Presented by:

Dr. Amr Medhat, B.Sc.Pharm, BCPS.

Clinical Pharmacist , Egyptair
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House Hospital
• Outlines
1- Intravascular Devices & Catheters
2-Tubes
3- Neurologic Monitoring Devices
4- Intra-abdominal Pressure (IAP)
5- Intra-aortic Balloon Pump (IABP )
6- left ventricular assist device [LVAD].
7- Hemodynamic Monitoring
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 1- Intravascular Devices
• One of the most commonly observed interventions
in the ICU is the placement of intravascular (IV)
access devices.

An intravascular device can be placed IV or intra-arterially.

Intravenous access devices Indications : -

1- Deliver fluids and medications
2- Hemodynamic monitoring
3- Blood draws.
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• Intravenous Route may be :-
1- I.V push ( Bolus )
“ One time rapid injection of medication
into the bloodstream “

2- I.V Infusion : Slow “drip” of medication over a

period of time

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Direct I.V set
• A medical device used to deliver fluids into a patient’s body in a
controlled manner such as medications – insulin , antibiotics,
chemotherapy drugs.

3 Way Cannula
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Y-Set
 Intravenous Device
Peripheral Line
Peripheral Cannula Medline Catheter
Peripherally inserted
Access to peripheral
Access site catheter that terminates in
Circulation
the upper arm

Dwell Time 72 to 96 hours One month

Infusion Infusion of non-irritating Infusion of irritating

types solutions solutions

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 Central Line
Peripherally Inserted Central Catheter (PICC)
Peripherally inserted catheter that terminates in the superior vena
Access cava
site
- Approximately 40-50 cm in length
Dwell
Time
Long-term venous access

Infusion
Infusion of irritating solutions
types

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 Central Line
Non-Tunneled Tunneled Catheters
Central Venous Catheter (i.e. Hickman )
Access Inserted into the subclavian,
Tunneled under the skin into subclavian vein
site jugular, or femoral vein

Dwell
Short-term venous access Long-term venous access
Time

- Infusion of irritating solutions - Infusion of irritating solutions

Infusion
- Central venous pressure and - Multiple ports
types SV02 monitoring - Dialysis or phoresis

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 Central Line
Dialysis Catheter Implanted ports
Non-tunneled catheter inserted into Port placed in surgically created
the subclavian, jugular, or femoral vein pocket
Access - Catheter off port is tunneled into
site -Curved or straight with 2 ports subclavian vein
- e.g Mahurkar catheter e.g ( Port-Cath )

Dwell
Weeks Months to years
Time
Infusion
Dialysis or Phoresis therapy Infusion of irritating solutions
types

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 Complications of I.V (Sets) Devices
1. Bleeding and Bruising may be easily controlled with
direct pressure for time.

2. Infections, and pneumothorax can be life-threatening.

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Complications of I.V Devices
3 - Air emboli
Occur when air is introduced directly into the intravascular space.
- Small air emboli may not result in severe consequence and be “ reabsorbed”
by the lungs

-Single large or continuous infusion of air can gain access into the systemic
arterial circulation

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 Complications of I.V Devices
Clinical symptoms of air emboli : respiratory distress , confusion ,
seizures , tachycardia , hypotension , and death.

-The immediate treatment :

1. Positioning of the patient into the left-lateral decubitus position and placing
the bed into Trendelenburg position
2. Administering 100% oxygen
3. Aspiration from a central venous catheter positioned near the right atrium
4. Hyperbaric oxygen therapy may be considered, and anticonvulsants for
seizures may be ordered

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 Complications of I.V Devices
4- Phlebitis, or Inflammation of a vein

Causes : Symptoms : Treatment :-

Extended dwell time, Redness and swelling 1- Removal of the access
localized infections, along the line of the device.
Clots, vein, throbbing and 2- Antibiotics if needed
Irritating solutions, burning at the IV site, for associated infections
and even the catheter and possibly low- 3- Anticoagulants if
material itself grade fever blood clots are present

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Complications of I.V Devices
5- Infiltration:
“Definition”
“ Inadvertent administration of a Non-vesicant solution into surrounding tissue
that may or may not cause damage “

decreased
“Symptoms “
perfusion
Cool, blanched skin, leaking from the insertion site, and pain. and tissue
ischemia

“ Treatment “
1- Removal of the access device.
2- Encouraging the use of the extremity to promote reabsorption of fluid,
and warm packs for comfort

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Complications of I.V Devices
6- Extravasation

Definition: Symptoms : Treatment

“ inadvertent
administration of a
vesicant solution or
medication into
surrounding tissues
that can cause tissue
damage and
destruction.”
1- Significant pain at
1- knowledge of the
the IV site.
medication or solution
that was administered
2- the skin may appear
inflamed , swollen, and
2- Antidote required to
ulceration may
attempt to counteract
develop hours to days
damaging effects.
after the event.

Antidotes are typically given SC. into the tissue surrounding the affected area and
through the catheter before it is removed. Early consultation may be helpful in
developing a treatment regimenProfessionl
to prevent
Trainingfurther
House tissue damage.
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• Pulmonary artery (PA) Catheter and intra-arterial
catheter are also considered intravascular devices.
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 Case
Match the characteristics to each type of vascular access device.

___ Peripheral IV
___ PICC
___ Central venous catheter
___ Dialysis catheter
___ Implanted ports

A. Central line placed surgically

B. Non-tunneled central catheter placed in jugular or femoral vein
C. Central line placed through initial peripheral access
D. IV access that typically lasts only 72 to 96 hours
E. Large bore IV placed centrally for specific procedures
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 Case
Which of the following would not typically be
considered a complication of intravenous access
devices?

A. Fat emboli
B. Infection
C. Phlebitis
D. Air emboli
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Urinary Catheters (Foley)

1- Monitoring a patient’s fluid volume status and renal function

Indications 2- Urine drainage in Acute urinary retention , Pre-operative ,
Patient requires strict prolonged immobilization

1- Urethral trauma and perforation during insertion .

Risks 2- Urinary outflow obstruction due to kinked catheters .

3- Urinary tract infection

- Quality initiatives for ICU patients often include re-evaluating the need for
urinary cathetersProfessionl
at least daily.
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 2-Rectal Tubes

1- The administration of medications via enemas:

Indications ( relief constipation )
2- Diagnostic barium enema “ Colon X- ray exam “

If the tube is incorrectly placed or kinks off

inadvertently :-

Complications -Leakage, extrinsic bowel obstruction, and discomfort may occur.

-prolonged insertion may lead to mucosal ulceration and lower
gastrointestinal bleeding
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 Chest Tubes
• Chest Tubes may be inserted into the pleural space for a variety of
reasons:-
1- Re-expansion of the lung in pneumothorax
2- Removal of blood in hemothorax
3- Drainage of fluid in pleural effusion
4- Post-operatively in thoracotomy or cardiac bypass

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The chest tube with a Trocar inserted into the pleural cavity, the
trocar is removed, and the chest tube is connected to a suction
unit via an extension tube.

Complications :-
1- Bleeding; injury to the lung, heart, or arteries.
2- Infection
3- Air leaks
4- Tension pneumothorax development

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 Case
Chest tubes are inserted into the pleural
space to help re-expand lungs that have
collapsed due to pneumothorax.

A. True
B. False

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 3- Neurologic Monitoring Devices

2- Damage 3- Rapid intervention

1- The brain is a highly
caused by lack of and aggressive
metabolic organ that
oxygen to the treatment are
requires consistent
CNS is measured required to provide
oxygen delivery.
in minutes. patients with the
optimal chance of
survival

4- Brain injury causes :-

- Trauma, tumors, blood clots and bleeding
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 CNS Pressure Monitoring
Normally, a pressure of 5 to 15 mmHg is maintained within the rigid box of the
skull through displacement one of three space-occupying entities:
Cerebral spinal fluid (CSF), blood, or brain tissue.

This ability of the brain to compensate for an increase in one compartment

through reduction in another is described by the Monro-Kelly Doctrine.

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 CNS Pressure Monitoring
Monitoring of intracranial pressure (ICP) -
- Placement of a fiberoptic monitor , The ICP bolt through a bole into one of three
spaces in the brain (i.e., ventricular, epidural, or subarachnoid).

Perfusion Monitoring :
Cerebral perfusion pressure (CPP)
= MAP- ICP.

Normal CPP is > 70 mmHg,

and treatment targets of CPP are usually
about 6O mmHg.

ICP tells us nothing about the

oxygenation of brain tissue, but several
methods are available for monitoring
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 Brain tissue hypoxia Evaluation : -

Because blood from the brain supplied through the Internal jugular veins, it
is possible to measure the partial pressure of oxygen within them Called Sj02

Oximetric central catheter placed in the jugular vein or intermittently via

blood draw.
- Normal SjO2ranges from 60% to 70%.

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 Brain tissue hypoxia Evaluation : -
Intraparenchymal sensor placed in conjunction with an ICP bolt near the area
of injury. ( Measure brain tissue oxygen )
Normal brain tissue oxygen pressure levels are greater than 30 mmHg,
treatment goals typically aimed at maintaining a level of 20 to 25 mmHg.

Intra- and extraventricular drains may be placed to reduce the amount of

circulating CSF, thus decreasing ICP.

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 4-Intra-Abdominal Pressure (IAP)
When pressure inside the abdominal compartment exceeds normal
Etiology : levels, intra-abdominal organ tissues become compromised
because the increased pressure reduce normal blood flow.
Clinical
Respiratory failure , oliguria or anuria, hypotension, and tachycardia.
manifestations

Laboratory blood urea nitrogen (BUN), creatinine, lactic acid, (ABGs) may be helpful
values to evaluate the extent of organ dysfunction and metabolic disturbance.

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4- Intra-Abdominal Pressure (IAP)

Without The patient may develop abdominal compartment syndrome

intervention (ACS) with irreversible organ failure and death.

IAP The Bladder pressures provide a reasonable indication if IAH

Evaluation is present, and readings are typically monitored

Normal IAP is <10 mmHg,

IAP Values 10 to 20 mmHg classified as mild IAH,
Interpretation 20 to 40 mmHg as moderate,
and > 40 mmHg as severe.
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Bladder Pressures Transducer

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 5- Intra-Aortic Balloon Pump ( IABP )

• A catheter inserted in a long tubular balloon into the femoral

artery and situates it in the descending aorta just distal to the left
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 5- Intra-Aortic Balloon Pump ( IABP )
lABPs are effective Circulatory assist devices :- Increase diastolic blood pressure
and improving forward flow . Ensure adequate perfusion and tissue oxygen
delivery & O2 delivery to coronary arteries in unstable angina

Indications :
1- Myocardial infarction (MI).
2- Septic shock with depressed myocardial
function
3- Left ventricular failure, cardiogenic shock.

Improper timing and/or positioning of an IABP can result in ineffective blood

pressure augmentation, as well as ischemia to the end organs of blocked arteries.
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 5- Intra-Aortic Balloon Pump ( IABP )

Complications o f IABP
includes :-
1. Balloon rupture
2. Bleeding or infection at the
insertion site
3. Limb ischemia, thrombosis
formation
4. Catheter migration, hematoma.

Important Note : The standard of care is that unfractionated heparin be used for
anticoagulation during the IABP use
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6- left ventricular assist devices (LVADs).

An implantable mechanical pump that helps pump blood from

Definition the lower chambers of your heart (the ventricles) to the rest of
your body.

- Cl index < 2.0 L/min/m2

- Hypotension with MAP <60 mm Hg
Indications - Cardiac filling pressures of either right or left atrium >20 mmHg
- Persistent inotropic dependence
- Life-threatening ventricular arrhythmias
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VADs are a. As a bridge to recovery
placed for
three
b. As a bridge to cardiac transplantation
reasons: c. As a therapeutic method

Infection,
Complications
Neuroembolic events, and bleeding.

Treatment of Congestive Heart Failure “Long-term Use of a LVAD”

A 3-year study in 129 patients with end-stage heart failure who

What is the were ineligible for cardiac transplantation and were randomly
REMATCH assigned to two groups: optimal medical management or LVAD
study? therapy.

- Data showed significant increases in 1 - and 2-year survival rates

of the LVAD cohort over the medical therapy cohort (52% vs. 25% )
as well as an improved quality of life.
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 Case
Urinary catheters are also known as:

A. Trocars
B. Foley
C. Peripheral cannula
D. IABP

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Professionl Training House
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 What is the purpose of
hemodynamic monitoring?

Oxygen and
The goal of hemodynamic monitoring is to
nutrition brought
assess whether the Circulatory system has
to the tissues and
adequate performance to sustain organ
waste products function and life.
are removed by
the flow of blood.

Hemodynamic monitoring provides data to guide therapy but

is not by itself therapeutic.
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Devices for Measuring Hemodynamics
1- The Arterial Line :
- This allows for monitoring of blood pressure and can be used for
blood draws for patients requiring frequent laboratory monitoring.

- Arterial lines are not used to administer medication.

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 The arterial pressure waveform
As blood leaves the ventricle, travels through the aorta, and finally enters
into the arteries, the elastic properties of the blood vessels maintain the
hemodynamic pressure of that contraction.

The arterial line visually transforms

that pressure into a waveform that can
be observed on the bedside monitor.

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The upstroke : on the waveform represents ventricular contraction.

Dicrotic notch: The closing of the aortic valve creates the notch and
indicates the beginning of diastole.

“ Run off” : A smooth downward

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• To have a proper waveform, the transducer must be in line with
the right atrium of the patient and regularly “zeroed” to
atmospheric pressure.

• Transducers below or above RA : give error reading

Complications of arterial lines :

Bleeding, infection, thrombosis, air emboli, hematomas, and
foreign body emboli from cannula disruption
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 2- Pulmonary Artery Pressure Monitoring
When providers need to know more about fluid volume status, cardiac
function, and whole body perfusion, they turn to the pulmonary artery
(PA) catheter

The "gold standard” for hemodynamic monitoring, the PA catheter provides

information on all of the parameters that make up cardiac output (CO):
Preload, Afterload, Contractility,
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The catheter is attached to a transducer system, allowing the PA waveform and
data to appear on the bedside monitor just like the arterial waveform.

The location of the catheter tip is determined by observing changes in the

waveform as the catheter passes from one area of the heart to the next.

Once in place, a “wedge” waveform appears as the balloon slides into a small
arteriole in the pulmonary artery, blocking off forward blood flow

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 PA Catheter Hemodynamics

It is important to understand the following

components of cardiac output:
Preload, Afterload, and contractility (which make up
stroke volume (SV) and heart rate (HR).
CO = HR x SV
Stroke Volume : the difference between end-diastolic
volume (preload) and end-systolic volume (afterload). ( 70ml )

Ejection fraction (EF) is SV expressed as a percentage

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Professionl Training House
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Preload : Afterload
- It is the pressure of the pressure that the
blood at maximum fill, ventricle must
just before the ventricle overcome to eject its
contracts to eject that volume of blood.
volume out.
Afterload On the
- Preload on the right right side of the
side of the heart may heart, this pressure is
be called right atrial called pulmonary
pressure (RAP) or vascular resistance
central venous (PVR)
pressure (CVP).
Afterload on the left
- The preload on the side called systemic
left side of the heart vascular resistance
called pulmonary (SVR).
capillary wedge
pressure (PCWP)
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 Preload
Preload is used to evaluate fluid volume status.
- however, in cases of mitral or aortic valvular disease, as well as obstructive or
cardiovascular shock, preload may appear elevated without changes in volume.

In contrast, cardiac dysrhythmias may decrease preload without being an

accurate reflection of volume status.

Afterload
Afterload is Elevated in situations where Vasoconstriction is occurring, such as
hypothermia, hypovolemia, vasopressor use, and hypoxia.

Afterload Decreases can be seen when Vasodilation is present, such as

anaphylactic shock, sepsis, and vasodilator medication administration.
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 Contractility

Contractility : is the ability of cardiac muscle fibers to shorten.

Although contractility cannot be measured with a traditional PA catheter, there

are special Oximetric PA catheters that have the ability to measure (SW)

Stroke Work Index (SWI) : The amount of work performed by the ventricle per
contraction , it provides information about myocardial contractility

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 Starling’s Law

The greater the amount of stretch on the ventricle, or End-diastolic

volume ( Preload) , the greater Stroke volume and CO

• Exceptions of law :
IF too much preload , contraction may actually become suboptimal.
The heart attempts to compensate for this through increase of heart rate and
decrease afterload.

It is essential that fluid volume status be optimized to promote

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 Central Venous pressure ( CVP )
• Central venous pressure is considered a direct measurement of
the blood pressure in the right atrium and vena cava .
• The CV catheter is an important tool used to assess right
ventricular function and Systemic fluid status.
• Normal CVP is 4-10 mm Hg.
• CVP Increase in hypervolemia & decrease in hypovolemia

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Systemic Vascular Resistance (SVR)

Represent left side afterload

• High SVR = Vasoconstriction
• Low SVR : Vasodilatation
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 Oxygenation Profile
Optimization of perfusion through the use of an arterial line, PA catheter not guarantee
adequate oxygen delivery to the tissues.
The overall goal is to ensure that Oxygen delivery meets Consumption
( to maintain aerobic metabolism )

Oxygen delivery (D02) is the volume of oxygen delivered to the systemic vascular bed
per minute and is the product of cardiac output (CO) and arterial oxygen concentration
(CaO2). DO2 = CO x CaO2

Oxygen Consumption (V02) : is the total amount of oxygen removed from the
blood due to tissue oxidative metabolism per minute

Extraction ratio ( 02ER). is the ratio of oxygen consumption (VO2) to oxygen

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 Oxygenation Profile
In summary, if V02 increased , 02ER will rise regardless of the
amount of D02

The amount of oxygen returned to the heart is venous oxygen (Sv02), which is
the balance of whole body tissue oxygenation.

In a balanced state, Sv02 plus 02ER should be close to 100%.

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 Oxygenation Profile
Fick’s equation :
Sv02 = Sa02 (arterial oxygen) — V02/13.9 (constant) X CO x hemoglobin.

In alkalosis,
Low levels of hemoglobin also
hemoglobin’s
Several factors result in less oxygen being
affinity for
affect D02:- transported
oxygen
1-Hemoglobin increases
2-Arterial O2 Decreased FiO2 does not allow the
3- (Fi02) lungs to inhale enough oxygen to
4- Body temp. In acidosis, meet the body’s needs
5- Acid-base hemoglobin’s
balance affinity for
All affect Sv02. There is higher affinity for
oxygen hemoglobin to O2 in hypothermia
decreases. and lower affinity in hyperthermia
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 Oxygenation Profile
Oxygen balance can also be evaluated through the use of
laboratory analysis of Lactic acid.

Too much demand or not enough delivery of oxygen and the tissues
revere to anaerobic metabolism and lactic acid production occurs.

Alternatively, Oximetric PA
(ABGs), Sv02, and lactic acid, only and Central line catheters
provide a snapshot of the patient’s current attached to special monitors
status and ongoing evaluation is often have the ability to observe
necessary. and trend, in real time, the
oxygen profile
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 Case
The oxygen extraction ratio (O2ER) is determined
solely by DO2.

A. True
B. False

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 Case
The arterial line can be commonly used for all of
the following except:

A. Blood pressure monitoring

B. Arterial blood draws
C. Medication delivery
D. Stroke volume variation

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Normal Hemodynamic Values

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• 10. Which one of the following medications is best to
recommend for treating M.M.’s lipids (from patient
case 8)?

A. Ezetimibe 10 mg/day.
B. Fenofibrate 145 mg/day.
C. Colesevelam 625 mg 6 tablets/day.
D. Atorvastatin 20 mg/day

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