs to be withdrawn
• If after maximal inflation fails to result in PCOP tracing or after 2-3
seconds delay too proximal – advanced with balloon inflated
67. • PCWP/PAOP interprets Left atrial pressures
more importantly – LVEDP
• Best measured in
• Supine position
• At end of expiration
• Zone 3 (most dependent region)
• Normal PCWP- 6-15 mmHg ; Mean :9mmHg
71. • Decreased PCWP:
• Hypovolemia
• Obstructive shock due to large pulmonary embolus
• Abnormal waveforms
• Large a waves:
• MS
• LV systolic /diastolic function
• LV volume overload
• MI
• Large v waves - MR
72. • Calculation of cardiac output:
• 2 methods
• Thermodilution method
• Fick’s Method
• Better measurement with Cardiac index
• Normal – 2.8- 4.2 l/min/m2
76. • Related to insertion of PAC:
• Arrhythmias (most common- Ventricular/ RBBB)
• Misplacement
• Knotting
• Myocardial/valve/vessel rupture
• Related to maintenance and use of PAC:
• Pulmonary artery perforation
• Thromboembolism
• Infection
77. ECHO/ DOPPLER
CARDIOGRAPHY
• A diagnostic Study that reveals information about:
• The structure and function of the heart
• Cardiac hemodynamics of the heart
78. THEORY AND TECHNIQUE OF THE STUDY
• Utilizes the Application of Ultasonic waves being reflected back on hitting a
structure
• This is done utilizing a transducer that both sends out the beam and then receives
it back
• The transducer can have one crystal or multiple crystals
• Utilizing the technique of doppler with ultrasound allows the ability to quantitate
the direction and velocity of objects
79.
80.
81. APPLICATION OF THE TECHNIQUE:
• M mode echo
• 2 DIMENSIONAL ECHO:
• Tran thoracic Echo- transducer directly on the chest wall
• Transesophageal Echo- probe placed into the esophagus and stomach
• Stress echocardiography- Tran thoracic echo at rest and post stress or
exercise
82. APPLICATION OF THE TECHNIQUE:
• Doppler can be viewed as:
• Continuous wave- continuous transmission of signal with 2nd transducer available to
receive the signal
• Pulsed Doppler- same probe transmits, waits an the receives
• Color flow- vectors directions given colors, usually blue if flow is away from transducer
and red if goes toward the transducer.
83.
84.
85.
86.
87.
88. THIS TECHNIQUE ALLOWS THE EVALUATION OF:
• Cardiac Chambers- size and motion or function
• The thickness of the walls of the heart
• Abnormal Objects in the heart: tumors or masses
• Valvular structure (size and shape)
• Valvular function (thickness, stenosis, or leakage)
• Blood flow- hemodynamics
• Other pathologies- fluid: pericardial effusionOther objects- vegetations etc.
• Mechanical valves
• Pacemaker wires