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msmarco_v2.1_doc_01_1666661193#16_2442923705
|
http://insuremekevin.com/uncontrollable-itching-on-arms-neck-from-stress-and-anxiety/
|
Uncontrollable Itching On Arms, Neck from Stress and Anxiety -
|
Uncontrollable Itching On Arms, Neck from Stress and Anxiety
Uncontrollable Itching On Arms, Neck from Stress and Anxiety
Uncontrollable itching with no apparent cause
I can’t itch and dissect a frog at the same time
The mystery itch
You can feel the tingling sensation of the nerves
Hydrocortisone to the rescue
The ancient cure of ice
I never leave home without a tube of cream
Mid-life crisis creates cure for the itch
To heck with climbing the corporate ladder
Equilibrium in the brain
Stress + Anxiety = Itching
I’m no doctor or physicist
Entropy:
I have not achieved nirvana just nervenda
Is the answer blowing in the wind
April 7, 2015 Update
Brachioradial pruritus: a pain in the neck
My epidemiology
About Kevin Knauss
Advertisement
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Select a Category to Review Specific Topics
Kevin Knauss
|
But I had to tell him all his time and effort just wasn’t producing a product that was acceptable. Second, I had been offered a position that sounds very good, but there are some draw backs that make me hesitant to accept it. I’m going to have to tell the person that has made the generous offer, that I really should accept, that I will have to decline. At about 11 PM while I was laying in bed asleep my neck lit up like a 100 watt light bulb with the itch. I had fallen asleep thinking about these two situations that I had to confront in the very near future. The itch was as strong as it had been years earlier when I faced similar stressful and anxiety filled dec
| 9,331 | 10,000 |
msmarco_v2.1_doc_01_1666712144#0_2442925531
|
http://insurewithgreenlight.com/
|
Get Low Cost Auto Insurance in Camden County, NJ » Greenlight Insurance Specialists
|
Low Cost Auto Insurance Coverage in Camden & Gloucester County, NJ
Low Cost Auto Insurance Coverage in Camden & Gloucester County, NJ
|
Get Low Cost Auto Insurance in Camden County, NJ » Greenlight Insurance Specialists
Low Cost Auto Insurance Coverage in Camden & Gloucester County, NJ
Greenlight Insurance Specialists, Inc. is an independent, full service insurance brokerage agency serving families and businesses in the New Jersey and Pennsylvania areas with personal and commercial insurance products. Our professional agents are dedicated to understanding you and your insurance needs. We work with you – and for you – to find the best coverage for your needs. Our friendly and caring agents are dedicated to obtaining the insurance coverage you need to protect what matters in your life. Play
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Roadways are the busiest during the holiday season. If you’re traveling with a small child, make sure their car seat is installed properly. Get a free child seat safety check by a certified technician here
| 0 | 1,000 |
msmarco_v2.1_doc_01_1666713538#0_2442926975
|
http://insurewithintegrity.com/insurance/
|
Insurance | Insure with Integrity
|
WE HAVE THE RIGHT PLAN FOR YOU
WE HAVE THE RIGHT PLAN FOR YOU
Medicare OPTIONS
MEDICARE SUPPLEMENT
MEDICARE ADVANTAGE (MAPD)
PRESCRIPTION DRUG PLAN (PDP)
Health INSURANCE
ACA
DENTAL INSURANCE
VISION INSURANCE
ADDITIONAL Insurance PRODUCTS
LONG TERM CARE
LIFE INSURANCE
TRAVEL GEOBLUE
|
Insurance | Insure with Integrity
WE HAVE THE RIGHT PLAN FOR YOU
Understanding Illinois health insurance can be difficult. At Integrity Insurance, we will help you sift through the maze of health insurance options available today. We’ll provide you with the facts so you can make more informed choices about your health care coverage and your future. Whether you need healthcare flexibility or the most affordable insurance that you can find — there are many insurance plans you can choose from and our team is here to find the perfect plan for you. GET A FREE QUOTE
Medicare OPTIONS
MEDICARE SUPPLEMENT
Illinois Medicare supplement insurance from Blue Cross Blue Shield of Illinois
LEARN MORE
MEDICARE ADVANTAGE (MAPD)
Explore plans that pay for Medicare and provide additional benefits
LEARN MORE
PRESCRIPTION DRUG PLAN (PDP)
Medicare prescription drug benefits available to Medicare beneficiaries
LEARN MORE
Health INSURANCE
Health insurance is a vital part of your full planning picture. Without it your safety and the safety of your family is jeopardized; most qualified health care providers will not treat you without health insurance. As we all know, health care is very costly; a prolonged illness or serious injury can easily bankrupt a family without insurance. Not having it is an endangerment to everything you have.
| 0 | 1,329 |
msmarco_v2.1_doc_01_1666713538#1_2442928847
|
http://insurewithintegrity.com/insurance/
|
Insurance | Insure with Integrity
|
WE HAVE THE RIGHT PLAN FOR YOU
WE HAVE THE RIGHT PLAN FOR YOU
Medicare OPTIONS
MEDICARE SUPPLEMENT
MEDICARE ADVANTAGE (MAPD)
PRESCRIPTION DRUG PLAN (PDP)
Health INSURANCE
ACA
DENTAL INSURANCE
VISION INSURANCE
ADDITIONAL Insurance PRODUCTS
LONG TERM CARE
LIFE INSURANCE
TRAVEL GEOBLUE
|
Without it your safety and the safety of your family is jeopardized; most qualified health care providers will not treat you without health insurance. As we all know, health care is very costly; a prolonged illness or serious injury can easily bankrupt a family without insurance. Not having it is an endangerment to everything you have. ACA
Individual healthcare plans under the Affordable Care Act
LEARN MORE
DENTAL INSURANCE
Get fast, free quotes to find affordable Illinois dental insurance
LEARN MORE
VISION INSURANCE
BlueCare Vision plans for Individuals
LEARN MORE
ADDITIONAL Insurance PRODUCTS
LONG TERM CARE
Explore plans that pay for Medicare and provide additional benefits
LEARN MORE
LIFE INSURANCE
Illinois Medicare supplement insurance from Blue Cross Blue Shield of Illinois
LEARN MORE
TRAVEL GEOBLUE
GeoBlue offers comprehensive international Travel Healthcare Insurance
LEARN MORE
| 992 | 1,887 |
msmarco_v2.1_doc_01_1666715947#0_2442930291
|
http://insurgency.wikia.com/wiki/Insurgency_Wiki
|
Insurgency Wiki | Fandom
|
Insurgency: Sandstorm
CONTENT PORTALS
NEWS
Sandstorm Release Date
New Insurgency: Sandstorm Info
Insurgency: Sandstorm Release Date
September 2018 for PC
FEATURED MEDIA
|
Insurgency Wiki | Fandom
The wiki dedicated to the Insurgency series that anyone can edit! 331 articles since creation on July 4 2012
Insurgency: Sandstorm
Stay tuned for info about the upcoming game
Read more >
Insurgency
Everything you need to know about Insurgency
Read more >
Weapons
From the Makarov to the Mk18
Read more >
Classes
Learn the differences of each
Read more >
CONTENT PORTALS
Classes
Equipment
Maps
Mechanics
Modes
Weapons
NEWS
Ysbert • 10 August 2018
0
Sandstorm Release Date
The release date is online on the Sandstorm website at http://insurgency-sandstorm.com/
The beta is already accessible for people who pre-order the game. For more information, see the Insurgency: Sandstorm article. For the contents of the game, see p…
Read Full Post
Ysbert • 19 June 2018
0
New Insurgency: Sandstorm Info
Two videos from E3 give us a whole lot of new information on Insurgency: Sandstorm. Many pages are already updated, including the Classes of Insurgency: Sandstorm article.
| 0 | 995 |
msmarco_v2.1_doc_01_1666715947#1_2442931735
|
http://insurgency.wikia.com/wiki/Insurgency_Wiki
|
Insurgency Wiki | Fandom
|
Insurgency: Sandstorm
CONTENT PORTALS
NEWS
Sandstorm Release Date
New Insurgency: Sandstorm Info
Insurgency: Sandstorm Release Date
September 2018 for PC
FEATURED MEDIA
|
For the contents of the game, see p…
Read Full Post
Ysbert • 19 June 2018
0
New Insurgency: Sandstorm Info
Two videos from E3 give us a whole lot of new information on Insurgency: Sandstorm. Many pages are already updated, including the Classes of Insurgency: Sandstorm article. We also got eyes on which weapons will be in the game. Now it should be noted …
Read Full Post
Ysbert • 31 May 2018
0
Insurgency: Sandstorm Release Date
NWI announced a release date estimation for Insurgency: Sandstorm: September 2018 for PC
Q1 2019 for console
The price has also been set:
| 717 | 1,286 |
msmarco_v2.1_doc_01_1666715947#2_2442932736
|
http://insurgency.wikia.com/wiki/Insurgency_Wiki
|
Insurgency Wiki | Fandom
|
Insurgency: Sandstorm
CONTENT PORTALS
NEWS
Sandstorm Release Date
New Insurgency: Sandstorm Info
Insurgency: Sandstorm Release Date
September 2018 for PC
FEATURED MEDIA
|
We also got eyes on which weapons will be in the game. Now it should be noted …
Read Full Post
Ysbert • 31 May 2018
0
Insurgency: Sandstorm Release Date
NWI announced a release date estimation for Insurgency: Sandstorm: September 2018 for PC
Q1 2019 for console
The price has also been set: $ 29
Players who bought Insurgency will get a 10% discount. Pre-ordering the game also gives an additional 10% off. …
Read Full Post
FEATURED MEDIA
Mapping Contest Content Update Released
The Insurgency series is the intellectual property of New World Interactive. This site is not endorsed by or affiliated with New World Interactive, or its licensors. All trademarks are the property of their respective owners.
| 996 | 1,701 |
msmarco_v2.1_doc_01_1666715947#3_2442933869
|
http://insurgency.wikia.com/wiki/Insurgency_Wiki
|
Insurgency Wiki | Fandom
|
Insurgency: Sandstorm
CONTENT PORTALS
NEWS
Sandstorm Release Date
New Insurgency: Sandstorm Info
Insurgency: Sandstorm Release Date
September 2018 for PC
FEATURED MEDIA
|
$ 29
Players who bought Insurgency will get a 10% discount. Pre-ordering the game also gives an additional 10% off. …
Read Full Post
FEATURED MEDIA
Mapping Contest Content Update Released
The Insurgency series is the intellectual property of New World Interactive. This site is not endorsed by or affiliated with New World Interactive, or its licensors. All trademarks are the property of their respective owners. Game content and materials are: © 2021 New World Interactive Inc. and its licensors. All Rights Reserved.
| 1,286 | 1,807 |
msmarco_v2.1_doc_01_1666718192#0_2442934806
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http://insurgentcountry.net/gram.htm
|
Gram Parsons Lyrics and Chords
|
Gram Parsons
|
Gram Parsons Lyrics and Chords
Gram Parsons
Flying Burrito Brothers, Byrds, International Submarine Band, Fallen Angels, Emmylou Harris
Updated June, 2016
For some news releases please visit
Sierra Records
Silver Shoes
The Gram Parsons Connection
Thanks to
Rick Lusher
for so many lyrics and chords! A great and huge Byrds Page
ByrdWatcher
See also the fantastic Gram Parsons Homepage byLarry Klug
A great and huge Byrds Lyrics/Chords Page
(McGuinn,Clark,Parsons,Hillman,Crosby,White etc.) die-augenweide.de/byrds/
GP on the Internet: Gram Parsons 70th Birthday Bash (Cosmic American Production)
The Strange Tale of Gram Parsons' Funeral in Joshua Tree (DesertUSA)
The Strange Death of Gram Parsons: 1973 (Byrd Watcher)
The Byrds speak on Gram Parsons (The Byrds Lyrics Page)
A Joshua Tree Motel Room, Haunted by the Ghost of a Country Legend (NYTimes)
Gram Parsons (The GettyImages)
1969 Desert Trippin' - Gram Parsons, Anita Pallenberg & Keith Richards (The Selvedge Yard)
The Gram Parsons Connection (Sid Griffin)
Gram Parsons - A Fallen Angel
Gram Parsons (Archives Vol. 1) (ColdfrontMag)
Emmylou Harris on how she and Gram Parsons got "fired" before their first gig in Boulder (Westword)
Gram Parsons Prints (Sonic Editions)
Emmylou.net - Gram Prasons
MR Gram Parsons
Gram Parsons Official Website
The Gram Parsons Story (RollingStones.net)
The Drug-Crazed Majesty of Gram Parsons (Los Angeles Magazine)
I've Said It Before, I'll Say It Again: Gram Parsons Wrote "Wild Horses" (No Depression)
Pieces Of The Sky: the Legacy Of Gram Parsons (American Songwriter)
Gram Parsons on Facebook
Why the Grievous Angel Style of Gram Parsons Lives On (Vogue)
Fallen Angel Gram Parsons gains flight in new documentary (SFWeekly)
Gandulf Hennig on Making, "Gram Parsons: Fallen Angel"
he Cult of Gram Parsons Lives on in Joshua Tree (L.A. Weekly)
Calling Me Home: Gram Parsons and the Roots of Country Rock (Bob Kealing)
Grievous Angels Court and Spark
Gram Parsons Notebook
Rare record found
Gram Parsons light still shines decades after his dead
Pals seize Parsons cosmic glo
Skip Spence Tribut
Gram Parsons the grievous angel
Gram Parsons exhibit
The Coal Porters
'Chris Hillman Tribute Concerts'
And don't overlook:
| 0 | 2,220 |
msmarco_v2.1_doc_01_1666718192#1_2442937312
|
http://insurgentcountry.net/gram.htm
|
Gram Parsons Lyrics and Chords
|
Gram Parsons
|
1) (ColdfrontMag)
Emmylou Harris on how she and Gram Parsons got "fired" before their first gig in Boulder (Westword)
Gram Parsons Prints (Sonic Editions)
Emmylou.net - Gram Prasons
MR Gram Parsons
Gram Parsons Official Website
The Gram Parsons Story (RollingStones.net)
The Drug-Crazed Majesty of Gram Parsons (Los Angeles Magazine)
I've Said It Before, I'll Say It Again: Gram Parsons Wrote "Wild Horses" (No Depression)
Pieces Of The Sky: the Legacy Of Gram Parsons (American Songwriter)
Gram Parsons on Facebook
Why the Grievous Angel Style of Gram Parsons Lives On (Vogue)
Fallen Angel Gram Parsons gains flight in new documentary (SFWeekly)
Gandulf Hennig on Making, "Gram Parsons: Fallen Angel"
he Cult of Gram Parsons Lives on in Joshua Tree (L.A. Weekly)
Calling Me Home: Gram Parsons and the Roots of Country Rock (Bob Kealing)
Grievous Angels Court and Spark
Gram Parsons Notebook
Rare record found
Gram Parsons light still shines decades after his dead
Pals seize Parsons cosmic glo
Skip Spence Tribut
Gram Parsons the grievous angel
Gram Parsons exhibit
The Coal Porters
'Chris Hillman Tribute Concerts'
And don't overlook: The Coal Porters' 'Gram Parsons Tribute Concerts'
Gram Parsons another side of th life - the lost recordings of GP 1965-1966
Lyrics & Chords
Lyrics
$ 1000 Wedding
A song for you
All alone
Big Mouth Blues
Blue Canadian Rockies
Blue eyes
Brand New Heartache
Brass Buttons
Break my mind
Cash on the barrelhead
California Cottonfields
Close up the Honkytonks
Christine's Tune
Cody, Cody
Crazy Arms
Dark end of the street
Dim Light, Stick Smoke
Do right woman
Do you know how it' feels...
Drug Store Truck Drivin' Man
Farther along
Folsom Prison Blues
Green, green grass of home
Hearts on fire
High Fashion Queen
How Much I've Lied
Hickory Wind
Hippie Boy
Hot Burrito #1
Hot Burrito #2
If you gotta go
I am a pilgrim
Image of me
In my hour of darkness
I shall be released
Juanita
Just_Because
Kiss the children
Lazy days
Let it be me
Life in prison
Lodi
Love hurts
Luxury Liner
Man in the fog
Millers's Cave
My uncle
Nothing was delivered
One day week
One hundred years from now
Pick me up
Return of the Grievous Angel
Satisfied me
She
Sin City
Sin City D-Flat
Song me back home
Six days on the road
Sleepless Night
Still feeling blue
Streets of Baltimore
Strong Boy
Take a message to Mary
That's all it took
The Angels Rejoiced Last Night
The Christian Life
The Train Song
To love somebody
Tonight the bottle let me down
Tried so hard
We'll sweep out the ashes ...
Wheels
White line fever
Wild Horses
Your Angel Steps Out Of Heaven
You're still on my mind
You win again
Ain't No Beatle, Ain't No Rolling Ston e
All I Have Are Memories
All The Things
Another Place, Another Time
Another Side Of This Life
Apple Tree
A River Is Made Out Of Raindrops
A Satisfied Mind
Almost Grown
Baby What You Want Me To Do
The Bells Of Rhymney
Big Country
Blurry Slurry Nights
Bonie Moronie
Break My Mind
The Button
Candy Man
Carolina Calypso
Codine
Cold, Cold Heart
Country Baptising
Cry One More Time
Darkest Years
Down In The Churchyard
Dream Baby
Everyone Loves A Winner
Forty Days
God's Own Singer
Goin' Away, Don't You Wanna Go? The Great Silkie
Hand Within The Glove
Hang On Sloopy
Hey Nellie Nellie
High Flying Bird
High On A Hilltop
Honky Tonk Women
I Can't Dance
I must have been somebody
I Just Can't Take It Anymore
I May Be Right
I Threw Away The Rose
Jambalaya
Jesus Is More Than A Name
Knee Deep In The Blues
L.A. Customs Blues
Las Vegas
Last Thing On My Mind
Lazy Days
Long Black Limousine
Lucille
Mama's Hungry Eyes
Mary Don't You Weep
Money Honey
The New Soft Shoe
No One Knows I'm Lonesome
November Nights
Oh, Didn't They Crucify My Lord
Older Guys
On My Journey Home
Pride Of Man
Race With The Wind
The Rain Came Down
Rolling Stone
Run, Little Boy, Run
Searchin
She Once Lived Here
She Thinks I Still Care
Somebody's Back In Town
Sum Up Broke
Sweet Dream Baby
Sweet Mental Revenge
Take A Message To Mary
That Kind Of Livin'
That's All Right
That's The Bag I'm In
They Still Go Down
The Train Song
Truck-Drivin' Man
Under Your Spell Again
Undo The Right
You Got A Reputation
You Win Again
Wake Up Little Susie
Wheel Of Fortune
When Will I Be Loved
You Don't Miss Your Water
Zah's Blues
Billy Ray Herrin: Billy Ray wrote: Hello Hans,
"... Walter Egan & Lona Heins are singing on my new CD "Down on Cypress Creek". The song "Time will hold the memories" is about Gram's father's death and the last time I saw him at the train depot in Waycross..."
"Billy Ray Herrin, out of Waycross, Georgia, is a passionate carrier of the torch of Gram Parsons, a country-rock pioneer
and a fellow Waycross native.
| 1,078 | 5,720 |
msmarco_v2.1_doc_01_1666718192#2_2442942397
|
http://insurgentcountry.net/gram.htm
|
Gram Parsons Lyrics and Chords
|
Gram Parsons
|
The Coal Porters' 'Gram Parsons Tribute Concerts'
Gram Parsons another side of th life - the lost recordings of GP 1965-1966
Lyrics & Chords
Lyrics
$ 1000 Wedding
A song for you
All alone
Big Mouth Blues
Blue Canadian Rockies
Blue eyes
Brand New Heartache
Brass Buttons
Break my mind
Cash on the barrelhead
California Cottonfields
Close up the Honkytonks
Christine's Tune
Cody, Cody
Crazy Arms
Dark end of the street
Dim Light, Stick Smoke
Do right woman
Do you know how it' feels...
Drug Store Truck Drivin' Man
Farther along
Folsom Prison Blues
Green, green grass of home
Hearts on fire
High Fashion Queen
How Much I've Lied
Hickory Wind
Hippie Boy
Hot Burrito #1
Hot Burrito #2
If you gotta go
I am a pilgrim
Image of me
In my hour of darkness
I shall be released
Juanita
Just_Because
Kiss the children
Lazy days
Let it be me
Life in prison
Lodi
Love hurts
Luxury Liner
Man in the fog
Millers's Cave
My uncle
Nothing was delivered
One day week
One hundred years from now
Pick me up
Return of the Grievous Angel
Satisfied me
She
Sin City
Sin City D-Flat
Song me back home
Six days on the road
Sleepless Night
Still feeling blue
Streets of Baltimore
Strong Boy
Take a message to Mary
That's all it took
The Angels Rejoiced Last Night
The Christian Life
The Train Song
To love somebody
Tonight the bottle let me down
Tried so hard
We'll sweep out the ashes ...
Wheels
White line fever
Wild Horses
Your Angel Steps Out Of Heaven
You're still on my mind
You win again
Ain't No Beatle, Ain't No Rolling Ston e
All I Have Are Memories
All The Things
Another Place, Another Time
Another Side Of This Life
Apple Tree
A River Is Made Out Of Raindrops
A Satisfied Mind
Almost Grown
Baby What You Want Me To Do
The Bells Of Rhymney
Big Country
Blurry Slurry Nights
Bonie Moronie
Break My Mind
The Button
Candy Man
Carolina Calypso
Codine
Cold, Cold Heart
Country Baptising
Cry One More Time
Darkest Years
Down In The Churchyard
Dream Baby
Everyone Loves A Winner
Forty Days
God's Own Singer
Goin' Away, Don't You Wanna Go? The Great Silkie
Hand Within The Glove
Hang On Sloopy
Hey Nellie Nellie
High Flying Bird
High On A Hilltop
Honky Tonk Women
I Can't Dance
I must have been somebody
I Just Can't Take It Anymore
I May Be Right
I Threw Away The Rose
Jambalaya
Jesus Is More Than A Name
Knee Deep In The Blues
L.A. Customs Blues
Las Vegas
Last Thing On My Mind
Lazy Days
Long Black Limousine
Lucille
Mama's Hungry Eyes
Mary Don't You Weep
Money Honey
The New Soft Shoe
No One Knows I'm Lonesome
November Nights
Oh, Didn't They Crucify My Lord
Older Guys
On My Journey Home
Pride Of Man
Race With The Wind
The Rain Came Down
Rolling Stone
Run, Little Boy, Run
Searchin
She Once Lived Here
She Thinks I Still Care
Somebody's Back In Town
Sum Up Broke
Sweet Dream Baby
Sweet Mental Revenge
Take A Message To Mary
That Kind Of Livin'
That's All Right
That's The Bag I'm In
They Still Go Down
The Train Song
Truck-Drivin' Man
Under Your Spell Again
Undo The Right
You Got A Reputation
You Win Again
Wake Up Little Susie
Wheel Of Fortune
When Will I Be Loved
You Don't Miss Your Water
Zah's Blues
Billy Ray Herrin: Billy Ray wrote: Hello Hans,
"... Walter Egan & Lona Heins are singing on my new CD "Down on Cypress Creek". The song "Time will hold the memories" is about Gram's father's death and the last time I saw him at the train depot in Waycross..."
"Billy Ray Herrin, out of Waycross, Georgia, is a passionate carrier of the torch of Gram Parsons, a country-rock pioneer
and a fellow Waycross native. His devotion to Parsons is evident, in words and music, throughout Down On Cypress Creek; but, nowhere is it more crystal-clear than in "Time Will Hold The Memories". As long as musicians like Herrin holds them,
Parsons' legacy is in good hands." Ben Fong-Torres
Author, Hickory Wind: The Life and Times of Gram Parsons
Billy Ray Herrin
| 2,220 | 6,057 |
msmarco_v2.1_doc_01_1666724681#0_2442946650
|
http://insurspective.com/2015/05/propulsion-plus-boat-coverage/
|
Propulsion Plus Boat Coverage - INSURSPECTIVE
|
Propulsion Plus Boat Coverage
Propulsion Plus Boat Coverage
About the author
|
Propulsion Plus Boat Coverage - INSURSPECTIVE
Propulsion Plus Boat Coverage
by Rena Todd | Posted on May 26, 2015
May 22, 2015
As part of the IIANC PARTNERS program, our Presidential PARTNERS are able to submit a guest blog posting to our blog, Insurspective. Please see below from IIANC Presidential PARTNER Progressive. Propulsion Plus is an optional coverage that pays to repair or replace the lower unit of an outboard motor, or the upper and lower units of a sterndrive motor, in the event of a mechanical breakdown. We see many claims from customers who thought they’d hit a hidden submerged object, when in fact their drive shaft or pinion gear failed. These kinds of failures cause the boat to lurch and often produce a “metal on metal” sound—as if there had actually been a collision. While collision coverage will take care of that submerged object loss, only Propulsion Plus will provide coverage when there is no collision and covered parts simply fail. Normal wear and tear is covered – even on the propeller. Customers can purchase Propulsion Plus for outboard and inboard/outboard boats that are no more than 10 years old and keep the coverage until the boat turns 21 years old. We determine the premium by the age of the boat at the time the coverage is first purchased—the newer the boat, the lower the annual premium for the life of the policy. For more information about Propulsion Plus and other specialized boat coverages from Progressive, visit ForAgentsOnly.com.
| 0 | 1,485 |
msmarco_v2.1_doc_01_1666724681#1_2442948504
|
http://insurspective.com/2015/05/propulsion-plus-boat-coverage/
|
Propulsion Plus Boat Coverage - INSURSPECTIVE
|
Propulsion Plus Boat Coverage
Propulsion Plus Boat Coverage
About the author
|
While collision coverage will take care of that submerged object loss, only Propulsion Plus will provide coverage when there is no collision and covered parts simply fail. Normal wear and tear is covered – even on the propeller. Customers can purchase Propulsion Plus for outboard and inboard/outboard boats that are no more than 10 years old and keep the coverage until the boat turns 21 years old. We determine the premium by the age of the boat at the time the coverage is first purchased—the newer the boat, the lower the annual premium for the life of the policy. For more information about Propulsion Plus and other specialized boat coverages from Progressive, visit ForAgentsOnly.com. About the author
| 794 | 1,502 |
msmarco_v2.1_doc_01_1666726506#0_2442949559
|
http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
|
CARDIAC HEMODYNAMICS
|
PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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CARDIAC HEMODYNAMICS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines". Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions. PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases. CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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MI and left ventricular failure are two examples of when left ventricular compliance decreases. CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP. Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease. Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease. Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP. VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg;
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP. VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic:
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
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msmarco_v2.1_doc_01_1666726506#7_2443176782
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http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
|
CARDIAC HEMODYNAMICS
|
PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions. -Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle. -Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia. -In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure. -Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
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http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle. -Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia. -In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure. -Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above). -Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg. -Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance. Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg. -Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance. Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool. Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting. In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting. In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus. Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter. INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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Care must be taken in the interpretation of all hemodynamic data derived from the catheter. INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures. 2. Single readings are not as important as the trend of values. 3.
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http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures. 2. Single readings are not as important as the trend of values. 3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
| 7,573 | 8,369 |
msmarco_v2.1_doc_01_1666726506#14_2443406650
|
http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
|
CARDIAC HEMODYNAMICS
|
PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve. 4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia. Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia. Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
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http://int-prop.lf2.cuni.cz/heart_sounds/ekg5/cham2.htm
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility! PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed: Many factors influence the aortic pressure waveform. Consider the following example: Greater ventricular filling (more filling time) resulted in greater systolic pressure.
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CARDIAC HEMODYNAMICS
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PRESSURE MEASUREMENTS
PULMONARY ARTERIAL (PA) LINES
ARTERIAL OR A-LINES
Insertion of The A-Line
THE CVP LINE
COMMON PROBLEMS
Vee Tac Presents.....
Hemodynamics is the study of the dynamic behavior of blood. As blood flows from chamber to chamber, as valves open and close, and as the myocardium contracts and relaxes, pressures are generated in various parts of the heart. These cardiovascular pressures can be measured and monitered through catheters whose tips are placed in the atria, pulmonary artery or systemic arteries. These are called "hemodynamic lines".
Hemodynamic lines have several uses. They enable you to sample venous and arterial blood without having to stick a patient over and over. They provide a way to monitor various waveforms, which can provide clues to patient status. The combination of pulmonary, arterial, and systemic arterial lines can be used to calculate cardiac output. Most important, these lines enable you to monitor directly various cardiac pressures. Interpretation of these pressures can guide you and the physician in planning and evaluating therapy in shock, fluid overload or deficit, cardiac failure, and other conditions.
PRESSURE MEASUREMENTS
The most important cardiac pressure is that of the left ventricle., because it is a major determinant of systemic perfusion. The pressure in the left ventricle just before systole is called the left ventricular end-diastolic pressure or LVEDP. This pressure reflects the compliance of the left ventricle - it's ability to receive blood from the left atrium during diastole. When the left ventricular compliance decreases, the LVEDP rises. MI and left ventricular failure are two examples of when left ventricular compliance decreases.
CORRELATION OF PRESSURES
There is a close correlation between LVEDP and other cardiac pressures. In the presence of a normal mitral valve, LVEDP is reflected by left atrial pressure or LAP. In the person with a normal mitral valve and normal lung function, the LVEDP is also reflected by the pressure in the pulmonary capillary bed, pulmonary capillary wedge pressure or PCWP) and the pressure in the pulmonary artery at the end of diastole. This latter pressure is sometimes referred to as the pulmonary artery end diastolic pressure or PAEDP.
Remember, this concept only hold true for patients with a normal mitral valve and no pulmonary disease.
Left arterial pressure can be monitored at bedside, but a LAP line can be dangerous because it provides a direct path for air or clots to enter the left ventricle and become systemic emboli. The pulmonary capillary and pulmonary arterial pressures can be monitored at the bedside with a balloon-tipped catheter placed in the pulmonary artery. With the balloon deflated, one can measure pulmonary artery systolic, diastolic, and mean pressures with the catheter. When the balloon is inflated, it wedges the catheter in a small distal branch of the pulmonary artery. The pressure recorded is that reflected back from the left atrium through the pulmonary capillary bed. This pressure is the Pulmonary capillary wedge pressure or PCWP.
VALUES FOR NORMAL RESTING CARDIAC PRESSURES
Note..these can vary somewhat from institution to institution..
- right atrium mean 0-8 mm Hg; A wave: 2-10 mm Hg; V wave: 2-10 mm Hg
- right ventricle systolic 15-30 mm Hg; end diastolic: 0-8 mmHg
- pulmonary artery systolic 15-30 mm Hg; end diastolic: 3-12 mm Hg
- wedge A wave 3-15 mm Hg; V wave: 3-12 mm Hg; mean: 5-12 mm Hg
- AVO2 difference (mL/L) 30-50
- cardiac output (L/minute) 4.0-6.5 (varies with patient size)
- cardiac index (L/minute/m2) 2.6-4.6
- pulmonary vascular resistance (dynes - second - cm-2) 20-130
- systemic vascular resistance (dynes - second - cm-2) 700-1600
CRITICAL VALUES
Pressure tracings may be virtually diagnostic of certain conditions.
-Mitral stenosis is associated with a pressure gradient in diastole across the mitral valve (wedge or left atrial pressure vs left ventricular pressure). A large V wave in the pulmonary artery wedge tracing may be seen with mitral regurgitation, since the amplitude of the V wave is affected by left atrial filling from the pulmonary veins as well as the regurgitant volume from the left ventricle.
-Decreases in right atrial pressure, pulmonary capillary wedge pressure, and cardiac index/output can indicate hypovolemia.
-In cases of elevated right atrial pressures with low wedge pressures and low cardiac index/output (especially in the face of an inferior wall myocardial infarction) one may suspect right ventricular involvement and failure.
-Pulmonary congestion due to left ventricular failure or volume overload will increase the pulmonary artery wedge pressure (ie, congestion usually occurs at a wedge pressure in excess of 18 mm Hg and frank pulmonary edema occurs with a wedge pressure in the upper twenties and above).
-Cardiogenic shock and pulmonary edema are characterized by signs of hypoperfusion, with hemodynamic data including systemic hypotension, markedly decreased cardiac index less than 2.1 L/minute/m2, and elevated wedge pressures, often well above 18 mm Hg.
-Septic shock is also characterized by clinical signs of hypoperfusion, but may be differentiated from cardiogenic shock by certain hemodynamic data which often include a normal or near normal wedge pressure, an elevated cardiac index/output, and a marked decrease in systemic vascular resistance.
Caution should be exercised in that these parameters are only general guidelines, and during the course of a patient's illness, such information may not always be exact. As always, history and physical examination are critical in the diagnostic assessment of each patient. The catheter can aid with diagnostic dilemmas, but is most useful as a management tool.
Pulmonary artery catheters can also be useful in the diagnosis of ventricular septal defects by sampling O2 saturations as the catheter is advanced from the great veins to the right atrium to the right ventricle and out into the pulmonary artery. An oxygen "step-up" from the right atrium to the right ventricle of approximately 10% is indicative of left to right shunting.
In the appropriate setting of acute myocardial infarction and sudden deterioration after a stable course, this diagnosis may be a consideration; right heart catheterization is one method to establish the diagnosis. Other causes of an O2 step-up include coronary fistula draining into the RV, primum atrial septal defects, and pulmonic insufficiency with a patent ductus arteriosus.
Cardiac tamponade is another diagnosis which can be documented by pulmonary artery catheter measurements. Rising intrapericardial pressures interfere with diastolic filling of the heart. Marked increases in the end-diastolic pulmonary artery (PA), right ventricular (RV) , and right atrial (RA) pressures to the same value ("equalization of the pressures") strongly suggest tamponade. Somewhat similar findings may be seen with constrictive and restrictive diseases. Pulmonary hypertension and increased pulmonary vascular resistance can suggest such diagnoses as pulmonary embolism or even mitral stenosis. Care must be taken in the interpretation of all hemodynamic data derived from the catheter.
INTERPRETING PRESSURE DATA
PLEASE REMEMBER...
1. Compare the values obtained to the patient's normal values rather than an arbitrary standard. If the patient has undergone cardiac Cath within the past few months, pressures obtained at that time may be used as baselines. If not, you must predict general values on the basis of your knowledge of the so-called normal values and your patient's pathology. For example, you would expect the patient with a narrowed tricuspid valve to have an elevated CVP. The patient with COPD probably would have both high CVP and PA pressures.
2. Single readings are not as important as the trend of values.
3. Consider the pressures in relation to each other. If one pressure is measured with a manometer and another with a transducer, you may want to convert them to the same scale. To convert millimeters of mercury (Hg) to centimeters of water, multiply by 1.36. Remember that abnormal values are not always due to a primary pathology of the monitored chamber. For example, and elevated CVP in association with normal or low PA pressures suggests that the cause lies between these two sites, that is, with the pulmonary valve, right ventricle, or tricuspid valve.
4. Remember that a normal valve does not necessarily indicate an absence of pathology. For example, a patient may have a normal CVP but be intensely vaso-constricted due to hypovolemia.
Step up to the blackboard please, and meet our patient. He has just had an MI less than one week ago, and now it appears he is going into heart failure. He is in serious need of our monitoring his hemodynamic status constantly and closely. In ordere to do this, we are using a transducer, which is an instrument that converts pressure waves into electrical energy so they can be displayed on an oscilloscope. We are doing this because his pressure has been too high for the water manometer. His flush system consists of heparinized 5% Dextrose and he is obtaining this by a countiuous low-flow flush device. This is most desirable because it is a closed system...and while it has a continuous low flow, if a rapid flow is needed, you can pull on the "tail" of the device and flush the system without breaking sterility!
PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed:
Many factors influence the aortic pressure waveform. Consider the following example:
Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects?
How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the filling of the ventricles the stronger the subsequent systolic contraction.
Other factors such as aortic valve condition, compliance (elasticity) of the aorta (related to age and disease), vascular resistance, cardiac output and technical considerations of recording can affect the arterial pressure waveform.
Pulmonary Artery Pressure
The pulmonary artery pressure waveform is similar in form to, but generally of lesser magnitude than, the aortic pressure waveform.
The type of catheter that allows you to monitor these waveforms is generally referred to by the name of one specific brand of catheter, the Swan-Ganz pulmonary artery catheter.
Insertion of the Swan-Ganz Catheter
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management. The threshold for performing this procedure varies considerably amongst clinicians; some authorities feel this technique is overutilized and is indicated in only rare circumstances.
Contraindications
-severe, uncorrectable coagulopathy
-presence of a left bundle branch block (LBBB) on EKG;
-placement of a right heart catheter may lead to complete heart block (A-V dissociation) if an underlying LBBB is present -local infection at the skin insertion site
-severe hypothermia; in this situation the myocardium is highly irritable and prone to malignant arrhythmias induced by the catheter
-inadequate monitoring equipment; continuous EKG monitoring with blood pressure measurements is necessary during catheter insertion
-patient refusal
Patient Preparation
Technique and risks of the procedure are explained to the patient. When patient is comatose or disoriented, the appropriate guardians should be contacted. Catheterization may be safely performed in an intensive care unit, specialized procedure room with telemetry and fluoroscopy, or a formal Cardiac Catheterization Laboratory. A standard emergency room or regular nursing floor is generally not equipped for this procedure. No specific patient preparation is required and often this procedure is performed on an urgent basis. Whenever possible, aspirin and nonsteroidal anti-inflammatory agents should be discontinued in advance, but this is not absolutely necessary. Effects of heparin or warfarin, however, should be reversed prior to catheterization. If an underlying coagulopathy is suspected (eg, disseminated intravascular coagulation, thrombocytopenia), appropriate laboratory studies should be obtained immediately including a platelet count and PT/PTT. In most cases parenteral sedation is unnecessary; however the use of agents such as meperidine (Demerol) is at the physician's discretion.
Complications
-balloon rupture
-conduction disturbance (ie, new right bundle branch block 5%)
-arrhythmias (3% ventricular tachycardia, 2% ventricular fibrillation)
-pulmonary infarction/pulmonary hemorrhage perforation or rupture of the pulmonary artery
-knotting of the catheter
-thrombosis of a blood vessel (ie, 1% to 2% superior vena cava syndrome)
-pulmonary emboli
-infection (0% to 5%)
-blood loss, including hemothorax, retroperitoneal bleed, etc
-inadvertent arterial puncture (6% femoral)
-pneumothorax and tension pneumothorax (0% to 6%)
-valvular trauma
-disconnection of the introducer apparatus with disappearance into the vein
Equipment
-I.V. pole and pressure monitor manifold, pressure monitor
-normal saline (250-500 mL) with heparin (1000 units) for flush
-pressure bag
-pressure tubing
-stopcocks (3-way)
-cutdown tray (for peripheral approach)
-vein introducer kit
-Swan-Ganz catheter kit
-1% lidocaine for local anesthesia
-bowl of sterile saline (flush and balloon integrity check)
-suture
-instrument set
-3 and 5 mL syringes
-25-gauge needle for anesthesia
-gloves, gowns, masks
-sterile dressing kit (surgical drapes)
-bedside table on which to place instruments
-telemetry monitor for heart rate and rhythm automatic blood
-pressure cuff, A-line
-Betadine scrub
Technique
Swan-Ganz catheterization can take place via a variety of approaches including internal jugular vein, subclavian vein, femoral vein, or brachial vein. The last of these approaches most commonly entails direct visualization of the brachial vein from a cut-down exposure. The procedure should be performed in a closely monitored setting, enabling constant recording of heart rate, rhythm, and frequent blood pressure readings, usually an intensive care unit. The procedure may be performed at the patient's bedside with or without the assistance of fluoroscopic guidance. Sterile technique is required for catheter insertion. The skin at the site of approach is most commonly prepped with a Betadine scrub. Often, if the internal jugular or subclavian veins are utilized, the patient is placed in a Trendelenburg position to assist with central venous distension and ease of access. The physician should scrub and wear gown, mask, and gloves. The patient is then draped with sterile sheets (most institutions drape the patient from head to toe, while others require a sterile field only at the site of access). The patient should be cooperative for catheter insertion. If a patient is uncooperative or becomes uncooperative during the procedure, sedation may be given at the discretion of the physician. Upon initiation of the procedure, the skin and subcutaneous tissue is infiltrated with lidocaine (1%) and a small gauge needle. Deeper tissues may then be infiltrated with lidocaine for the comfort of the patient. A thin gauged needle (21-gauge, 112") is usually attached to a 5 mL syringe and used to localize the vessel of interest for a central venous approach. Once the vessel has been located, a large gauge needle (16- or 18-gauge) is then attached to a syringe and placed into the vessel following the course of the "finder needle." When blood is aspirated easily into the syringe, the syringe is disconnected from the needle and a flexible guidewire is threaded through the needle into the vein. Wire placement can cause a variety of complications, most often ventricular ectopy. If an increase in ectopy is observed, the guidewire should be withdrawn several centimeters. Once the guidewire has been passed into the vessel, the needle is removed from the patient. At no time should the physician lose control of the tip of the guidewire. Failure to control the guidewire can cause serious complications and death if lost in the patient. Once the needle is removed, a dilator is advanced over the guidewire and through the skin, to facilitate passage of a venous introducer. The introducer should be flushed with heparinized saline prior to insertion to avoid air emboli. Once the tract along the guidewire is dilated, the dilator should be slipped off the guidewire (maintaining guidewire position in the vein). The introducer and dilator can then be put together as a unit (dilator within introducer) and slid over the guidewire into the vein, again taking care to control the tip of the guidewire outside the patient's body. After the placement of the introducer and guidewire assembly, the guidewire and dilator should be removed from the patient. This leaves only the venous introducer sheath within the patient. At this point, if the introducer has a side port lumen, venous blood should be aspirated and the introducer then flushed. If blood cannot be aspirated via a side-port lumen, the introducer is incorrectly placed and must be reinserted. No blood should come from the center of the introducer since this piece is usually accompanied by a one-way ball valve which does not allow blood leakage. The introducer should then be secured to the patient's skin with sutures. When the venous introducer has been placed, the Swan-Ganz catheter can then be inserted. Prior to catheter insertion, the balloon tip should be checked under sterile water for leaks and the catheter flushed. The catheter should then be connected to the appropriate pressure monitoring lines and flushed again via the pressure tubing to ensure that the catheter is bubble-free and that a column of uninterrupted fluid exists from the tubing through the tip of the catheter. The catheter can then be guided via the introducer, through the central venous system, through the right atrium, right ventricle, pulmonary artery, and into the wedge position. The catheter usually passes smoothly through the circulation, with the aid of the inflated balloon at its tip. The catheter should never be withdrawn with the balloon inflated. Catheter position can be ascertained by pressure wave forms, although fluoroscopy can be quite helpful in guiding the catheter into the wedge position. A chest radiograph is usually obtained after catheter insertion to verify position, as well as to rule out the possibility of pneumothorax if the subclavian or internal jugular approach was utilized.
ARTERIAL OR A-LINES
Arterial lines are catheters placed in systemic arteries to facilitate recording of continuous accurate data about blood pressure in a patient who is hemodynamically unstable, and to allow frequent sampling of arterial blood gases without the need for repeated arterial sticks. Arterial lines are commonly placed percutaneously in the radial, brachial, or femoral arteries.
The normal arterial waveform has a sharp upstroke and a more gradual downstroke with an evident DICROTIC NOTCH, due to a small rise in pressure that occurs at the time of aortic valve closure. End diastole should be seen very clearly...
Insertion of The A-Line
Procedure Commonly Includes
Insertion of an indwelling catheter directly into the arterial circulation for continuous blood pressure (BP) monitoring. Indications
May be divided into three categories:
-hemodynamic monitoring of the unstable patient (acutely hypotensive or hypertensive) including those on vasopressor or vasodilator agents
-multiple sampling of arterial blood, particularly in the mechanically ventilated patient
-determination of cardiac output (less common)
Contraindications
Poor collateral circulation around the artery to be cannulated constitutes a relative contraindication. Thrombus formation at the catheter site is common and can result in distal extremity ischemia if collaterals are inadequate. Also, coagulopathies, systemic anticoagulation (eg, heparin), and interventional thrombolysis are considered contraindications and reversal may be required.
Patient Preparation
The risks and benefits of the procedure are explained. After the site of cannulation is selected by the physician, the area is prepared using povidone-iodine scrub for a minimum of 30 seconds. A sterile technique should be maintained.
Aftercare
Meticulous care is required to avoid line-related infections. Recommendations by the Centers for Disease Control include:
-handwashing prior to any manipulation of the system
-applying topical antiseptics to the insertion site immediately after catheter is placed
-covering the site with sterile dressing
-recording date of catheter insertion and each dressing change -daily inspection of catheter site
-replacing sterile dressing every 48-72 hours with new antibiotic ointment
-flushing of line using normal saline in a closed flush system
-changing flush solution every 24 hours
-changing arterial line site every 4 days or less
-removing catheter promptly at the first sign of infection
Complications
Estimates of significant complications range from 15% to 40%. Thrombosis is the most frequent complication. Incidence of thrombosis increases if:
-the catheter is left in place more that 3-4 days
-a large diameter catheter is used
-multiple puncture attempts are required
-hypotension, decreased cardiac output, atherosclerosis, or hypothermia are present
-prolonged pressure is required to control bleeding after catheter removal; thrombosis rate under optimal conditions is approximately 5% to 8%; symptomatic occlusion requiring surgery is much less <1%)
Infectious complications are also frequent, with the catheter serving as either a primary or secondary site of bacteremia. Factors predisposing to infection include prolonged (more than 4 days) catheter insertion, the use of cutdown for insertion, local inflammation, and infection from a secondary source. Other complications include hemorrhage or hematoma formation, pseudoaneurysms, vasovagal reactions, and local skin necrosis. Distal embolization of small clots or air may occur if improper line-flush technique is used.
Equiptment
Varies somewhat depending on artery selected. A 19- or 20-gauge teflon catheter-over-needle is used in most instances. 16 cm catheters are used for femoral and axillary sites, shorter (114" to 2") catheters are used for radial, brachial, and dorsalis pedis sites. If the Seldinger technique is used, a flexible guidewire is also needed. Other equipment includes sterile gloves, hair covers, povidone-iodine, 1% lidocaine without epinephrine, and 3-0 or 4-0 silk suture and suture equipment.
Technique
The radial artery is generally considered the site of choice; alternate sites include femoral, axillary, brachial and dorsalis pedis arteries. For radial artery cannulation, the presence of collateral flow must first be established using the modified Allen test. Following this, the wrist is dorsiflexed 60 degrees and using a sterile technique 1% lidocaine is used to infiltrate overlying skin. Catheter-over-needle is inserted at a 30 degree angle to skin and advanced until arterial blood is seen in the needle hub. The needle is held fixed while the surrounding catheter is advanced into the artery. The needle is removed and the catheter hub is attached to the connecting tubing. After suturing the catheter in place, a wrist board may be used to stabilize the neutral wrist position. The Seldinger technique may be used for larger arteries. Here, the artery is located with a simple 20-gauge needle. Once arterial blood is returned, a flexible guidewire is passed through the needle; the needle is removed and the teflon catheter is threaded over the guidewire into the artery.
Data Acquired
Graphic waveform of arterial pressure, with pressure on the vertical axis (mm Hg) and time on the horizontal axis
Normal Arterial Pressure Tracing
The peak of each waveform represents the systolic blood pressure and the trough represents the diastolic blood pressure (in mm Hg). Normal values for blood pressure obtained by arterial cannulation are slightly higher than those obtained by routine sphygmomanometry, ranging from 5-20 mm Hg higher. This is due to a combination of physiologic and technical factors, reviewed elsewhere. If indirect pressure readings (ie, cuff pressures) are greater than arterial line readings, instrument error is likely. The entire system (tubing, calibration, seals, catheter, etc) should be carefully inspected; the transmitted arterial waveforms may also appear "damped," further suggesting technical error. A normal "square wave" response is also shown in Figure A. This waveform is seen whenever the tubing system is flushed. Most monitoring systems are equipped with a "flush valve" which can be opened and closed rapidly (routinely performed by nursing staff). A rapid-velocity stream flows through the tubing, removing bubbles and debris. The resulting waveform is by nature artifactual, but abnormalities in its configuration suggest underlying technical problems.
Damped Arterial Pressure Tracing
In normal individuals, peak systolic blood pressures vary somewhat with respiration, a finding difficult to appreciate with bedside sphygmomanometry, but easily observed with direct arterial blood pressure monitoring. When a healthy person inspires, there is a transient fall in blood pressure. On the blood pressure monitoring screen, this appears as a "dip" in the pressure tracings, which returns to baseline during expiration. The maximum drop in systolic blood pressure (pulsus paradoxus) should not exceed 8-10 mm Hg. Values less than this are physiologic and should not be confused with cardiac tamponade.
CRITICAL Values
Cutoff values for hypertension, as defined in textbooks, are the same for blood pressure obtained by arterial cannulation and routine sphygmomanometry. A "hypertensive urgency" is characterized by marked elevations in diastolic (and sometimes systolic) blood pressure, accompanied by retinal hemorrhages, exudates, and papilledema. End-organ damage is likely within several days if blood pressure is not adequately controlled. In a "hypertensive emergency" (malignant hypertension), the retinal findings described are present along with such alarming features as acute renal failure, seizures, blurred vision, mental status deterioration, stroke, and congestive heart failure. End-organ damage is already apparent. Although both hypertensive urgencies and emergencies show marked blood pressure elevations (eg, diastolic blood pressure greater than 120-140 mm Hg), there are no precise cutoff values. These syndromes should not be arbitrarily diagnosed or excluded on the basis of arterial line blood pressure readings alone; they are complex clinical diagnoses. Similarly, no black-and-white cutoff values exist for defining hypotension. Most physicians would consider a systolic blood pressure in the 70-80 mm Hg range abnormal if the individual was previously healthy. However, systolic blood pressures in the 80-90 mm Hg range are not unheard of in the patient with end stage cardiac disease or on multiple vasodilatory agents. Conversely, a "normal" systolic blood pressure of 110 mm Hg may indicate significant hypotension in the dialysis patient whose baseline is 200 mm Hg. A drop in systolic blood pressure during inspiration >10 mm Hg is significant. This increased paradoxical pulse may be seen in cardiac tamponade, severe asthma, pulmonary embolism, and other conditions. Arterial cannulation is useful in monitoring the patient with cardiac tamponade, but is seldom used to make the diagnosis. Disparity in blood pressure readings between direct and indirect measurements greater than 20 mm Hg may occur in shock states. This is due to reflex peripheral vasoconstriction (increased systemic vascular resistance). Korotkoff sounds may be barely audible when direct measurement of central arterial pressures are low-normal. Large discrepancies may also be seen in patients with severe peripheral atherosclerosis (arteriosclerosis obliterans), where systolic pressure drops off dramatically distal to a luminal occlusion. It should be emphasized that inaccuracies may occur in both direct and indirect systems. Clinical importance should be placed on the trends in blood pressure values, regardless of the system used.
Limitations
Accuracy is limited by errors introduced by the equipment, which transforms mechanical energy (pulse) into electrical energy (tracing). Factors such as the natural frequency of the transducer, clamping, and compliance may cause artifact. Other sources of error include improper leveling of equipment, improper assembly, and air in the tubing.
Additional Information
Arterial cannulation is generally considered a procedure of low technical difficulty. The true difficulty lies in avoidance of thrombosis and infection and careful patient selection.
THE CVP LINE
The large veins (superior and inferior vena cavae) run into the right atrium. A catheter inserted into the jugular vein and passed down towards the right atrium, and connected to a pressure transducer measures the central venous pressure, which is essentially identical to the right atrial pressure since there are no valves between the right atrium and the large veins.
While most nurses, from med/surg to critical care, have assisted doctors in the insertion of CVP lines, it is important to know the type of doctor you are going to assist with this procedure in order to know how to prepare. Please check out and study the following link for this information, and then return to this page by hitting your BACK key...
VERY IMPORTANT LINK
PLEASE CLICK HERE
COMMON PROBLEMS
Arterial lines and PA lines both share some common problems that all nurses must be aware of, these being damping, spurius readings thrombosis, and infection. Exsanguination also can occur if a stopcock is accidently left open after an arterial blood sample is drawn. The blood in the artery is under such high pressure that a patient can lose a significant amount of blood, even if the connection just comes loose. For this reason, limbs with arterial lines are ALWAYS uncovered and pressure alarms should be set to alert you if accidental disconnection occurs. In addition, when the line is removed, you should maintain firm pressure on the site for at least 5 minutes to prevent hematoma formation due to high intravascular pressure.
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PULMONARY ARTERIAL (PA) LINES
Aortic Pressure
Pumping by the heart results in the development of pressure in the aorta and the arteries. If pressure in the aorta is recorded over time a pressure wave can be observed: Many factors influence the aortic pressure waveform. Consider the following example: Greater ventricular filling (more filling time) resulted in greater systolic pressure. Can you think of a basic law of the heart which this situation reflects? How about the Frank/Starling mechanism. Starling stated that "the energy of contraction is a function of the length of the muscle fibre." So the greater the fi
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Early Systolic Murmur
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LLSB: Early Systolic Murmur
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Early Systolic Murmur
LLSB: Early Systolic Murmur
Early systolic murmurs begin with the first sound and peak in the first third of systole. Early murmors have the greatest intensity in the early part of the cycle. Common causes are a small ventricular septal defect (VSD), or the innocent murmurs of childhood. The latter murmur is normal if the following are present: normal splitting of the second sound
normal jugular venous and carotid pulses
normal precordial palpation
normal chest x-ray and ECG
The early systolic murmur of a small VSD stops before midsystole, because as ejection continues and the ventricular size decreases, the small defect is sealed shut causing the murmur to soften or cease. This murmur is characteristic of the type of children's VSD which may disappear with age. The sound you heard is an early systolic murmur . It was recorded at the LLSB of a 20 year-old female with a small muscular VSD.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
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Eucerin: About skin | Daily skincare routine for the face
About Skin
Skin treatment
Caring for skin – A daily skincare routine for the face
Your daily face care routine
About facial cleansing & toning
All about the facial care routine
All about sun protection for the face
Thorough but gentle daily cleansing and a good moisturising care will help to keep your skin healthy. Quality skincare products, chosen to match your specific skin type and skin concern, can protect facial skin from damaging external influences such as the sun, hot and cold climates and air pollution. They can also help to soothe irritated skin, restore it to a healthy condition and prevent the development of skin diseases. Daily face care routine
Your daily face care routine
Four basic steps
Good skincare involves four basic steps: cleanse, tone, care and protect
Cleanse
Thorough cleansing is the first step in effective skincare. Cleansing removes dirt, sweat, sebum and make-up and prepares the skin for care. Cleansed skin is better able to absorb the active ingredients in care products. Read More
Tone
Toning removes any traces of cleanser, refreshes the skin, while restoring its natural pH value. Read More
Care
Care products moisturise and replenish skin.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
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cleanse, tone, care and protect
Cleanse
Thorough cleansing is the first step in effective skincare. Cleansing removes dirt, sweat, sebum and make-up and prepares the skin for care. Cleansed skin is better able to absorb the active ingredients in care products. Read More
Tone
Toning removes any traces of cleanser, refreshes the skin, while restoring its natural pH value. Read More
Care
Care products moisturise and replenish skin. Many also target and treat specific skin concerns. Read More
Protect
Sun protection is important for the days when your skin is going to be exposed to harmful UV rays: the main cause of premature skin ageing. Most day creams already come with an SPF 15. Read More
Attention Box
Your skincare routine should take place twice a day – in the morning and in the evening.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Many also target and treat specific skin concerns. Read More
Protect
Sun protection is important for the days when your skin is going to be exposed to harmful UV rays: the main cause of premature skin ageing. Most day creams already come with an SPF 15. Read More
Attention Box
Your skincare routine should take place twice a day – in the morning and in the evening. The specific routine will vary depending on the time of day and the particular needs and condition of your skin. Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone? An effective face care routine starts with thorough but gentle cleansing and toning to: remove dirt, sweat, sebum and make-up without drying out the skin. prepare skin for your face care regime.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
The specific routine will vary depending on the time of day and the particular needs and condition of your skin. Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone? An effective face care routine starts with thorough but gentle cleansing and toning to: remove dirt, sweat, sebum and make-up without drying out the skin. prepare skin for your face care regime. The valuable ingredients in face care products are absorbed more effectively when applied to cleansed skin. Cleansing is particularly important for skin prone to acne as it helps skin to maintain its natural healthy balance and supports the natural regenerative process. How to cleanse and tone
There are two main steps to a thorough cleansing routine: a cleansing milk or gel followed by a toner. If you are wearing eye make-up then it is advisable to add a separate eye-make-up-remover as a third step in your cleansing routine.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
The valuable ingredients in face care products are absorbed more effectively when applied to cleansed skin. Cleansing is particularly important for skin prone to acne as it helps skin to maintain its natural healthy balance and supports the natural regenerative process. How to cleanse and tone
There are two main steps to a thorough cleansing routine: a cleansing milk or gel followed by a toner. If you are wearing eye make-up then it is advisable to add a separate eye-make-up-remover as a third step in your cleansing routine. Step 1
Eye-make-up-remover
To gently remove make-up from the lashes and delicate area around the eye. Eye-make-up-remover is best applied with a cotton pad wiped gently across the eye area. Read More
Step 2
A cleansing milk or gel
Choose a cleanser that suits your skin type. Cleansing milk is best for skin that is prone to dry skin types. For normal, combination or oily skin types, Eucerin recommends a gel cleanser.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Step 1
Eye-make-up-remover
To gently remove make-up from the lashes and delicate area around the eye. Eye-make-up-remover is best applied with a cotton pad wiped gently across the eye area. Read More
Step 2
A cleansing milk or gel
Choose a cleanser that suits your skin type. Cleansing milk is best for skin that is prone to dry skin types. For normal, combination or oily skin types, Eucerin recommends a gel cleanser. Read More
Step 3
Toner
Toning removes any last traces of cleanser and refreshes the skin, while restoring its natural pH value. Toner should be applied with a cotton pad, wiped gently across the face. Read More
Gel cleansers should be rinsed off thoroughly with lukewarm water. Avoid using water that is too hot, especially on sensitive skin, as extreme temperatures can cause irritations. Cleansing milks are applied and removed with cotton pad and do not require water.
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msmarco_v2.1_doc_01_1666790309#6_2443548933
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
|
Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Read More
Step 3
Toner
Toning removes any last traces of cleanser and refreshes the skin, while restoring its natural pH value. Toner should be applied with a cotton pad, wiped gently across the face. Read More
Gel cleansers should be rinsed off thoroughly with lukewarm water. Avoid using water that is too hot, especially on sensitive skin, as extreme temperatures can cause irritations. Cleansing milks are applied and removed with cotton pad and do not require water. You can, however, gently remove cleansing milk with lukewarm water if you prefer. Three-in-one products provides a convenient combination of cleanser, toner and eye-make-up-remover. Though best results are always achieved by using a separate cleanser, toner and eye make–up remover. Three-in-one cleansers should be applied by wiping a cotton pad gently across your face and eye area. How to choose an appropriate cleanser and toner
Cleansing is the key first step in your skincare routine:
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
You can, however, gently remove cleansing milk with lukewarm water if you prefer. Three-in-one products provides a convenient combination of cleanser, toner and eye-make-up-remover. Though best results are always achieved by using a separate cleanser, toner and eye make–up remover. Three-in-one cleansers should be applied by wiping a cotton pad gently across your face and eye area. How to choose an appropriate cleanser and toner
Cleansing is the key first step in your skincare routine: cleansed skin absorbs the active ingredients in care products more effectively. Water alone will not clean your face. You need to use a surfactant (a detergent that dissolves both water and fat) to bind with the dirt and remove it gently from your skin. It is important to choose products that are gentle on skin. Frequent washing with ordinary soaps or aggressive surfactants can weaken the barrier function of skin by:
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
cleansed skin absorbs the active ingredients in care products more effectively. Water alone will not clean your face. You need to use a surfactant (a detergent that dissolves both water and fat) to bind with the dirt and remove it gently from your skin. It is important to choose products that are gentle on skin. Frequent washing with ordinary soaps or aggressive surfactants can weaken the barrier function of skin by: changing the pH from its naturally slightly acidic state of between 5.4 and 5.9 to a neutral or even alkaline pH, reducing its ability to fight bacteria
disrupting the proteins in horny layer (the outermost layer of the skin)
removing skin-protecting lipids (the fats that hold cells together in the epidermis)
When skin’s barrier function is weakened its sensitivity is increased and it is more prone to dryness and irritaton. Read more about skin structure. Cleansers
Choose a cleanser that: will be gentle on your skin and will not dry it out
has been formulated for your specific skin type and concern
has been thoroughly tested and is, ideally, compatible with sensitive skin
When choosing between a milk and a gel product the general rule is that the drier the skin the more it will prefer a cleansing milk. It leaves your skin’s own lipids untouched, your skin stays balanced.
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msmarco_v2.1_doc_01_1666790309#9_2443555038
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
changing the pH from its naturally slightly acidic state of between 5.4 and 5.9 to a neutral or even alkaline pH, reducing its ability to fight bacteria
disrupting the proteins in horny layer (the outermost layer of the skin)
removing skin-protecting lipids (the fats that hold cells together in the epidermis)
When skin’s barrier function is weakened its sensitivity is increased and it is more prone to dryness and irritaton. Read more about skin structure. Cleansers
Choose a cleanser that: will be gentle on your skin and will not dry it out
has been formulated for your specific skin type and concern
has been thoroughly tested and is, ideally, compatible with sensitive skin
When choosing between a milk and a gel product the general rule is that the drier the skin the more it will prefer a cleansing milk. It leaves your skin’s own lipids untouched, your skin stays balanced. Cleansing gels are ideal for cleansing normal to combination skin types. A creamy cleanser nourishes dry skin and helps to maintain its natural moisture balance. Toning removes any traces of cleanser and refreshes the skin. Toners
Eucerin recommends alcohol- free toners for most skin types. Alcohol based toners have a cooling effect, but they can strip skin of its natural lipids.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Cleansing gels are ideal for cleansing normal to combination skin types. A creamy cleanser nourishes dry skin and helps to maintain its natural moisture balance. Toning removes any traces of cleanser and refreshes the skin. Toners
Eucerin recommends alcohol- free toners for most skin types. Alcohol based toners have a cooling effect, but they can strip skin of its natural lipids. Skin may then over-produce lipids in an attempt to replace those that are missing. Alcohol can intensify the dryness in dry skin and, for those with oily or combination skin, an alcohol-containing toner can help to regulate excessive oiliness by removing sebum. Three-in-one products
Three-in-one products, also known as micellar cleansers, offer cleansing, toning and eye-make-up- removal all in one. Oil molecules suspended in water lift away dirt and make-up quickly and gently. Micellar cleansers offer a convenient alternative to using three individual products.
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Skin may then over-produce lipids in an attempt to replace those that are missing. Alcohol can intensify the dryness in dry skin and, for those with oily or combination skin, an alcohol-containing toner can help to regulate excessive oiliness by removing sebum. Three-in-one products
Three-in-one products, also known as micellar cleansers, offer cleansing, toning and eye-make-up- removal all in one. Oil molecules suspended in water lift away dirt and make-up quickly and gently. Micellar cleansers offer a convenient alternative to using three individual products. The Eucerin DermatoCLEAN range of cleansers includes a gel, milk, toner, eye make-up remover and three-in-one product. All of the range has been tested on, and proven to be compatible with, sensitive skin and contains products for all skin types. The Eucerin DermoPURIFYER range has been specially formulated for skin prone to acne. For hypersensitive, hyperreactive skin Eucerin recommends Eucerin Re-Balance Soothing Cleansing Cream. For skin that is prone to redness try Eucerin ANTI-REDNESS Soothing Cleansing Gel.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
The Eucerin DermatoCLEAN range of cleansers includes a gel, milk, toner, eye make-up remover and three-in-one product. All of the range has been tested on, and proven to be compatible with, sensitive skin and contains products for all skin types. The Eucerin DermoPURIFYER range has been specially formulated for skin prone to acne. For hypersensitive, hyperreactive skin Eucerin recommends Eucerin Re-Balance Soothing Cleansing Cream. For skin that is prone to redness try Eucerin ANTI-REDNESS Soothing Cleansing Gel. Face Care
All about the facial care routine
Why care? Care products should hydrate and replenish skin. Moisturisation not only increases skin’s water content, it protects it and encourages orderly desquamation (the process by which skin sheds dead cells) leaving it feeling smooth, soft and comfortable. Many care products also target and treat specific concerns. Specific skin concerns such as ageing, hyperpigmentation and acne can effectively be treated with special care products that contain a high concentration of active ingredients.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
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Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Face Care
All about the facial care routine
Why care? Care products should hydrate and replenish skin. Moisturisation not only increases skin’s water content, it protects it and encourages orderly desquamation (the process by which skin sheds dead cells) leaving it feeling smooth, soft and comfortable. Many care products also target and treat specific concerns. Specific skin concerns such as ageing, hyperpigmentation and acne can effectively be treated with special care products that contain a high concentration of active ingredients. These special care products are often in a concentrate or serum format. Step 1
Special care
As they contain the most active ingredients in your skincare routine, special care products should be applied onto a freshly cleansed skin, and before the application of a day or night cream, to ensure they are absorbed with maximum efficiency and penetration into the skin. Read More
Step 2
Day or night care
A moisturising day or night cream should be used to hydrate and replenish facial skin as well as to provide active ingredients to address any particular skin concerns that you may have. Read More
Step 3
Eye Care
Eye care products should be applied carefully, and after your day or night care product, by gently dabbing the cream around the delicate eye area. Read More
Topical medication prescribed by a dermatologist to treat conditions such as acne or Atopic Dermatitis should be applied in the same way as a special care product:
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
|
Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
These special care products are often in a concentrate or serum format. Step 1
Special care
As they contain the most active ingredients in your skincare routine, special care products should be applied onto a freshly cleansed skin, and before the application of a day or night cream, to ensure they are absorbed with maximum efficiency and penetration into the skin. Read More
Step 2
Day or night care
A moisturising day or night cream should be used to hydrate and replenish facial skin as well as to provide active ingredients to address any particular skin concerns that you may have. Read More
Step 3
Eye Care
Eye care products should be applied carefully, and after your day or night care product, by gently dabbing the cream around the delicate eye area. Read More
Topical medication prescribed by a dermatologist to treat conditions such as acne or Atopic Dermatitis should be applied in the same way as a special care product: always first on gently cleansed skin before the application of day or night cream. Special care products should be allowed to absorb into the skin for a couple of minutes before a day or night care product is applied. If you are using a special care product then it should be allowed to absorb for a couple of minutes before applying a day or night cream. If your skin does not require a special care product, then the day or night cream should be applied directly onto a thoroughly cleansed face. How to choose an appropriate care product
Care products should be matched to your skin type and should address any particular concerns that you may have.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
|
Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
always first on gently cleansed skin before the application of day or night cream. Special care products should be allowed to absorb into the skin for a couple of minutes before a day or night care product is applied. If you are using a special care product then it should be allowed to absorb for a couple of minutes before applying a day or night cream. If your skin does not require a special care product, then the day or night cream should be applied directly onto a thoroughly cleansed face. How to choose an appropriate care product
Care products should be matched to your skin type and should address any particular concerns that you may have. Your care product choice can also adapt to suit the season (for example, many people prefer to use a lighter fluid product in the warm weather and a richer cream during the cold winter months.) Learn more in skin types and concerns and take our skin test to help determine your own skin type. If you would like advice on how to treat a specific skin concern then contact a dermatologist. Read more about the Eucerin care products for specific skin types in dry skin, sensitive skin, skin prone to redness, acne, ageing skin, hypersensitive skin or Atopic Dermatitis on face or body. Apply a small amount of the day or night care onto the fingertips and massage it gently into skin.
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
|
Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
Your care product choice can also adapt to suit the season (for example, many people prefer to use a lighter fluid product in the warm weather and a richer cream during the cold winter months.) Learn more in skin types and concerns and take our skin test to help determine your own skin type. If you would like advice on how to treat a specific skin concern then contact a dermatologist. Read more about the Eucerin care products for specific skin types in dry skin, sensitive skin, skin prone to redness, acne, ageing skin, hypersensitive skin or Atopic Dermatitis on face or body. Apply a small amount of the day or night care onto the fingertips and massage it gently into skin. The delicate skin around your eyes needs special care. Day care and night care
Many care products can be used both morning and evening. Others are formulated for specific use during the day or at night: AM: Some moisturisers contain a sun protection factor (SPF).
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http://int.eucerin.com/about-skin/skin-treatment/daily-routine-for-face
|
Eucerin: About skin | Daily skincare routine for the face
|
Caring for skin – A daily skincare routine for the face
Caring for skin – A daily skincare routine for the face
Daily face care routine
Your daily face care routine
Four basic steps
Cleanse
Attention Box
Cleansing & Toning
About facial cleansing & toning
Why cleanse and tone?
How to cleanse and tone
Step 1
How to choose an appropriate cleanser and toner
Cleansers
Toners
Three-in-one products
Face Care
All about the facial care routine
Why care?
Step 1
How to choose an appropriate care product
Protection
All about sun protection for the face
Why protect?
How to protect
How to choose the right sun protection product
Content Parts/Title FAQ (1)
|
The delicate skin around your eyes needs special care. Day care and night care
Many care products can be used both morning and evening. Others are formulated for specific use during the day or at night: AM: Some moisturisers contain a sun protection factor (SPF). This makes them suitable for daytime use but they should not be used in the evening. Other care products that contain pigments (for example, some of the products that treat redness or acne) should also only be used to during the day. PM: Skin r
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
Skin Concerns
Scalp and hair problems
Dandruff – Symptoms, causes and solutions
What is dandruff? Major causes of dandruff
Recommended solution
Dandruff is a skin condition that is difficult to hide and is an issue that affects roughly 50% of the adults world’s population. If you suffer or know someone who suffers from a form of dandruff, it’s important to know about its causes and – most importantly – that it can be controlled. What Is It? What is dandruff? The distinctive flakes and scales caused by dandruff
Dandruff is a very common scalp condition that comes in two forms. Greasy dandruff or seborrhoeic dermatitis occurs when oily and yellow flakes or scales form on your scalp and stick to your head and hair. Dry dandruff occurs when dry, white and loose flakes or scales form on your scalp and fall from your head and hair. Other symptoms can include itching, redness, and a greasy or dry scalp.
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Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
What is dandruff? The distinctive flakes and scales caused by dandruff
Dandruff is a very common scalp condition that comes in two forms. Greasy dandruff or seborrhoeic dermatitis occurs when oily and yellow flakes or scales form on your scalp and stick to your head and hair. Dry dandruff occurs when dry, white and loose flakes or scales form on your scalp and fall from your head and hair. Other symptoms can include itching, redness, and a greasy or dry scalp. Major Causes
Major causes of dandruff
1. Skin hyperproliferation is triggered by Malassezia globosa 2. Microinflammations of the scalp occur 3. Visible flakes form
Dandruff occurs when your scalp’s cell renewal process shortens, leading to the rapid shedding of your scalp’s horny skin cells, which stick together to form visible flakes. This process – known as skin hyperproliferation – is triggered by a micro-organism called Malassezia globosa, which thrives on the natural lipids or oils produced by your scalp.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
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Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
Major Causes
Major causes of dandruff
1. Skin hyperproliferation is triggered by Malassezia globosa 2. Microinflammations of the scalp occur 3. Visible flakes form
Dandruff occurs when your scalp’s cell renewal process shortens, leading to the rapid shedding of your scalp’s horny skin cells, which stick together to form visible flakes. This process – known as skin hyperproliferation – is triggered by a micro-organism called Malassezia globosa, which thrives on the natural lipids or oils produced by your scalp. It’s this micro-organism that irritates your scalp, causing microinflammations and scalp itchiness. All of the above can be triggered by a variety of factors, including: Genetic predisposition – dandruff tends to run in families
Climatic conditions – e.g. sun exposure, cold, heat, wind
Physical or emotional stress
Hormonal changes
Lifestyle factors, such as diet or alcohol intake
Microinflamations and your scalp
What are microinflammations? They’re mild inflammations of the skin. They’re so mild, in fact, that even clinical testing won’t pick them up.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
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Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
It’s this micro-organism that irritates your scalp, causing microinflammations and scalp itchiness. All of the above can be triggered by a variety of factors, including: Genetic predisposition – dandruff tends to run in families
Climatic conditions – e.g. sun exposure, cold, heat, wind
Physical or emotional stress
Hormonal changes
Lifestyle factors, such as diet or alcohol intake
Microinflamations and your scalp
What are microinflammations? They’re mild inflammations of the skin. They’re so mild, in fact, that even clinical testing won’t pick them up. But if we study skin tissue encountering microinflammations, we can detect the presence of inflammatory immune cells – in other words, the skin is responding to irritation with inflammation and thereby attempting to repair itself. If these skin cells are then subjected to further irritation, the skin can flip into a “true” inflammatory response. 1. Healthy skin 2. Microinflammation 3.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
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Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
But if we study skin tissue encountering microinflammations, we can detect the presence of inflammatory immune cells – in other words, the skin is responding to irritation with inflammation and thereby attempting to repair itself. If these skin cells are then subjected to further irritation, the skin can flip into a “true” inflammatory response. 1. Healthy skin 2. Microinflammation 3. Inflammation (Erythem)
How are they related to scalp conditions? There’s growing evidence that microinflammations of the scalp are involved in most common scalp disorders – from thinning hair and dandruff, to scalp dryness, itchiness and sensitivity. If you experience sudden hair loss or brittle hair, you may have an underlying health problem such as thyroid disease, iron deficiency, or an autoimmune disease. Some medications can also cause hair loss. Contact a dermatologist in all instances to get further information.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
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Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
Inflammation (Erythem)
How are they related to scalp conditions? There’s growing evidence that microinflammations of the scalp are involved in most common scalp disorders – from thinning hair and dandruff, to scalp dryness, itchiness and sensitivity. If you experience sudden hair loss or brittle hair, you may have an underlying health problem such as thyroid disease, iron deficiency, or an autoimmune disease. Some medications can also cause hair loss. Contact a dermatologist in all instances to get further information. Common Myths
One common misconception about dandruff is that it occurs when you don’t wash your hair often enough. Dandruff can lead to thinning hair or hair loss
Dandruff means your hair and scalp are dirty
Dandruff can be treated with vinegars, natural oils or baby shampoo
There’s no evidence to suggest any of the above is true. Solutions
Recommended solution
The scalp treatment should be used daily with or without washing the hair first. Use Eucerin DermoCapillaire ANTI-DANDRUFF GEL SHAMPOO for greasy dandruff or Eucerin DermoCapillaire ANTI-DANDRUFF CREME SHAMPOO for dry dandruff to wash out flakes without irritating your scalp. Follow with Eucerin DermoCapillaire ANTI-DANDRUFF SCALP TREATMENT for a regimen that’s clinically and dermatologically proven to fight dandruff.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
Common Myths
One common misconception about dandruff is that it occurs when you don’t wash your hair often enough. Dandruff can lead to thinning hair or hair loss
Dandruff means your hair and scalp are dirty
Dandruff can be treated with vinegars, natural oils or baby shampoo
There’s no evidence to suggest any of the above is true. Solutions
Recommended solution
The scalp treatment should be used daily with or without washing the hair first. Use Eucerin DermoCapillaire ANTI-DANDRUFF GEL SHAMPOO for greasy dandruff or Eucerin DermoCapillaire ANTI-DANDRUFF CREME SHAMPOO for dry dandruff to wash out flakes without irritating your scalp. Follow with Eucerin DermoCapillaire ANTI-DANDRUFF SCALP TREATMENT for a regimen that’s clinically and dermatologically proven to fight dandruff. Do you have dandruff? You may have dandruff if…
You have greasy yellow or white flakes that stick to your hair and scalp: This is typical of greasy dandruff or seborrhoeic dermatitis. You have dry white flakes that fall from your hair and scalp: This is typical of dry dandruff.
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
Do you have dandruff? You may have dandruff if…
You have greasy yellow or white flakes that stick to your hair and scalp: This is typical of greasy dandruff or seborrhoeic dermatitis. You have dry white flakes that fall from your hair and scalp: This is typical of dry dandruff. You’re experiencing scalp itchiness or irritation, as well as visible flaking or scaling: Many people with greasy and dry dandruff experience these symptoms too. You may have another scalp condition if…
You have dryness, itching or irritation, but no visible flakes: You may have a dry, itchy or sensitive scalp. You have red, scaly, silvery-looking patches on your scalp:
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
You’re experiencing scalp itchiness or irritation, as well as visible flaking or scaling: Many people with greasy and dry dandruff experience these symptoms too. You may have another scalp condition if…
You have dryness, itching or irritation, but no visible flakes: You may have a dry, itchy or sensitive scalp. You have red, scaly, silvery-looking patches on your scalp: You may have Psoriasis. Important Information
See your doctor or your dermatologist if you’re concerned, your symptoms are severe, or your scalp becomes inflamed, weepy or sore. You May Also Like
Greasy dandruff
DermoCapillaire Anti-Dandruff Gel Shampoo
Visibly reduces greasy dandruff
Gently cleanses scalp and hair
Soothes itching
Suitable for seborrheic dermatitis
Lightly fragranced
Dry dandruff
DermoCapillaire Anti-Dandruff Creme Shampoo
Visibly reduces dry dandruff
Gently cleanses scalp and hair
Soothes itching
Lightly fragranced
Dry and greasy dandruff
DermoCapillaire Anti-Dandruff Intensive Scalp Treatment
Effective treatment for dry and greasy dandruff
Soothes itching
Leave-on formula
Suitable for seborrheic eczema
Fragrance-free
Hypersensitive scalp
DermoCapillaire Hypertolerant Shampoo
Extremely mild shampoo
Gently cleanses while soothing an irritated scalp
Suitable for a hypersensitive scalp
Suitable for babies and children
Fragrance-free
With click on OK, we are using cross-website tools to provide you individual information for marketing purposes via partners, also beyond our website. These enable personalised online advertisements and extended analysis and evaluation options regarding the target group and user behaviour. You also agree that the data may also be transferred to third countries outside the European Economic Area without an adequate level of data protection (esp.
| 4,025 | 5,809 |
msmarco_v2.1_doc_01_1666803893#9_2443590592
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http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
You may have Psoriasis. Important Information
See your doctor or your dermatologist if you’re concerned, your symptoms are severe, or your scalp becomes inflamed, weepy or sore. You May Also Like
Greasy dandruff
DermoCapillaire Anti-Dandruff Gel Shampoo
Visibly reduces greasy dandruff
Gently cleanses scalp and hair
Soothes itching
Suitable for seborrheic dermatitis
Lightly fragranced
Dry dandruff
DermoCapillaire Anti-Dandruff Creme Shampoo
Visibly reduces dry dandruff
Gently cleanses scalp and hair
Soothes itching
Lightly fragranced
Dry and greasy dandruff
DermoCapillaire Anti-Dandruff Intensive Scalp Treatment
Effective treatment for dry and greasy dandruff
Soothes itching
Leave-on formula
Suitable for seborrheic eczema
Fragrance-free
Hypersensitive scalp
DermoCapillaire Hypertolerant Shampoo
Extremely mild shampoo
Gently cleanses while soothing an irritated scalp
Suitable for a hypersensitive scalp
Suitable for babies and children
Fragrance-free
With click on OK, we are using cross-website tools to provide you individual information for marketing purposes via partners, also beyond our website. These enable personalised online advertisements and extended analysis and evaluation options regarding the target group and user behaviour. You also agree that the data may also be transferred to third countries outside the European Economic Area without an adequate level of data protection (esp. USA). It is possible that authorities may access the data without any legal remedy. You can withdraw your consent at any time with future effect here. We are using tools to analyze our users’ behavior in order to optimize our website. You can object to this at any time here.
| 4,399 | 6,085 |
msmarco_v2.1_doc_01_1666803893#10_2443593050
|
http://int.eucerin.com/skin-concerns/scalp-and-hair-problems/greasy-and-dry-dandruff
|
Eucerin: Scalp and hair problems| About greasy and dry dandruff
|
Dandruff – Symptoms, causes and solutions
Dandruff – Symptoms, causes and solutions
What Is It?
What is dandruff?
Major Causes
Major causes of dandruff
Microinflamations and your scalp
How are they related to scalp conditions?
Common Myths
Solutions
Recommended solution
Do you have dandruff?
You may have dandruff if…
You may have another scalp condition if…
Important Information
You May Also Like
|
USA). It is possible that authorities may access the data without any legal remedy. You can withdraw your consent at any time with future effect here. We are using tools to analyze our users’ behavior in order to optimize our website. You can object to this at any time here. Change Settings
| 5,810 | 6,101 |
msmarco_v2.1_doc_01_1666810893#0_2443594080
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
Hyperpigmentation – What causes dark spots and how can I reduce them? Uneven skin pigmentation (or hyperpigmentation as it is often known) is a common skin complaint. Dark spots – known as age spots or sun spots – or dark patches of skin frequently appear on the face, hands and other parts of the body regularly exposed to the sun. This article outlines the different types of hyperpigmentation and explains what causes them. We look at how you can help prevent hyperpigmentation in the first place, as well as steps you can take to reduce dark spots or patches once they have formed. What is hyperpigmentation and what are the different types? Hyperpigmentation results in flat, darkened patches of skin that can vary in size and color. Hyperpigmentation is the term used to describe areas on uneven pigmentation in skin. Hyperpigmentation appears as darkened patches or spots on the skin that make skin look uneven. The spots are known as age spots or sun spots and hyperpigmentation is also at the heart of skin conditions such as melasma and post-inflammatory hyperpigmentation .
| 0 | 1,142 |
msmarco_v2.1_doc_01_1666810893#1_2443596316
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http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
What is hyperpigmentation and what are the different types? Hyperpigmentation results in flat, darkened patches of skin that can vary in size and color. Hyperpigmentation is the term used to describe areas on uneven pigmentation in skin. Hyperpigmentation appears as darkened patches or spots on the skin that make skin look uneven. The spots are known as age spots or sun spots and hyperpigmentation is also at the heart of skin conditions such as melasma and post-inflammatory hyperpigmentation . People with dark skin are normally more affected by hyperpigmentation marks than those with a lighter skin tone as skin pigmentation is stronger in dark skin
Hyperpigmentation: pigment spots such as age spots
Age/sun spots are common on the face
Pigment spots such as age spots (which are also known as sun spots) are caused by sun exposure. For this reason, they appear mainly on body parts that are frequently exposed such as the face, neck, décolleté, hands and arms. They tend to be small, darkened patches of skin. You can read more about what causes them and find out how to reduce them in What causes age spots and how can I reduce them?
| 643 | 1,787 |
msmarco_v2.1_doc_01_1666810893#2_2443598552
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http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
People with dark skin are normally more affected by hyperpigmentation marks than those with a lighter skin tone as skin pigmentation is stronger in dark skin
Hyperpigmentation: pigment spots such as age spots
Age/sun spots are common on the face
Pigment spots such as age spots (which are also known as sun spots) are caused by sun exposure. For this reason, they appear mainly on body parts that are frequently exposed such as the face, neck, décolleté, hands and arms. They tend to be small, darkened patches of skin. You can read more about what causes them and find out how to reduce them in What causes age spots and how can I reduce them? Hyperpigmentation: melasma
Hyperpigmentation on the upper lip can occur due to hormonal changes
Melasma – a form of hormone-induced hyperpigmentation – is common during pregnancy
Also known as chloasma, melasma is a condition where larger patches of hyperpigmentation develop mainly on the face. Although it can affect both men and women, melasma is most common in women and is thought to be triggered by changes in hormone levels. Melasma occurs in 10–15 percent of pregnant women and in 10–25 percent of women taking oral contraceptives 1 and is sometimes referred to as “the mask of pregnancy”. You can read more about melasma in What causes melasma and how can I reduce dark patches on my skin?
| 1,142 | 2,486 |
msmarco_v2.1_doc_01_1666810893#3_2443601022
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http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Hyperpigmentation: melasma
Hyperpigmentation on the upper lip can occur due to hormonal changes
Melasma – a form of hormone-induced hyperpigmentation – is common during pregnancy
Also known as chloasma, melasma is a condition where larger patches of hyperpigmentation develop mainly on the face. Although it can affect both men and women, melasma is most common in women and is thought to be triggered by changes in hormone levels. Melasma occurs in 10–15 percent of pregnant women and in 10–25 percent of women taking oral contraceptives 1 and is sometimes referred to as “the mask of pregnancy”. You can read more about melasma in What causes melasma and how can I reduce dark patches on my skin? The International Dermal Institute, Melasma Unmasked by Dr Claudia Aguirre quoting Kang, H. Y., & Ortonne, J. P. (2010). What should be considered in treatment of melasma. Annals of Dermatology, 22 (4), 373-378. Hyperpigmentation: Post-inflammatory hyperpigmentation
Acne sufferers commonly experience post-inflammatory hyperpigmentation
Post-inflammatory hyperpigmentation occurs when a skin injury or trauma heals and leaves a flat area of discolouration behind.
| 1,787 | 2,951 |
msmarco_v2.1_doc_01_1666810893#4_2443603301
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
The International Dermal Institute, Melasma Unmasked by Dr Claudia Aguirre quoting Kang, H. Y., & Ortonne, J. P. (2010). What should be considered in treatment of melasma. Annals of Dermatology, 22 (4), 373-378. Hyperpigmentation: Post-inflammatory hyperpigmentation
Acne sufferers commonly experience post-inflammatory hyperpigmentation
Post-inflammatory hyperpigmentation occurs when a skin injury or trauma heals and leaves a flat area of discolouration behind. It’s commonly found among acne sufferers and can also be caused by cosmetic procedures such as dermabrasion, laser treatment and chemical peels. There are other factors that can cause patches of skin to become darker – such as scarring, birthmarks, solar or actinic keratoses and skin cancers – but these aren’t considered to be forms of hyperpigmentation. Important Information
Consult your dermatologist or pharmacist if you’re concerned about any of your dark spot or if they start to bleed, itch, or change in size or color. What causes and/or triggers hyperpigmentation? Hyperpigmentation is caused by an increase in melanin.
| 2,486 | 3,582 |
msmarco_v2.1_doc_01_1666810893#5_2443605505
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
It’s commonly found among acne sufferers and can also be caused by cosmetic procedures such as dermabrasion, laser treatment and chemical peels. There are other factors that can cause patches of skin to become darker – such as scarring, birthmarks, solar or actinic keratoses and skin cancers – but these aren’t considered to be forms of hyperpigmentation. Important Information
Consult your dermatologist or pharmacist if you’re concerned about any of your dark spot or if they start to bleed, itch, or change in size or color. What causes and/or triggers hyperpigmentation? Hyperpigmentation is caused by an increase in melanin. Melanin is the natural pigment that gives our skin, hair and eyes their color. A number of factors can trigger an increase in melanin production, but the main ones are sun exposure, hormonal influences, age and skin injuries or inflammation. Sun exposure and hyperpigmentation
Sunlight triggers melanin production and is the number one cause of hyperpigmentation
Sun exposure is the number one cause of hyperpigmentation as it’s sunlight that triggers the production of melanin in the first place. Melanin acts as your skin’s natural sunscreen by protecting you from harmful UV rays, which is why people tan in the sun. But excessive sun exposure can disrupt this process, leading to hyperpigmentation.
| 2,952 | 4,285 |
msmarco_v2.1_doc_01_1666810893#6_2443607957
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Melanin is the natural pigment that gives our skin, hair and eyes their color. A number of factors can trigger an increase in melanin production, but the main ones are sun exposure, hormonal influences, age and skin injuries or inflammation. Sun exposure and hyperpigmentation
Sunlight triggers melanin production and is the number one cause of hyperpigmentation
Sun exposure is the number one cause of hyperpigmentation as it’s sunlight that triggers the production of melanin in the first place. Melanin acts as your skin’s natural sunscreen by protecting you from harmful UV rays, which is why people tan in the sun. But excessive sun exposure can disrupt this process, leading to hyperpigmentation. Once dark spots have developed, sun exposure can also exacerbate the issue by making age spots (or sun spots ), melasma and post-inflammatory hyperpigmentation spots even darker. Hyperpigmentation and hormones
Hormonal influences are the main cause of a particular kind of hyperpigmentation known as melasma or chloasma. It’s particularly common among women and is thought to occur when the female sex hormones estrogen and progesterone stimulate the overproduction of melanin when skin is exposed to the sun. Hyperpigmentation can also be a side effect of certain hormone treatments. Hyperpigmentation and age
As skin ages, the number of melanin-producing cells (known as melanocytes) decreases but the remaining ones increase in size and their distribution becomes more focused.
| 3,583 | 5,066 |
msmarco_v2.1_doc_01_1666810893#7_2443610540
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Once dark spots have developed, sun exposure can also exacerbate the issue by making age spots (or sun spots ), melasma and post-inflammatory hyperpigmentation spots even darker. Hyperpigmentation and hormones
Hormonal influences are the main cause of a particular kind of hyperpigmentation known as melasma or chloasma. It’s particularly common among women and is thought to occur when the female sex hormones estrogen and progesterone stimulate the overproduction of melanin when skin is exposed to the sun. Hyperpigmentation can also be a side effect of certain hormone treatments. Hyperpigmentation and age
As skin ages, the number of melanin-producing cells (known as melanocytes) decreases but the remaining ones increase in size and their distribution becomes more focused. These physiological changes explain the increase of age spots in those over 40. You can read more about how skin ages in skin aging. Hyperpigmentation, skin injuries and inflammation
As its name suggests, post-inflammatory hyperpigmentation occurs following skin injury or inflammation such as: cuts, burns, chemical exposure, acne, Atopic Dermatitis or Psoriasis. Skin is left darkened and discoloured after the wound has healed.
| 4,285 | 5,497 |
msmarco_v2.1_doc_01_1666810893#8_2443612840
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
These physiological changes explain the increase of age spots in those over 40. You can read more about how skin ages in skin aging. Hyperpigmentation, skin injuries and inflammation
As its name suggests, post-inflammatory hyperpigmentation occurs following skin injury or inflammation such as: cuts, burns, chemical exposure, acne, Atopic Dermatitis or Psoriasis. Skin is left darkened and discoloured after the wound has healed. Hyperpigmentation, disease and medication
Certain illnesses and medications are known to cause hyperpigmentation. Hyperpigmentation is also symptomatic of certain illnesses such as some autoimmune and gastrointestinal diseases, metabolic disorders and vitamin deficiencies. It can also be triggered by certain medications such as chemotherapy drugs, antibiotics, antimalarials and anti-seizure drugs. How can I prevent the formation of hyperpigmentation? Using a broad-spectrum sunscreen every day can help prevent hyperpigmentation.
| 5,067 | 6,031 |
msmarco_v2.1_doc_01_1666810893#9_2443614887
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Hyperpigmentation, disease and medication
Certain illnesses and medications are known to cause hyperpigmentation. Hyperpigmentation is also symptomatic of certain illnesses such as some autoimmune and gastrointestinal diseases, metabolic disorders and vitamin deficiencies. It can also be triggered by certain medications such as chemotherapy drugs, antibiotics, antimalarials and anti-seizure drugs. How can I prevent the formation of hyperpigmentation? Using a broad-spectrum sunscreen every day can help prevent hyperpigmentation. Sun protection is the most significant step you can take in helping to prevent hyperpigmentation in the first place. It’s important to remember that the sun’s rays affect skin even on cloudy days, so give your skin the daily protection it needs. As well as reducing hyperpigmentation, Eucerin Anti-Pigment Day SPF 30 offers effective UVA and UVB (SPF 30) protection and prevents the formation of additional sun-induced pigment spots. Used in combination with the Dual Serum, now in a mono-chamber pack but with same proven efficacy, as part of a holistic skincare routine will also help prevent and reduce pigment spots. Limiting skin’s exposure to the sun will also help to reduce instances of hyperpigmentation.
| 5,497 | 6,745 |
msmarco_v2.1_doc_01_1666810893#10_2443617231
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Sun protection is the most significant step you can take in helping to prevent hyperpigmentation in the first place. It’s important to remember that the sun’s rays affect skin even on cloudy days, so give your skin the daily protection it needs. As well as reducing hyperpigmentation, Eucerin Anti-Pigment Day SPF 30 offers effective UVA and UVB (SPF 30) protection and prevents the formation of additional sun-induced pigment spots. Used in combination with the Dual Serum, now in a mono-chamber pack but with same proven efficacy, as part of a holistic skincare routine will also help prevent and reduce pigment spots. Limiting skin’s exposure to the sun will also help to reduce instances of hyperpigmentation. Try to keep out of the sun during its most intense hours and wear protective clothing including sunhats and glasses whenever possible. When skin is exposed to the sun, apply and regularly reapply a sun protection product: with a suitable SPF level
which has been specially formulated for your skin type and condition
You can find out more about the Eucerin range of superior sun protection products here. How can I reduce existing pigment spots? While prevention is best, once you have pigment spots there are steps you can take to help fade them and prevent their reappearance
Dermo-cosmetic solutions for hyperpigmentation
If you are concerned by hyperpigmentation, look out for skincare products that have been formulated to address this concern and that are clinically and dermatologically proven to be effective.
| 6,031 | 7,563 |
msmarco_v2.1_doc_01_1666810893#11_2443619863
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Try to keep out of the sun during its most intense hours and wear protective clothing including sunhats and glasses whenever possible. When skin is exposed to the sun, apply and regularly reapply a sun protection product: with a suitable SPF level
which has been specially formulated for your skin type and condition
You can find out more about the Eucerin range of superior sun protection products here. How can I reduce existing pigment spots? While prevention is best, once you have pigment spots there are steps you can take to help fade them and prevent their reappearance
Dermo-cosmetic solutions for hyperpigmentation
If you are concerned by hyperpigmentation, look out for skincare products that have been formulated to address this concern and that are clinically and dermatologically proven to be effective. The Eucerin Anti-Pigment range reduces dark spots and prevents their re-appearance
Eucerin Anti-Pigment reduces hyperpigmentation on the face, neck and hands
The Eucerin Anti-Pigment range has been specially formulated to reduce hyperpigmentation for more even and radiant skin. All four products in the range – a day cream, night cream, serum and spot corrector – contain Thiamidol, an effective and patented ingredient that acts at the root cause of hyperpigmentation by reducing melanin production. It has been clinically and dermatologically proven to reduce dark spots and prevent their re-appearance. First results are visible after two weeks and improve continuously with regular use. Furthermore, with SPF 30 and UVA filters, Eucerin Anti-Pigment Day offers effective protection from the sun and prevents the formation of additional sun-induced pigment spots.
| 6,746 | 8,431 |
msmarco_v2.1_doc_01_1666810893#12_2443622646
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http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
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Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
The Eucerin Anti-Pigment range reduces dark spots and prevents their re-appearance
Eucerin Anti-Pigment reduces hyperpigmentation on the face, neck and hands
The Eucerin Anti-Pigment range has been specially formulated to reduce hyperpigmentation for more even and radiant skin. All four products in the range – a day cream, night cream, serum and spot corrector – contain Thiamidol, an effective and patented ingredient that acts at the root cause of hyperpigmentation by reducing melanin production. It has been clinically and dermatologically proven to reduce dark spots and prevent their re-appearance. First results are visible after two weeks and improve continuously with regular use. Furthermore, with SPF 30 and UVA filters, Eucerin Anti-Pigment Day offers effective protection from the sun and prevents the formation of additional sun-induced pigment spots. The Dual Serum now comes in a mono-chamber pack, making it even easier to apply. The formula still has the same proven efficacy as it combines active ingredients Thiamidol and Hyaluronic Acid to prevent and reduce pigment spots. Whilst Thiamidol is Eucerin-patented, there are other actives commonly used to treat hyperpigmentation – though with varying efficacy. These include: Arbutin, Azelaic Acid, Kojic Acid, other Resorcinol derivatives such as B-Resorcinol and Vitamin C and its derivatives.
| 7,563 | 8,930 |
msmarco_v2.1_doc_01_1666810893#13_2443625111
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http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
The Dual Serum now comes in a mono-chamber pack, making it even easier to apply. The formula still has the same proven efficacy as it combines active ingredients Thiamidol and Hyaluronic Acid to prevent and reduce pigment spots. Whilst Thiamidol is Eucerin-patented, there are other actives commonly used to treat hyperpigmentation – though with varying efficacy. These include: Arbutin, Azelaic Acid, Kojic Acid, other Resorcinol derivatives such as B-Resorcinol and Vitamin C and its derivatives. A dermo-cosmetic solution is non-invasive and can be used year-round, as part of your daily skincare routine, to reduce hyperpigmentation. It can also be used to extend the results of a dermatological treatment. Hyperpigmentation removal: dermatological treatments
A chemical peel is one way to remove hyperpigmentation and reveal new and evenly pigmented skin. Laser treatments have a similar effect to chemical peels, but the treatment can be applied more precisely.
| 8,432 | 9,399 |
msmarco_v2.1_doc_01_1666810893#14_2443627166
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
A dermo-cosmetic solution is non-invasive and can be used year-round, as part of your daily skincare routine, to reduce hyperpigmentation. It can also be used to extend the results of a dermatological treatment. Hyperpigmentation removal: dermatological treatments
A chemical peel is one way to remove hyperpigmentation and reveal new and evenly pigmented skin. Laser treatments have a similar effect to chemical peels, but the treatment can be applied more precisely. Dermatological treatments such as chemical peels and laser therapy can help to reduce hyperpigmentation: Chemical peels involve applying a chemical solution to the face, neck and hands to exfoliate skin (remove dead skin cells), stimulate the growth of new skin cells and reveal new skin. Read more about chemical peels in What are chemical peels and how do they work ? Laser therapies have much the same effect, but tend to be more precise, as the dermatologist has more control over the intensity of the treatment. They involve ‘zapping’ the affected areas with high-energy light.
| 8,930 | 9,982 |
msmarco_v2.1_doc_01_1666810893#15_2443629310
|
http://int.eucerin.com/skin-concerns/uneven-skin/hyperpigmentation
|
Hyperpigmentation | Hyperpigmentation in general |Eucerin
|
Hyperpigmentation – What causes dark spots and how can I reduce them?
Hyperpigmentation – What causes dark spots and how can I reduce them?
What is hyperpigmentation and what are the different types?
Hyperpigmentation: pigment spots such as age spots
Hyperpigmentation: melasma
Hyperpigmentation: Post-inflammatory hyperpigmentation
Important Information
What causes and/or triggers hyperpigmentation?
Sun exposure and hyperpigmentation
Hyperpigmentation and hormones
Hyperpigmentation and age
Hyperpigmentation, skin injuries and inflammation
Hyperpigmentation, disease and medication
How can I prevent the formation of hyperpigmentation?
How can I reduce existing pigment spots?
Dermo-cosmetic solutions for hyperpigmentation
Hyperpigmentation removal: dermatological treatments
|
Dermatological treatments such as chemical peels and laser therapy can help to reduce hyperpigmentation: Chemical peels involve applying a chemical solution to the face, neck and hands to exfoliate skin (remove dead skin cells), stimulate the growth of new skin cells and reveal new skin. Read more about chemical peels in What are chemical peels and how do they work ? Laser therapies have much the same effect, but tend to be more precise, as the dermatologist has more control over the intensity of the treatment. They involve ‘zapping’ the affected areas with high-energy light. The mildest treat
| 9,399 | 10,000 |
msmarco_v2.1_doc_01_1666823472#0_2443631003
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http://int.safety1st.com/service/faq.aspx
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Safety 1st FAQ
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Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
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Safety 1st FAQ
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Frequently asked questions
Welcome to our FAQ section. Here you'll find expert answers to frequently asked questions plus a wide range of easy-to-understand information, tips and advice on many popular topics. We hope you find everything you need to know! Show questions & answers for
Select a category
Select a category
Accessories
Car seats
Home equipment
Home safety
Strollers
Warranty
Select a category Accessories Car seats Home equipment Home safety Strollers Warranty
Show results
Results for Accessories
Can I wash the Shopping trolley protect in the washer? Answer
The fabric of the Shopping trolley protect has been specially treated to make it easy to wash, including in the washer. Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat? Answer
No, but they must wear a seat belt. Can 3 car seats fit on the back seat of my car? Answer
It depends on what type of car you have. We recommend taking your car to the retailer to check.
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msmarco_v2.1_doc_01_1666823472#1_2443643934
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat? Answer
No, but they must wear a seat belt. Can 3 car seats fit on the back seat of my car? Answer
It depends on what type of car you have. We recommend taking your car to the retailer to check. Can I mount my car seat (Group 0+/1) onto the frame of my stroller? Answer
No, unfortunately it's not possible with our current range of products. Can I mount my car seat (Group 1) onto the frame of my stroller? Answer
No, unfortunately it's not possible with our current range of products. Can I put a car seat on the front passenger seat?
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msmarco_v2.1_doc_01_1666823472#2_2443656479
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Can I mount my car seat (Group 0+/1) onto the frame of my stroller? Answer
No, unfortunately it's not possible with our current range of products. Can I mount my car seat (Group 1) onto the frame of my stroller? Answer
No, unfortunately it's not possible with our current range of products. Can I put a car seat on the front passenger seat? Answer
Yes, you can put infant and child car seats on the front passenger seat, but the back seat is preferable. An infant car seat for 0-13 months may only be used on the front passenger seat if there is no frontal airbag or if you're sure it has been deactivated. For car seats for older children (9 months to 12 years), we recommend placing the seat in the rearmost position if the front seat is equipped with an airbag. Do children taller than 1.35 meters have to sit in a child car seat? Answer
No, but they must wear a car seat belt.
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msmarco_v2.1_doc_01_1666823472#3_2443669274
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Answer
Yes, you can put infant and child car seats on the front passenger seat, but the back seat is preferable. An infant car seat for 0-13 months may only be used on the front passenger seat if there is no frontal airbag or if you're sure it has been deactivated. For car seats for older children (9 months to 12 years), we recommend placing the seat in the rearmost position if the front seat is equipped with an airbag. Do children taller than 1.35 meters have to sit in a child car seat? Answer
No, but they must wear a car seat belt. Do Safety 1st car seats fit in all cars? Answer
Our child car seats are universal so they should fit in almost any car. In accordance with the ECE R44/03 and ECE R44/04 standards, car seats are universal if not more than a certain length of seat belt is required for installation. Car manufacturers sometimes build the belts into their cars so that they are just short of being long enough for correct installation. If the user manual of your car says that the seat belts are suitable for the use of universal car seats, this should not be a problem.
| 1,345 | 2,436 |
msmarco_v2.1_doc_01_1666823472#4_2443682278
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Do Safety 1st car seats fit in all cars? Answer
Our child car seats are universal so they should fit in almost any car. In accordance with the ECE R44/03 and ECE R44/04 standards, car seats are universal if not more than a certain length of seat belt is required for installation. Car manufacturers sometimes build the belts into their cars so that they are just short of being long enough for correct installation. If the user manual of your car says that the seat belts are suitable for the use of universal car seats, this should not be a problem. How do I install the top tether correctly? Answer
IsoFix fitting systems have a top tether or support leg to stop the seat pitching forward. It's vital to always check that the top tether is tightened correctly. A green indicator on the top tether will show when the tension is correct. To get the best tension, look for the shorter routing directly from the top of the car seat to the top tether hook.
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
How do I install the top tether correctly? Answer
IsoFix fitting systems have a top tether or support leg to stop the seat pitching forward. It's vital to always check that the top tether is tightened correctly. A green indicator on the top tether will show when the tension is correct. To get the best tension, look for the shorter routing directly from the top of the car seat to the top tether hook. We recommend removing the headrest so the top tether uses the shorter route, ensuring that it's always installed very tightly and will be most efficient in an impact. How do I wash the fabric cover? Answer
You can wash the cover by hand in accordance with the instructions on the care label. The instruction manual contains detailed instructions on how to remove the fabric cover. How long can I use the Safety 1st car seats without a break when travelling by car?
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msmarco_v2.1_doc_01_1666823472#6_2443707924
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
We recommend removing the headrest so the top tether uses the shorter route, ensuring that it's always installed very tightly and will be most efficient in an impact. How do I wash the fabric cover? Answer
You can wash the cover by hand in accordance with the instructions on the care label. The instruction manual contains detailed instructions on how to remove the fabric cover. How long can I use the Safety 1st car seats without a break when travelling by car? Answer
Children should not lie in a fixed position for too long unnecessarily, as they need to have the chance to develop their motor system and arm, back and neck muscles. As manufacturers of the first car seat for babies in Europe, we have, of course, been including this in our instructions for many years. So don't put a baby in his or her seat for the whole day because it's convenient, but give them the opportunity to move around. This also applies to front-facing baby carriers and all other products in which a baby sits, hangs or lies in a stationary position. However, it's not a problem if you need to make a relatively long car trip or holiday journey once in a while.
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Answer
Children should not lie in a fixed position for too long unnecessarily, as they need to have the chance to develop their motor system and arm, back and neck muscles. As manufacturers of the first car seat for babies in Europe, we have, of course, been including this in our instructions for many years. So don't put a baby in his or her seat for the whole day because it's convenient, but give them the opportunity to move around. This also applies to front-facing baby carriers and all other products in which a baby sits, hangs or lies in a stationary position. However, it's not a problem if you need to make a relatively long car trip or holiday journey once in a while. Our advice is to stop once every 2 hours. After all, the baby needs to eat and be changed too. How safe is the Safety 1st Manga car seat? Answer
The Safety 1st Manga booster seat is compliant with European standards. It's fully secure for your toddler.
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msmarco_v2.1_doc_01_1666823472#8_2443733830
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Our advice is to stop once every 2 hours. After all, the baby needs to eat and be changed too. How safe is the Safety 1st Manga car seat? Answer
The Safety 1st Manga booster seat is compliant with European standards. It's fully secure for your toddler. Nevertheless, for long trips or for younger children, we advise you to use a booster seat with backrest in order to offer more comfort to your child and to reinforce the protection around their head in the case of a collision. How should I clean the car seat? Answer
You can clean the car seat with a vacuum cleaner or blow it clean with compressed air. Any food stuck to it can be removed using a slightly damp cloth. Make sure that the foam parts do not get wet.
| 3,987 | 4,704 |
msmarco_v2.1_doc_01_1666823472#9_2443746460
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Nevertheless, for long trips or for younger children, we advise you to use a booster seat with backrest in order to offer more comfort to your child and to reinforce the protection around their head in the case of a collision. How should I clean the car seat? Answer
You can clean the car seat with a vacuum cleaner or blow it clean with compressed air. Any food stuck to it can be removed using a slightly damp cloth. Make sure that the foam parts do not get wet. I had an accident while the child was sitting in the car seat. Can I still use the seat? Answer
No - we recommend that the seat should no longer be used. At impact speeds from 30 km/h invisible damage may occur. In this case, to be on the safe side, you should replace the seat.
| 4,240 | 4,983 |
msmarco_v2.1_doc_01_1666823472#10_2443759116
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
I had an accident while the child was sitting in the car seat. Can I still use the seat? Answer
No - we recommend that the seat should no longer be used. At impact speeds from 30 km/h invisible damage may occur. In this case, to be on the safe side, you should replace the seat. Destroy the old seat to make sure it can't be used for another child. If the car can be repaired, you should also have all the seat belts activated during the accident replaced. I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
| 4,704 | 5,266 |
msmarco_v2.1_doc_01_1666823472#11_2443771590
|
http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Destroy the old seat to make sure it can't be used for another child. If the car can be repaired, you should also have all the seat belts activated during the accident replaced. I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem? Answer
This may happen because the belt buckle is not pulled forward enough. Pushing it forward by hand will release the blockage so that you can loosen the harnesses. I can still pull out my car seat belt, which means the car seat can move around. Is this safe? Answer
Yes.
| 4,984 | 5,541 |
msmarco_v2.1_doc_01_1666823472#12_2443784061
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Answer
This may happen because the belt buckle is not pulled forward enough. Pushing it forward by hand will release the blockage so that you can loosen the harnesses. I can still pull out my car seat belt, which means the car seat can move around. Is this safe? Answer
Yes. If there is a sudden stop or accident, the car seat belt will lock automatically and the child car seat will be unmovable as a result. I dropped my car seat on the ground. Do I have to replace it? Answer
No, it's not necessary unless it hit the ground very hard or you dropped it from a considerable height. Is Isofix safer than installing a car seat with a seat belt?
| 5,266 | 5,910 |
msmarco_v2.1_doc_01_1666823472#13_2443796619
|
http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
If there is a sudden stop or accident, the car seat belt will lock automatically and the child car seat will be unmovable as a result. I dropped my car seat on the ground. Do I have to replace it? Answer
No, it's not necessary unless it hit the ground very hard or you dropped it from a considerable height. Is Isofix safer than installing a car seat with a seat belt? Answer
The IsoFix method prevents car seats from being installed incorrectly, but it isn't safer than when the seat is installed using the traditional method. IsoFix prevents incorrect installation because a color indicator (red or green) indicates the correct installation of various parts. Is it possible to mount my car seat (Group 1) onto the frame of my pushchair? Answer
No, unfortunately this is not possible with our current range of products. Is it safe to use second-hand car seats?
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http://int.safety1st.com/service/faq.aspx
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Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
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Answer
The IsoFix method prevents car seats from being installed incorrectly, but it isn't safer than when the seat is installed using the traditional method. IsoFix prevents incorrect installation because a color indicator (red or green) indicates the correct installation of various parts. Is it possible to mount my car seat (Group 1) onto the frame of my pushchair? Answer
No, unfortunately this is not possible with our current range of products. Is it safe to use second-hand car seats? Answer
We advise against buying a used car seat. You can't know for certain how a second-hand car seat has been used and car seats that have been involved in an accident are no longer guaranteed to be safe. The car seat may also be damaged in some other way or may be incomplete. Is it true that booster/cushion seats without back support are no longer allowed? Answer
Not only Safety 1st, but also independent consumer organizations like the Dutch Consumers’ Association advise strongly against using a seat booster without back support.
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msmarco_v2.1_doc_01_1666823472#15_2443822347
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Answer
We advise against buying a used car seat. You can't know for certain how a second-hand car seat has been used and car seats that have been involved in an accident are no longer guaranteed to be safe. The car seat may also be damaged in some other way or may be incomplete. Is it true that booster/cushion seats without back support are no longer allowed? Answer
Not only Safety 1st, but also independent consumer organizations like the Dutch Consumers’ Association advise strongly against using a seat booster without back support. Back support is essential, particularly because of side impact protection and because of the positioning of the seat belt around the neck and chest. Booster seats and cushions without back support are not prohibited, but must comply with the minimum requirements of the ECE R44/03 and ECE R44/04 standards. Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car? Answer
Yes, the carrying handle must always be placed upright when driving. This protects the child if the baby car seat rotates towards the back of the rear car seat.
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msmarco_v2.1_doc_01_1666823472#16_2443835397
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
Back support is essential, particularly because of side impact protection and because of the positioning of the seat belt around the neck and chest. Booster seats and cushions without back support are not prohibited, but must comply with the minimum requirements of the ECE R44/03 and ECE R44/04 standards. Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car? Answer
Yes, the carrying handle must always be placed upright when driving. This protects the child if the baby car seat rotates towards the back of the rear car seat. The carrying handle also protects against any large objects that might fly through the air near the child. Once the child is securely buckled in the harnesses, his head and arms won't hit the carrying handle if there's an accident. What is Isofix? Answer
IsoFix is a new attachment system for car seats in modern cars. Special IsoFix attachment points are installed in the car in the factory when the car is produced.
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
The carrying handle also protects against any large objects that might fly through the air near the child. Once the child is securely buckled in the harnesses, his head and arms won't hit the carrying handle if there's an accident. What is Isofix? Answer
IsoFix is a new attachment system for car seats in modern cars. Special IsoFix attachment points are installed in the car in the factory when the car is produced. This means that the car seat doesn't need to be installed in the car using the car seat belts. Car seats that are more than a few years old can't be installed using IsoFix. IsoFix seats have been specially designed for this system and are equipped with IsoFix adapters. That is why Safety 1st introduced a special IsoFix convertible car seat: Safety 1st Primeofix for children from birth to around 4 years.
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msmarco_v2.1_doc_01_1666823472#18_2443861057
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
This means that the car seat doesn't need to be installed in the car using the car seat belts. Car seats that are more than a few years old can't be installed using IsoFix. IsoFix seats have been specially designed for this system and are equipped with IsoFix adapters. That is why Safety 1st introduced a special IsoFix convertible car seat: Safety 1st Primeofix for children from birth to around 4 years. What should I do if my child opens the buckle on his harness belt? Answer
Like all international safety experts, we recommend you immediately stop in a safe place and fasten the buckle again. You should tell the child not to open it and the reason for this. It's always possible that an inventive child will open the buckle, and it would contravene legal safety standards if the force needed to open the buckle was so great that the child could never do it himself. The position of the buckle, the color of the button, and the operating or opening force are all laid down in European standards.
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
|
What should I do if my child opens the buckle on his harness belt? Answer
Like all international safety experts, we recommend you immediately stop in a safe place and fasten the buckle again. You should tell the child not to open it and the reason for this. It's always possible that an inventive child will open the buckle, and it would contravene legal safety standards if the force needed to open the buckle was so great that the child could never do it himself. The position of the buckle, the color of the button, and the operating or opening force are all laid down in European standards. It must always be possible for someone without any knowledge of car seats to see immediately how to release the child in an emergency. When should I change from a Group 1 car seat to a Group 2/3 car seat? Answer
For your child's safety we recommend using the Group 1 car seat (9 months to 3 1/2 years/9-18kg) for as long as possible. Don't switch to a next stage car seat until your child has reached the maximum weight limit or the top of their head sticks out above the top edge of the seat. To make sure your child has the best possible protection, we advise against making the switch as long as the back of your child's head is still fully supported by the shell.
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msmarco_v2.1_doc_01_1666823472#20_2443887147
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http://int.safety1st.com/service/faq.aspx
|
Safety 1st FAQ
|
Frequently asked questions
Show questions & answers for
Results for Accessories
Can I wash the Shopping trolley protect in the washer?
Results for Car seats
Are children taller than 1.35 metres required to sit in a child car seat?
Can 3 car seats fit on the back seat of my car?
Can I mount my car seat (Group 0+/1) onto the frame of my stroller?
Can I mount my car seat (Group 1) onto the frame of my stroller?
Can I put a car seat on the front passenger seat?
Do children taller than 1.35 meters have to sit in a child car seat?
Do Safety 1st car seats fit in all cars?
How do I install the top tether correctly?
How do I wash the fabric cover?
How long can I use the Safety 1st car seats without a break when travelling by car?
How safe is the Safety 1st Manga car seat?
How should I clean the car seat?
I had an accident while the child was sitting in the car seat. Can I still use the seat?
I can no longer lengthen the harness when the buckle is open. It's as if it's stuck. What's the problem?
I can still pull out my car seat belt, which means the car seat can move around. Is this safe?
I dropped my car seat on the ground. Do I have to replace it?
Is Isofix safer than installing a car seat with a seat belt?
Is it possible to mount my car seat (Group 1) onto the frame of my pushchair?
Is it safe to use second-hand car seats?
Is it true that booster/cushion seats without back support are no longer allowed?
Should the carrying handle of the Safety 1st One-Safe XT be placed in an upright position when installed in the car?
What is Isofix?
What should I do if my child opens the buckle on his harness belt?
When should I change from a Group 1 car seat to a Group 2/3 car seat?
When should I make the transition from a Group I car seat to a Group 2/3 car seat?
When should my child switch from his Safety 1st infant car seat to the next car seat?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Which strollers can I attach the Safety 1st One Safe-XT baby car seat to?
Why do babies have to travel facing backwards in car?
Why do babies have to travel in a rearward-facing position?
Why do I need a car seat?
At what level should the harness straps be for my child in the forward facing toddler position?
At what level should the harness straps be for my child in the rear facing position?
How should I adjust the seat belt on my child riding in a booster seat?
My child is not yet 40 lbs. What car seat should I use?
What is the difference between a 3-point harness and a lap belt carrycot?
Results for Home equipment
Does Happy Swing have a harness?
How safe is a babywalker?
How safe is Happy Step?
How Safe is the Air Plane?
How safe is the Safety 1st Ludo baby walker?
When can my child use the swing?
When should I make the transition from the walker mode to the pusher mode?
Can I adjust the bouncer?
Can I choose between a bouncing and fixed position?
Can I remove the headrest of the bouncer?
Do the Safety 1st bouncers have a harness?
Does Happy Swing have a harness?
How do I clean a bouncer?
How safe is the bouncer?
When can my child use the bouncer?
When can my child use the swing?
When can my child use the Easy Booster?
When can my child use the Easy Care feeding booster?
When can my child use the feeding booster?
When can my child use the Smart Lunch?
When can my child use the Travel Booster?
What age does my child need to be in order to use a booster seat?
Can I wash the Comfort Cushion in the washer?
Is the Safety 1st Timba highchair secure enough without a tray?
When can I start using the Safety 1st Kanji highchair?
When can I start using the Timba highchair?
When can my child use the Smart Lunch?
When should I change the positions on the Timba basic highchair?
When can I change the positons on the Totem highchair?
Results for Home safety
Can I use a bed rail on a water or air mattress?
Can I use a bed rail on any type of bed?
Do bed rails guarantee my child’s safety while they’re asleep?
How do I clean the bed rail?
How do I know my bed rail is safe?
How do I make sure my children are safe in bed while we’re away from home?
I’ve been offered a second-hand bed rail. Should I use it?
What are bed rails for?
Will my child be able to unlock the bed rail?
Where should I install a bed rail on the bed?
Do I need more than one bed rail?
When will my child be ready for a bed without rails?
Do all Safety 1st U-Pressure Fit Gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all Safety 1st Wall Fix safety gates fit the same space?
Do all safety barriers have 2 pressure fit handles?
Do all safety gates have 3 actions to open?
How many U-Pressure Fit 14cm extensions can I install on my safety gate?
How many U-Pressure Fit 16cm gate extensions can I install on my child safety gate?
How many U-Pressure Fit 28cm extensions can I install on my safety gate?
How many U-Pressure Fit 7cm extensions can I install on my safety gate?
How many U-Pressure Fit 8cm extensions can I install on my safety gate?
How many Y spindle (s) can I fit on my safety gate?
How soon will I need the U-Pressure Fit Easy Close Metal safety gate?
Is it possible to use Modular child safety gates outdoors?
Is the Safe Contact monitor free of interferences?
Do all Safety 1st Gates fit the same space?
Do all Safety 1st Gates fit the same space?
What is a safety barrier?
What is a U-Pressure Fit gate?
What is a Wall Fix Extending gate?
What is exactly the VOX feature?
What is the safe distance between Modular child safety gates and a hearth?
What technology is used by Safety 1st baby monitors?
When should I start to use the safety gate U-Pressure Fit Auto Close?
When should I start to use the safety gate U-Pressure Fit Easy Close Deco?
When should I start to use the Simply Pressure XL safety barrier?
When should I start to use the Travel Safety Barrier?
When should I fit the U-Pressure Fit Easy Close Extra Tall safety gate?
When should I start to use the U-Pressure Fit Easy Close Wood safety gate?
When should I start to use the Wall Fix Extending Metal safety gate?
When should I start to use the Wall Fix Extending Wood child safety gate?
When should I start using the safety gate U-Pressure Fit Easy Close Wood & Metal?
Will the Easy Close Extra Tall keep my child safe from dogs?
What is the age limit for safeguarding products?
Should I use batteries if possible or the AC adapter?
What can I do if my monitor is not working properly?
Why can I hear my neighbors and can they hear me?
Can I install a safety gate or safety barrier across a window?
Do safety gates guarantee that my child is safe in the home?
How can I make sure other people’s homes are safe for my children when I go out with them?
How do I clean my safety gate?
How do I know the gates are safe
How do I order replacement parts and extensions?
How many Easy Close Extra Tall 7cm extensions can I install on my safety gate?
How many Modular Extension (s) 72cm can I fit on my safety gate?
How many safety gates do I need in stairs?
I’ve been offered a second-hand safety gate. Should I use it?
Parts for my safety gate are missing. What should I do?
What are safety gates and barriers for?
What is a pressure fit safety gate
What size of safety gate do I need?
What types of safety gates are available?
What’s the best type of safety gate for the top of the stairs?
When should I buy a safety gate or barrier?
Where are safety gates useful?
Why there is a gap between the frame and handle in U-Pressure Fit gates?
Will any Safety 1st gates or barriers fit any space?
Will my child be able to open the safety gate or safety barrier himself?
Why install a Safety Gate?
When should I buy a Safety Gate?
Results for Strollers
Can I clip the infant car seat and Dormicoque+ carrycot on the Safety 1st Easy Way stroller without removing the seat?
Can I clip the infant car seat on to the Safety 1st Easy Way stroller without removing the seat?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Go chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Easy Way chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Ideal Sportive chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Kokoon chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal chassis?
Can I fix a Maxi-Cosi infant car seat on the Safety 1st Trendideal Comfort chassis?
Can I remove the seat unit of the Safety 1st Easy Way to clip an infant car seat on its frame?
Can the Safety 1st safety carrycot Dormicoque+ be used for sleeping at night?
Can we add a bumper bar on the Safety 1st Compa'City buggy?
Can we remove the seat unit of the Safety 1st Kokoon to fix an infant car seat on the stroller frame?
How easy is it to remove the seat unit of the Safety 1st Kokoon and fix the infant car seat or the carrycot on the stroller frame?
How old should my child be to use the Safety 1st Easy Way seat?
Is my child the right age for the Safety 1st Peps seat?
Is my child the right age for the Safety 1st Slim?
My child no longer fits into the carrycot and is still unable to sit independently. What should I do?
What age is most suitable for the Safety 1st Compa'City?
What age is suitable for the Safety 1st Easy Way seat?
What age is the Safety 1st Easy Go seat most suitable for?
What age is the Safety 1st Ideal Sportive seat suitable for?
What age is the Safety 1st Kokoon seat suitable for?
What age range is suitable for the Safety 1st Easy Way seat?
What age range is the Safety 1st Compa'City seat suitable for?
What age range is the Safety 1st Trendideal Comfort 2in1 designed for
What age range is the Safety 1st Trendideal seat designed for?
What age range is the Safety 1st Trendideal seat designed for?
What ages are most suitable for Safety 1st Duodeal seats?
What is the difference between a 3-point harness and a lap belt carrycot?
What should I do if the stroller’s tires are flat?
Why do babies have to travel facing backwards?
What is included with my Travel system?
What is included with my Travel system
Are you allowed to transport a child in a pram body or a soft carrycot in the car?
Can I remove the logos and labels from the cover and frame?
Can I take my stroller on an airplane?
Can I use lubricants that contain silicone or other types of lubricants?
Do all Safety 1st strollers meet all legal requirements?
How should I maintain my stroller?
I have lost my instruction manual. Where can I get a new one?
Is it possible to attach a ride-along board to a Safety 1st stroller?
Why does the manufacturer advise strongly against exposure to seawater?
Why is it better to deflate the tyres when transporting the stroller in an aircraft?
Results for Warranty
Are rips and tears covered by the 24-month warranty?
Can I order spare parts for my Safety 1st?
How can I find out the status of my repair?
How do I make a request for service under the warranty?
How long are spare parts available for my Safety 1st?
How long will a spare part delivery take?
How long will my repair take?
I hear Safety 1st has a 24-month warranty. What do I need to do to get it?
Is normal wear and tear covered by the 24-month warranty?
What do repairs cost?
What do spare parts cost?
What does the 24-month warranty cover?
What isn’t covered by the 24-month warranty?
Who pays for shipping?
Will my Safety 1st be repaired or replaced?
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It must always be possible for someone without any knowledge of car seats to see immediately how to release the child in an emergency. When should I change from a Group 1 car seat to a Group 2/3 car seat? Answer
For your child's safety we recommend using the Group 1 car seat (9 months to 3 1/2 years/9-18kg) for as long as possible. Don't switch to a next stage car seat until your child has reached the maximum weight limit or the top of their head sticks out above the top edge of the seat. To make sure your child has the best possible protection, we advise against making the switch as long as the back of your child's head is still fully supported by the shell. When should I make the transition from a Group I car seat to a Group 2/3 car seat? Answer
For the safety of your child, we recommend using the Group I car seat (9 months to 3 1/2 years/9-18 kg) for as long as possible. Don't switch your child to a next-stage car seat until they have reached the maximum weight limit for the Group 1 seat, or the top of your their head protrude
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The only FDA
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Intracorneal
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Reshaping
the Cornea
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Home Intacs 2017-04-28T15:47:44+01:00
About Intacs ®
Intacs® Corneal Implants are an ophthalmic medical device designed for the reduction or elimination of myopia and astigmatism in patients with keratoconus so that their functional vision may be restored and the need for a corneal transplant procedure can potentially be deferred. Intacs® Corneal Implants are products from Addition Technology, Inc., a Company of AJL Ophthalmic, S.A..
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Patient Testimonials
Thank you all of you for the amazing job you’ve performed for me. I am now able to see perfectly without glasses or contacts. I can’t stress how thankful I am. Before the surgery I feared the thought of eventually losing my sight and needing transplants, but now I have a whole new lookout on life and my future. ( Treated by Brian Boxer Wachler, MD in Beverly Hills, CA.) Ashley Lamb, Patient Services Representative, Brentwood
I feel very lucky to have found and taken part in these new and exciting treatments for keratoconus. The treatments were quick with minimal discomfort. The very next day my vision in my left eye was clear beyond my expectations with Intacs. In addition, the staff was very nice and professional. (
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About Intacs ®
Upcoming Events
Patient Testimonials
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Treated by Brian Boxer Wachler, MD in Beverly Hills, CA.) Ashley Lamb, Patient Services Representative, Brentwood
I feel very lucky to have found and taken part in these new and exciting treatments for keratoconus. The treatments were quick with minimal discomfort. The very next day my vision in my left eye was clear beyond my expectations with Intacs. In addition, the staff was very nice and professional. ( Treated by Brian Boxer Wachler, MD in Beverly Hills, CA.) Matt Shura, Firefighter/Paramedic,Gilbert, AZ
After nearly 20 years of compounding restrictions to my life as a result of continuing degradation of my vision – I CAN SEE AGAIN! I am truly shocked at just how easy the surgery was, and just how much of the world I had been missing. Thank you! ( Treated by Brian Boxer Wachler, MD in Beverly Hills, CA.)
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