REGISTERED CARDIOVASCULAR INVASIVE
SPECIALIST EXAM RCIS EXAM | ALL
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES | GRADED A+ | VERIFIED
ANSWERS | LATEST VERSION
You are assisting a new cardiologist do a right heart cath on a cyanotic
child. Before inflating the balloon he asks you "What should I use to inflate
this balloon?"
You should answer______.
a. "Air"
b. "CO2"
c. "Sterile Saline"
d. "50%-50%, contrast and saline" ---------CORRECT ANSWER----------------
-ANSWER b. CO2 is 20 times more soluble in blood than air. If the balloon
breaks or leaks in the right heart it will be more quickly absorbed. Since
cyanotic shunts move across the septum in a R-L direction, some of the
gas may pass through the R-L shunt. If it does embolize into the left heart it
might lead to a dangerous arterial embolism or stroke.
Get the CO2 from a CO2 tank off the table.
O2 gas is heavier than air, so let it bleed into a glass or basin through a
sterile tube on the table. Then fill the balloon syringe by aspirating CO2
from the bottom of the glass. Use this to inflate the balloon. One problem
with CO2 is that it diffuses rapidly through rubber. So you may have to
replenish the CO2 frequently.
Never inflate a Swan-Ganz balloon with any fluid, especially contrast! Its
high viscosity may prevent you from removing it through the tiny catheter
lumen.
See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed
catheters" Keywords: Cyanotic kid
When inserting a Swan-Ganz catheter the balloon should be inflated in the:
a. Sheath
b. Femoral vein
c. IVC-RA
,d. RV
e. PA ---------CORRECT ANSWER-----------------ANSWER c. RA. The
balloon should not be inflated until it reaches the large vena-cava or RA. If
inflated in the sheath or small vein it may rupture the balloon or damage the
vessel. In an average sized adult the RA is usually reached after inserting
the catheter 15-20 cm from the Internal Jugular (I.J.) vein or 30 cm. from
the femoral vein. The inflated balloon then floats downstream with the RA-
RV-PA blood flow. See: Baim and Grossman, chapter on "Balloon-tipped
Flow-directed catheters" Keywords: Inflate Swan balloon in RA
The most stable place to leave a Rt. Ht. catheter positioned is with the tip in
the:
a. RA
b. RV
c. PA
d. PAW ---------CORRECT ANSWER-----------------ANSWER c. PA. Most
monitoring catheters are left in the PA position because it produces fewer
arrhythmias than the RA (PACs) or RV (PVCs). After obtaining a PA wedge
the balloon is deflated to prevent obstruction of blood flow, and the catheter
is pulled back out of wedge so in cannot damage the lung. Monitoring
Swan-Ganz catheters may be left in the PA position long term.
See: Baim and Grossman, chapter on "Balloon-tipped Flow-directed
catheters" Keywords: PA most stable position
305. On the second day of pulmonary artery catheter monitoring an RV
waveform is observed from the distal catheter port. Which one of the
following is the most
appropriate action?
a. Advance the catheter 10 cm with the balloon deflated
b. Switch monitoring lines to the proximal port of the catheter
c. Inflate the balloon with 1.5 ml air and withdraw the catheter
d. Inflate the balloon with 1.5 ml air and advance the catheter
e. Leave in RV, you can still get PA systolic pressure from RV ---------
CORRECT ANSWER-----------------
,All of the following statements regarding PA catheter insertion are true
EXCEPT:
a. Following vessel puncture, SaO2 analysis of a withdrawn blood sample
should be <95%.
b. Use a Paceport Swan in patients with LBBB.
c. The major risk of internal jugular cannulation is carotid artery puncture.
d. Air embolism is of concern at the time of guidewire and catheter insertion
---------CORRECT ANSWER-----------------ANSWER a. Following vessel
puncture, SaO2 analysis of a withdrawn blood sample should be <95% is
not true. The SvO2 (not SaO2) must be less than 85% to be sure you are in
the vein. Patients may develop RBBB if the RBB is irritated during catheter
passage through the RV. If the patient has pre-existing LBBB, complete
heart block may ensue, requiring pacing via a paceport catheter, a pacing
Swan or external transcutaneous pacing. The carotid artery is close to the
internal jugular. Take precautions against air embolism by placing the
patient in the Trandelenburg position.
See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and
http://www.pacep.org/pages/start/ref.html?xin=asahq
To help prevent pulmonary artery rupture when wedging a Swan-Ganz
catheter:
a. Check the pulmonary artery occlusion pressure frequently
b. Withdraw PAC slightly if a PAOP waveform is obtained with inflation of
<1.25 ml air
c. Advance PAC slightly if a PAOP waveform is obtained with inflation of
<1.25
ml air
d. Always use 1.5 ml air to inflate the balloon for a PAOP ---------CORRECT
ANSWER-----------------ANSWER b. Withdraw PAC slightly if a PAOP
waveform is obtained with inflation of <1.25 ml air. You want the catheter to
wedge with <1.5 ml of air. But, if the wedge air volume is <1.25 the hard
catheter tip may be exposed. Darovic says: "The following guidelines
should prevent damage or rupture of the pulmonary artery:
1. Do not advance the catheter with the balloon deflated
2. Slow balloon inflation while continuously observing the PA waveform.
Inflation is stopped immediately when the PA trace changes to a wedged
pressure trace.
, 3. Do not inflate the balloon with fluid...
4. Keep the wedging time and the number of balloon inflation/deflation
cycles to a minimum. If a close pulmonary artery diastolic/wedge pressure
relationship exists, pulmonary artery diastolic pressure may be used to
assess left atrial pressure.
5. Position the catheter tip in a central pulmonary vessel so that the full or
nearly full recommended inflation volume produces the wedge waveform.
6. Avoid excessive catheter manipulation
7. Avoid irrigating the pulmonary artery lumen under high pressure. ... The
damped tracing may be due to spontaneous wedging, and forced irrigation
may produce rupture of the pulmonary artery."
See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and
http://www.pacep.org/pages/start/ref.html?xin=asahq
Which statement regarding thrombus formation on Swan-Ganz catheters is
most correct?
a. All intravascular monitoring catheters are thrombogenic.
b. Heparin should be added to the IV solutions of all patients with a PA
catheter.
c. Catheters occluded by thrombus should be flushed vigorously with saline
to clear the catheter.
d. Thrombus begins to form on catheters only after 3 to 5 days in the vessel
---------CORRECT ANSWER-----------------ANSWER a. All intravascular
monitoring catheters are thrombogenic. Even heparin does not guarantee
they will not clot. However, many physicians are not using heparin for right
heart cath or PA monitoring. And, if a catheter does become clotted, do
NOT flush the catheter into the circulation. That causes an embolus.
Darovic says: "Any catheter in the vascular system can promote thrombus
formation, particularly in patients who have prolonged circulatory failure. . ..
Prevention of catheter thrombus formation requires consideration of
anticoagulation I hypercoagulable patients if pulmonary artery pressure
monitoring is prolonged or if catheter insertion is known to have been
traumatic."
See: Darovic, chapter on "Pulmonary Artery Pressure Monitoring" and
http://www.pacep.org/pages/start/ref.html?xin=asahq
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