this is my college presentation and i hope it doesnt bore you. i have used abstract clipart with literal meaning of the text. send your remarks

1. JJM MEDICAL COLLEGE DAVANGERE DEPARTMENT OF ANAESTHESIOLOGY SEMINAR ON Blood pressure , ECG , Central venous pressure CHAIRPERSON PRESENTED BY DR.RAVISHANKAR . R B DR.RAVIVARMA.D PROFESSOR PG IN ANAESTHESIA DEPT OF ANAESTHESIA

2. 1. Indirectbp measurement2. Directbp measurement3. Intra operative ECG4. Central venous pressure

3. “ Not everything that counts can be counted. And not everything that can be counted counts.” - Albert Einstein adapted from THE ICU BOOK by PAUL MARINO

4. Blood pressure

5. “Of all the procedures done in clinical medicine that have important consequences, measurement of blood pressure is likely the one that is done most haphazardly” – kaplan,M.D adapted from THE ICU BOOK by PAUL MARINO

7. Indirect measurement

8. “It should be clearly recognized that arterial pressure cannot be measured with precision by means of sphygmomanometers” – American heart association 1951

11. Inherent variability of blood pressure

13. If the bladder is too small for the size of the arm, the pressure measurements will be falsely elevated

14. A cuff that is larger than needed will not produce spurious pressure recordingsAm J Cardiol1989;63:983-985

15. dimensions

16. DO NOT “MISCUFF” Miscuffingis considered the most common source of errors in the blood pressure measurement

17. Rapid assessment

21. auscultatory method

22. “It is what we think we know already that often prevents us from learning” - Claude Bernard

25. Lowest hearing frequency – 16 Htz“ A situation exists where the human ear being used to measure BP is, at best, basically deaf to some sound it should be detecting” adapted from Am J Cardiol 1989;63:983-985

27. The diaphragm is designed to detect high frequency sounds

28. Since korotkoff sound is in the lower frequency BELL should be used for BP measurementRecommendations for blood pressure measurement. Circulation 2005;111:697-716

29. SBP decreases by 8 mm DBP increases by 5 mm SBP increases by 8 mm DBP decreases by 5 mm

31. In case of slow heart rate it is 1 mm per pulse

32. When the rate is greater than 3 mm per secSystolic is underestimated and diastolic is over estimated

34. low flow states can diminish theintensity of these sounds.

35. When this occurs, the sounds may not be heard at first and this will result in falsely low recordings for the systolic bloodpressure.Cohn JN. Blood pressure measurement in shock. JAMA 1967; 119:118.

37. When an inflated cuff is placed over an artery, the pulsatilepressure changes in the artery will be transmitted to the inflated cuff, producing similar changes in cuff pressure.

40. It is most evident in the popularity of pressor or vasoconstrictor agents in the management of clinical shock.

42. When vascular impedance (i.e., compliance and resistance) is increased the velocity of the flow wave is decreased.

46. Have pt open and close fist several times

47. Tightly clench fist

48. Occlude radial and ulnar a

49. Lower hand, open fist, release ulnar a

51. Angle of entry

53. Advancement of guide wire

55. The waveform

57. These reflected waves originate from vascular bifurcations and from narrowed blood vessels.

60. This fluid-filled system can oscillate spontaneously, and the oscillations can distort the arterial pressure waveform

61. What is an under damped system ?

63. Systolic pressure variation in predicting fluid responsiveness

64. electrocardiography

65. Lead placement

66. Modified 3 leads systems

67. Colour blind

69. Avoid placing leads over bony areas. In patients with large breasts, place the electrodes under the breast.

70. Apply tincture of benzoin to the electrode sites if the patient is diaphoretic. The electrodes will adhere to the skin better.

72. calibration A standard signal of 1milli volt should moves the stylus vertically 1 cm

73. artifacts

74. Waves and

76. Standard lead llis perpendicular to lead AVL

78. Heart rate in odd situations

80. Prognostic value of routine preoperative ECG “ Due to improvement in accuracy of clinical cardiac risk factors to identify patients who are at increased risk of peri operative cardiac events, the routine use of ECG in all patients is of questionable value” noordzij et al: Am J Cardiol 2006;97:1103-1106

83. Most modern electrocardiographic monitors allow the operator a choice of several bandwidths. (1) a diagnostic mode with a bandwidth of 0.05 to 130 Hz (2) a monitoring mode with a bandwidth of 0.5 to 40 Hz (3) a filter mode with a bandwidth of 0.5 to 20 Hz.

86. Arrhythmias

88. ST segment pattern

90. rapidly up-slopingST segment that is also depressed less than 1.5 mm is considered normal

92. Evolution of MI

93. Automated ST monitoring

114. Central venous pressure

116. 1956 - Seldinger first described his guide wire directed technique for central vein cannulation

118. Pit falls

120. He who works with his hands is a laborer. He who works with his head and his hands is a craftsman. - St. Francis of Assisi adapted from THE ICU BOOK by PAUL MARINO

122. Catheters designed for short-term cannulation are usually made of polyurethane

124. Multipurpose catheter

125. Indication for central cannulation

126. Why subclavian ? 1993;21:1118–1123.

127. Subclavian vein

128. Internal jugular

129. Ultrasound-Guided Central Venous Cannulation

130. complications Vascular injury Venous air embolism Pneumothorax Arrhythmias Pulmonary embolism Infection

133. It corresponds to the position of the right and left atrium when the patient is in the supine position.

137. In general, a change in CVP or wedge pressure of less than 4 mm Hg should not be considered a clinically significant change.

139. REFERENCES : 1. MILLERS ANAESTHESIA 7th edition 2. THE ICU BOOK- paulmarino 3rd edition 3. SCHAMROTH ECG 4. Am J Cardiol 1989;63:983-985 5. Recommendations for blood pressure measurement. Circulation 2005;111:697-716 6. Cohn JN. Blood pressure measurement in shock. JAMA 1967; 119:118. 7. noordzij et al: Am J Cardiol 2006;97:1103-1106