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Anaesthesia > Anaestheska III Week 5+ > Flashcards

Anaestheska III Week 5+ Flashcards

1
Q

What are the properties of an ideal breathing circuit?

A 
Simple and safe
Deliver intended fio2
Spont and controlled vent
Low FGF requirement
Protect from barotrauma
Remove waste
Easy maintenance and low cost
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2
Q

What is dead space?

A

Where no gas exchange occurs

There is a mix of inspired and expired gases

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3
Q

How does the APL valve work?

A

Lightweight disk sits on knife edge seating held on by spring
Tension in spring = valve opening pressure
Dial movement adjusts the tension

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4
Q

What are safety issues with APL?

A

Malfunction could keep APL open = ^^ dead space
High positive pressure if left closed resulting in barotrauma - safety relief valve at 60cmh20
Exhaled water vapour may cause disk to stick - hydrophobic material

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5
Q

Describe the reservoir bag.

A

Ellipsoidal, anti-static rubber
0.5-2L size
Accommodates FGF during expiration as reservoir for next inspiration
Can assist ventilation and act as visual aide for spont breathing
Highly compliant so accommodates gas limiting the pressure to 40cmH20

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6
Q

Describe circuit tubing.

A

Must provide laminar flow: uniform shape and large diameter
Must have optimal compliance
Corrugations a resist kinking and improve flexibility

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7
Q

What is the design of the mapleson A magill system?

A

Bag in middle
FGF opposite end
APL patient end

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8
Q

How does the Magill system work?

A

Insp: APL closes, FGF comes in and mixes with exhaled dead space gas
Exp: pt expires forcing APL open, bag is refilling
Pause: exp gas meets FGF in tube and is forced out APL

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9
Q

Pro vs con for magill circuit?

A

Yes spontaneous
FGF=MV
No controlled
3xMV needed

Large dead space not for

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10
Q

How does the Lack system work?

A

Insp: APL closes and FGF comes in outer tube
Exp: patient expires into tube so APL opens; FGF fills bag
Pause: expired gas forced through inner tube and out APL by incoming FGF

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11
Q

Pro vs con of lack?

A

As with Magill
Risk of inner tube malfunction causing high dead space
APL at machine end makes system less cumbersome

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12
Q

What is the design of the Mapleson B system?

A

Bag one end
FGF, patient and APL at other
Corrugated tube in middle acts as reservoir

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13
Q

How does the Mapleson B work?

A

Insp: mix of alveolar and FGF inhaled
Exp: expires into tube and bag; APL opens
Pause: expired gas and FGF forces out

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14
Q

Pro vs con for Mapleson B?

A 
No spontaneous
FGF 2x MV needed
No controlled
FGF 2x MV needed
Gas waste and pollution
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15
Q

What is the design for the Mapleson C?

A 
(Waters without absorber)
Bag one end
FGF, patient and APL other 
Short tube 
Used in emergencies
Works like Mapleson B
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16
Q

What is the design for the Mapleson D-Bain system?

A 
APL and bag one end
FGF and patient at other
Co-axial (also parallel version)
Inner tube FGF
Outer tube expired gas
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17
Q

How does the Bain system work?

A

Insp: FGF flow to patient via inner tube
Exp: expires into reservoir tube which mixes with the still flowing FGF
Pause: FGF washes expired gas out, also filling system with FGF for next inspiration

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18
Q

Pro vs con for Bain system?

A 
No spontaneous 
FGF 2xMV needed
Yes controlled
70ml/kg needed
Good for head/neck surgery
Low R and dead space
Assisted scavenging
Inner tube may fail
Bag movement not good indicator
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19
Q

How does the Ayres T piece work?

A

Insp: FGF flow to patient from reservoir tube
Exp: expires into reservoir tube which mixes with FGF still flowing
Pause: FGF washes expires gas out; fills system with FGF for next inspiration

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20
Q

Pro vs con for Ayres T piece?

A 
Yes spontaneous 
3x MV needed
Yes controlled
FGF=MV due to longer exp pause allowing refill time
Low R and dead space
Valveless - less leaks
Pollution and gas waste
Tube length long enough to not entrain air
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21
Q

How does the Jackson Rees Modification work?

A

As with Mapleson E

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22
Q

Pro vs con for Jackson Rees modification?

A 
Yes spontaneous and controlled
2.5-3x MV needed
Visual respiratory movements
Easy IPPV
Tubing length vs entrainment
Pollution and gas waste
Great
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23
Q

What is the design of the Mapleson A Lack system?

A

Co-axial version of A designed to assist scavenging
Inspiration outer tube, exp inner
Parallel version also available
FGF, APL and bag machine end

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24
Q

What is soda lime for?

A

Absorbs carbon dioxide
Low FGF requirement so highly efficient
Low pollution
Conserves, warms and humidifies

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25
Q

What is the physical design of the soda lime canister?

A

Vertical
Two ports: one delivers insp gas, other receives exp gas
Each port has unidirectional valve

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26
Q

What happens if carbon dioxide rebreathing occurs?

A

Acidosis results

Acts as an anaesthetic and will cause coma

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27
Q

What are the components of soda lime?

A

94% calcium hydroxide
Sodium hydroxide
Potassium hydroxide
Water

pH 13.5
Colour change ethyl violet dye <10

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28
Q

Why is silica added to the soda lime?

A

Granules prone to powder formation which can cause high resistance and stick to valve
The silica helps to harden and prevent powder formation

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29
Q

Why is zeolite added to soda lime?

A

Helps maintain pH for longer and retain moisture to increase the amount of carbon dioxide absorption
Also helps reduce formation of carbon monoxide and compound A

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30
Q

What are the risks of soda lime?

A 
Dust on valves
Dust cause high resistance
Corrosive (alkaline)
Compound A
Carbon monoxide 
Channeling
Leaks
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31
Q

What is the granule size of soda lime?

A

4-8 mesh
(4-8 openings per inch)

3-4mm spheres which allow more even gas flow throughout. Also allows longer life, lower dust and reduced resistance

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32
Q

What’s the mechanism of soda lime?

A

Exhaled gas go to canister where carbon dioxide gets absorbed and heat + water is produced (exothermic)
This warm/humid gas then rejoins FGF

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33
Q

Why does low FGF exhaust like faster?

A

Most exhaled gases go out the APL but with low flows very little exits the APL so therefore goes through the lime

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34
Q

What are the safety features of soda lime?

A 
Clear canister houses valves and lime
Colour change
Sphere, specific sized granules
Added silica
Uneven canister filling can result in channeling
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35
Q

How is compound A formed?

A

When sevo used with soda lime
Due to alkali metal in lime degrading the sevo
Increased by temp, low FGF and high sevo concentration

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36
Q

How is carbon monoxide formed?

A

When volatiles containing CHF2 moiety (enf, des, iso) used with dry granules
Production of carboxyhaemoglobin can occur

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37
Q

What is a closed system?

A

No gas escapes
FGF replaces what is consumed by patient and lime
FGF and pollution both very low
FGF must match perfectly

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38
Q

What is a semi closed system?

A

Pressure relief valve allows excess gas to escape

High flows can be used

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39
Q

What may happen if unidirectional breathing valves fail?

A

Low efficiency
Rebreathing
Hypercarbia

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40
Q

What is the unit of measurement for theatre pollution?

A

Ppm

Particles per million

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41
Q

What are some methods to reduce theatre pollution?

A 
Theatre ventilation with 15-20 air changes per hour
Non-recirculated 
Circle system
TIVA
RA
Scavenging
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42
Q

What are some causes of pollution?

A 
Bad mask fit
Paed breathing systems
Failure to turn of gases at end and to intubate
Uncuffed tube
Vaporiser filling
Exhaling vapour in recovery
Machine leaks
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43
Q

What’s the ideals of scavenging?

A 
Not affect ventilation
Not affect dynamics of system
Collecting device, system to carry away and method for regulating pressure 
Checked daily 
Passive/active
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44
Q

Describe passive scavenging.

A

Simple, no cost
Collecting system has shroud connects to APL
30mm connector
Receiving system can be used (2 valves protect against high and negative pressures)
Disposal via copper pipes to atm or ventilation system
Driven by patient effort

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45
Q

What is the safety features of passive scavenging?

A

Valves to protect from high and negative pressure
30mm/19 connection prevent connect to breathing system
Wind at outlet causing +/- pressure
Outlet should have mesh
Protect the tubing to prevent leaks
Need long tubes (^R)

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46
Q

Describe active scavenging.

A

Collection and transfer similar to passive
Receiving system usually valveless, open ended reservoir between receiving and disposal
Antibacterial filter downstream
Flow indicator between reservoir and disposal
Reservoir has 2 valves
Vacuum created by fan, pump or Venturi system
Cope with 30-130L/min rates

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47
Q

What are safety features of the active scavenging system?

A

30/19mm connector
Receiving system capable of coping with changes in flow rates
Increased demand (-P) allow ambient air to entrain so maintaining pressure
Opposite occurs with high +P occurs
Reservoir prevents -/+P to patient
Independent pump used

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48
Q

What are the order of components for active scavenging?

A 
From expiratory valve:
30mm connection
Collecting system
Transfer system
Receiving system
Vacuum generator
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49
Q

What are the features of an ideal filter?

A 
Filter air and liquid borne from 99.99-99.999%
Bidirectional
Minimal dead space
Minimal resistance
Unaffected and not affect agent
Work when wet and dry
Prevent liquids passage
Light, not bulky, not traumatic
Humidify
Transparent
Low cost
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50
Q

What are the basic components of a filter?

A

2 ports: 15mm and 22mm
Sample port on anaesthetic side
Filtration element in middle

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51
Q

What is an electrostatic filter?

A

Material exposed to electric field producing felt-like material and high polarity. One type of fibre becomes + and other -
Usually 2 polymer fibres used
Flat layer of material used so low R
Relies on charge to attract particles
99.99% effective
Charge efficiency high when dry but low when wet and increases R
Charge decays with time so limited life

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52
Q

What happens when a hygroscopic layer is added to electrostatic filter?

A

= HMEF

Pressure drop across element and therefore resistance is higher with water absorption

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53
Q

What is a hydrophobic filter?

A

Lasts long periods
Rely on natural electrostatic interactions
99.999% efficiency
Pleated paper of inorganic fibres achieve high SA and higher R
Forces between H2O are > forces between H2O and filter therefore it collects on surface without absorbing

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54
Q

What are the characteristics of the ideal filter?

A 
Provide humidification 
Low resistance
Low dead space
Microbiological protection
Maintain body temp
Safe and convenient 
Economical
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55
Q

What is a HME?

A

Heat and moisture exchanger
Passive and effective
Retains a portion of expiratory moisture + heat
It then returns it on inspiration
Achieves 60-70%
Warmed to 29-34 degrees
Delivers absolute humidity of 30g/m3 at 30 degrees

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56
Q

How does the HME work?

A

Exhaled gas passes causing water vapour to condense on cooler HME medium. This is evaporated and returned to patient with next inspiration, humidifying gas.
>temp difference = > transfer
5-20mins before optimal
0.2 nanometer pore size = HMEF

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57
Q

What might affect the HME performance?

A

Water vapour content and temperature of insp/exp
Flow rates - how much time gas is in contact with medium
Larger medium = better performance
Low thermal conductivity helps maintain temp difference across HME

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58
Q

What are the safety features of a HME?

A 
May obstruct from mucus or water 
Single use
Max 24hours use: risk of H2O accumulation = ^R
Efficiency low with ^TV
2 way gas flow required to work
Place close to patient
Increases dead space and R (WOB)
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59
Q

What are the components of a hot water bath?

A

Disposable reservoir with inlet and outlet for insp gas to pass
Heated sterile water partly filled
Thermostat controlled element with temp sensors in reservoir and near pt
Tubing delivers gas to pt
Water trap along tubing between pt and humidifier (lower than pt)
Electric power

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60
Q

Describe the receiver system for the AGSS?

A

Main interface between breathing and disposal system.
Must protect from +/-P
Provides capacity to cope with peak flows
Can be open: reservoir tubular open to atm therefore providing air break (needs active disposal)
Closed: reservoir is bag with P release valves

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61
Q

Describe the disposal system for the AGSS?

A

Passive: driven by respiration, tube from patient to outside, short and wide tube to reduce R

Active: fan/pump draws gas, used with open receiver system

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62
Q

What are the affects of dry and cold gases?

A 
Dehydration
Hypothermia
Infection
Atelectasis/shunt
Reduced FRC
Reduced compliance 
Cell damage - dysfunction mucocilliary elevator, damaged cilia
Thick mucus
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63
Q

What is a nebuliser?

A

Produces most of micro droplets of water suspended in a gaseous medium
Amount of water droplets delivered does not depend on temperature
Smallest droplets more stable and get further in airway
Can deliver medicine

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64
Q

How does a gas driven nebuliser work?

A

Capillary tube with bottom end in water container
Top end close to Venturi constriction
High pressure gas flows through Venturi = -P
H2O drawn up capillary tube and broken into fine spray
Smaller droplets achieved as spray hits anvil/baffle
Mostly 2-4 micrometer produced

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65
Q

How does a spinning disk nebuliser work?

A

Centrifugal force created by motor driven spinning disk causes micro droplets to be thrown out

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66
Q

What is a laryngoscope?

A

Perform laryngoscope and aide intubation
Handle - houses battery
Blade connects to handle
Light source: bulb screwed onto blade, electric connection made when open
Light can be in handle or transmitted along fibre optic

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67
Q

How does a laryngoscope work?

A

Blade advance and lifts epiglottis to view cords
4 Mac sizes
Left blade available
Interchangeable blades on handle: ISO international standard - colour marks same systems (green)

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68
Q

How does a straight blade work?

A

Advanced over posterior border of epiglottis which is lifted upward/forward in order to view larynx

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69
Q

How does a curved blade work?

A

Inserted at right angle
Sweeps tongue to left
Tip reaches vallecula which pulls epiglottis up from behind

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70
Q

What is a McCoy blade?

A

Like Mac but with hinged tip operated by lever at handle

Also available as straight blade

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71
Q

What are the safety features of laryngoscopes?

A

Can cause trauma
Light source may fail
Large cheat difficult - short handle or angled blade
Needs sterilisation

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72
Q

What is the polio and kessel blade?

A

At angle to help with DI

Polio 135 degrees
Kessel 110 degrees

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73
Q

What is a fibreoptic scope?

A

Aide intubation
Evaluate airway
Confirm placement
Perform trachea bronchial toilet

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74
Q

How does a fibreoptic scope work?

A

Uses light transmitted through fibres
Fibres provide low refraction
Light enters at a specific angle, travels fibre repeatedly striking and reflecting glass at same angle until it comes out the end
Each fibre carries small part of the picture so arrangement crucial throughout scope
Variable cord length and diameter

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75
Q

What are safety features of fibreoptic scopes?

A 
3.0-7.0 diameter tubes useable
Easily damaged
Needs reprocessing
Light failure
Blocked channels
Only use one channel at a time
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76
Q

What are magill forceps?

A

Small/large

Used to guide tube, remove foreign body, insert throat pack

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77
Q

What’s a retrograde intubation set?

A

Assists DI
18G intro needle, guide wire, 14G hollow guide catheter with distal side port, 15mm
Intro inserted into cricoid membrane
Guide wire advanced in retrograde direction to exit oral/nasal
Catheter inserted antegrade into trachea
Tube introduced over catheter

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78
Q

What are the features of an ET tube?

A 
PCV/silicone
Radio opaque line
Outer/inner diameter
Beveled tip
Cuff
Murphy eye
Vocal cord indicator
15mm connection
Level markings (cm)
Single use marking
Pilot cuff
One way valve
Oral/nasal marking
Curvature
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79
Q

What is the bevel for?

A

Left facing and oval shaped
Improves view of cords when laryngoscope inserted on the right
Shape allows to push through cords, separating them

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80
Q

What is a high pressure, low volume cuff?

A

Prevents passage of secretions
High pressures on walls of airway
Can cause necrosis

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81
Q

What is a low pressure, high volume cuff?

A

Pressure applied over larger area so less pressure risk over longer time
Possible wrinkles so less reliable seal

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82
Q

Why should pressure be regularly checked?

A

May increase with nitrous oxide use and temperatures
Could be a slow leak
Movement from moving patient
Nearby surgery

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83
Q

Why is a nasal tube advantageous?

A

Can’t bite
More tolerated
Frees up the mouth
Epistaxis risk

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84
Q

What are 8 risks of intubation?

A 
Linking
Herniated cuff
Occlusion by secretions
Bevel against wall
Oesophageal intubation
Trauma - sore throat
Dental damage
Failed airway
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85
Q

What is an armoured tube?

A 
Plastic or silicone rubber
Embedded spiral of metal or tough nylon
Had a thicker wall so OD bigger
Wire prevents kinking
Strong, flexible
Introducer often used
Cannot cut to length
High risk bronchial intubation 
2x markers for vocal cords
86
Q

What is a RAE tube?

A 
Ring, Adair, Elwyn
Preformed shape
Bend where tube emerges so that connection at chin/forehead
High risk bronchial intubation
Cuffed RAE = 1 Murphy eye
Uncuffed = 2 Murphy eye
87
Q

What is a laser tube?

A

Withstand carbon dioxide or potassium-titanyl-phosphate laser
Reduce fire and damage risk
Beams are reflected and de focused to reduce strike of healthy tissue
Flexible stainless steel body or wrap of laser proof foil
Double cuff for extra protection
Cuff may be filled with meth blue or saline

88
Q

What’s an evoked potential tube?

A 
Used if risk of nerve damage
Bipolar stainless steel contact electrodes are embedded in tube above cuff where they touch cords
This is connected to a nerve stimulator
Earth connects to patient
Provide visual and audible warnings 
NIM = neural integrity monitor
89
Q

What is a micro laryngeal tube?

A

Better excess to larynx
Small diameter; same length
Sufficient length for nasal too
Ivory PCV to reduce trauma

90
Q

What are the components of a tracheostomy tube?

A

Introducer
Wings on proximal part allow fixation
Adjustable flange to fit variable thickness of tissue
Cuff/uncuff
15mm
Square tip to reduce obstruction risk against tracheal wall
Suction lumen above cuff
Some have inner cannula: secretions can collect/dry out (obstruction) on inner which can then be replaced instead of whole thing
Neonate to adult size
Some have one-way flap valve and window for speech

91
Q

What are the benefits of a tracheostomy?

A 
More comfort
Less sedation needed
Better access for oral hygiene
Allow oral nutrition
Aides bronchial suction
Less dead space
Less resistance
Less glottis trauma
92
Q

What are the safety features of a tracheostomy?

A 
Haemorrhage
Mis placement, occlusion
Pneumothorax
Blocked by secretion
Infection
Over inflation
Granulomata 
Tracheal dilatation
Scar
93
Q

What is a fenestrated tube?

A

Window in curve channels air to cords allowing speech
After deflation patient can breathe around cuff, through window and through tube - less R and weaning
May be fenestrated inner cannula

94
Q

What is a larnygectomy tube?

A

Cuffed tube inserted through tracheostomy to facilitate IPPV during neck surgery
Offer better access by allowing breathing system to be connected away from field
Replaced with tracheostomy at end

95
Q

What is a speaking valve?

A

One way speaking valve can be fitted to tube (if cuffed must be down)
Mounts on top

96
Q

What’s a tracheostomy button?

A

Once tracheostomy removed, button inserted into stoma to keep patent and allow suction still

97
Q

What’s a percutaneous tracheostomy tube?

A

Insert between 1+2 or 2+3 ring
Withdraw any tube to tip just below cords
Insert intro needle and seldinger guide wire through to trachea
Use F/O throughout, ensure midline puncture, free of tube, posterior wall not damaged and assess position
Forceps/dilatory dilate tissue over wire
Trache inserted over wire then remove
Can be done at bedside

98
Q

What is a double lumen tube?

A

Selectively deflate one lung while vent other
2 separate colour codes lumen: tracheal and bronchial
Each have bevel and cuff with colour coded pilot balloon, labelled
2 curves: standard anterior to fit trachea and other for L/R
Y connector - each lumen to limb

99
Q

What is a left DLT?

A

Inflates left lung and deflates right lung
ALWAYS USE
Left lobe to carina is 5cm

100
Q

What is a right DLT?

A

Inflates right lung and deflates left lung
Risk of upper lobe obstruction
Eye in bronchial cuff to facilitate vent of upper lobe
Right lobe to carina is 2.5cm

101
Q

How is position of DLT checked?

A

Use F/O
Auscultation
Inflate tracheal until no leak - both lungs vent
Clamp tracheal
Inflate bronchial until no leak (3ml) - one lung vent
Check other lung vent by clamping bronchial and opening tracheal - one lung vent

102
Q

What is an endobronchial blocker?

A

Alternative to DLT
Blocker catheter with distal cuff, pilot balloon and guide loop
Multi port adaptor - 15mm
Blocker advanced over F/O using loop and tracked into main bronchus
Inflate cuff when in place
Vent maintained in other lung via tube

103
Q

What is an oropharyngeal airway?

A

Anatomically shaped device fits into oropharynx to maintain airway patency
Anaesthetic reduces tone resulting in obstruction by tongue or soft palate
000-6

104
Q

What are the components of an oropharyngeal airway?

A 
Curved body
Inner channel
Flat anteroposteriorly
Curved laterally 
Flange to prevent travel
Bite portion is straight and prevents occlusion
Colour code
105
Q

How does oropharyngeal airway work?

A

Keeps airway patent by preventing tongue and epiglottis from falling back
Size = distance from incisor to mandible angle or corner of mouth to tragus
Adult: Insert upside down partially then rotate 180 degrees - prevent tongue being pushed back
Paed: insert right way up and depress tongue if needed

106
Q

What’s a Bergman airway?

A

Assists with F/O
Guides F/O
Maintains airway and protect scope
Side opening allows removal of F/O

107
Q

What are the risks of an oropharyngeal airway?

A

Trauma to tissue
Broken teeth
Could trigger gag
Can make worse if incorrect fit

108
Q

What is a nasopharyngeal airway?

A 
Through nose to nasopharynx 
Distal end sits just above epiglottis 
Curved body
Left facing bevel
Proximal flange 
Softer plastic
109
Q

What’s the mechanism of a nasopharyngeal airway?

A

Alternate to oropharyngeal of mouth won’t open or not tolerated
Need lubrication
Left bevel eases insertion through right nostril

110
Q

What are the safety features of nasopharyngeal airways?

A

Don’t use if on blood thinners, deformities of nose or sepsis
Don’t force - false passage
Too big may cause necrosis

111
Q

What are the advantages of a supraglottic airway?

A 
Don't need direct vision
Quick
Low CVS disturbance
Low coughing
Conduit for intubation - aperture aligns with glottic opening
Useful in CICO
2nd generation has gastric port
112
Q

What are the components of a laryngeal mask?

A 
Transparent tube
Wide diameter (low R)
15mm
Elliptical cuff
Forms seal around posterior larynx
Inflates via pilot balloon with valve
Bars to prevent epiglottis obstruction
113
Q

What are the components of a proseal?

A

Lumen adjacent to airway traverses floor of mask to tip to drain secretion/air
Contained in bite block
3D elliptical cuff inflation with 2nd cuff behind bowl to improve seal (rear boot or dorsal cuff)
Seal up to 35cmH2O

114
Q

What is a reinforced LMA?

A

Stainless steel wire spiral in wall

Flexible, kink resistant

115
Q

How do you check an LMA?

A 
Inflate and check for hernia
Check lumen patent
Tube bends to 180 degree without occlusion
Inspect for faults, damage, wear
Inspect when removed for blood
116
Q

What is an I-gel?

A 
Extraglottic airway
Anatomical fit without cuff
Has second drain tube
Large lumen
15mm
Non-inflatable gel like cuff with ridge at superior anterior edge to prevent epiglottis occlusion 
Wise oval cross sectional body to prevent rotation and bite 
Gel material moulds into place
117
Q

What is a seldinger technique?

A

Obtain access to lumen
Lumen penetrated by needle, wire passed through, needle removed, then catheter passed over wire
Risk haemorrhage, perforation organ, infection, equipment loss inside

118
Q

What is a face mask?

A 
Anatomic fit
Range of sizes
Air filled cuff supports body - helps snug fit 
22mm
Transparent
Flavoured
Size proportional to dead space 
Valve to change cuff volume
119
Q

What is a catheter mount?

A 
Flexible link between system and airway
Variable length
Corrugated tubing
Concertina design
15mm and 22mm ends
May have inbuilt sample port or humidifier
120
Q

What is ECG?

A

Electrocardiogram
Measure electrical activity of heart with potentials of 0.5-2 MV at skin
Shows HR, ischemia, arrhythmia, conduction
No assessment of output or function
Bipolar leads measure change between 2 electrodes

121
Q

What are the components of ECG?

A

Skin electrodes:
Silver/silver chloride electrode
Held in cup separate from skin by foam pad and conduction gel
Colour coded cable to machine
Variable length and no. Electrodes
Must be all one length in set to reduce electromagnetic interference

122
Q

How does ECG work?

A 
Clean skin, abrade, good gel contact, all same type
Less impedance on bony prominence
High/low pass clean signal
Signal boosted by amplifier 
3-lead most common: 2 active 1 earth
123
Q

What is the CM5 arrangement?

A

R- manubrium sternum
L- 5th intercostal space L anterior axillary
N- L shoulder

Detects ST changes very well!
Lead II ideal for arrhythmias!

124
Q

What are safety features of ECG?

A

Incorrect placement
Muscular interference
Diathermy current travel here if pad not on correctly
High/low ventricular rate alarms and ST segment monitor
Raised ST can show early ischemia
Interference from mains, diathermy

125
Q

What is Einthoven’s triangle?

A 
Arrangement of 3-lead
Lead II follows direction of depolarisation so is best 
Dot 1 (R) always -
Dot 3 (L) always +
Dot 2 varies depending on lead set
Unused dot is earth 
Heart current travels from - to +
126
Q

What is a 5-lead ECG?

A

Utilises V1 which gives view of heart directly below it
More comprehensive picture, better arrhythmia analysis, better ischemic monitor, more balance representation of right and left heart
V1 is right stern all border, 4th space

127
Q

What creates an upright or upside down ECG trace?

A

Depolarisation toward + dot is upright

If travelling away it creates inverted wave

128
Q

What is DINAMAP?

A

Device for indirect non-invasive automatic mean arterial pressure

129
Q

What are the components of NIBP?

A

Microprocessor controls sequence and pneumatic pump
Pneumatic pump causes inflation
Solenoid valve causes deflation
Pressure transducer detects oscillations

130
Q

How does NIBP work?

A

Microprocessor control sequence of inflation via pneumatic pump
Pump inflates cuff to higher P than previous systolic
Solenoid valve deflates incrementally
Return of flow causes oscillations sensed by transducer and interpreted by microprocessor

131
Q

What are safety features of NIBP?

A

Cuff must be correct size:
Cover 2/3 of arm, middle of bladder over brachial artery, bladder width 40% of mid circumference of limb
Can do venous stasis
Must inflate/deflate quick (3mmHg/s)
Can be affected by arrhythmia
External pressure on cuff can affect
Frequent measurement can cause ulna nerve palsy and petechial haemorrhage of skin

132
Q

What is pulse oximetry?

A

Measure of how much haemoglobin in the artery is carrying oxygen %

133
Q

What is beers law?

A

Amount of light absorbed is proportional to concentration of light absorbing substance - haemoglobin
The more haem = more absorbed

134
Q

What is lambert’s law?

A

Amount of light absorbed is proportional to the length of the light pathway - size of artery
Wider artery has same haem per unit area but more overall area so therefore more light is absorbed

135
Q

What are the LEDs used and there wavelengths and how does they relate to pulse oximetry?

A

Red - 660 nm
Infrared - 940 nm
Oxyhaemoglobin absorbs more IR than red
Deoxyhaemoglobin absorbs more red than IR
They absorb a different amount of light at different wavelengths
Pulse ox works out sats by comparing how much red/IR is absorbed as a ratio

136
Q

How does the pulse ox distinguish arterial results from surrounding tissue?

A

Surrounding tissue will also absorb some light
Arteries are pulsatile so any changing absorbable just be from an artery as path length changes with each pulse (lambert)
Unchanging absorption must be from surrounding tissue

137
Q

What is the plethysmographic waveform?

A

Graphical form of pulsatile change in absorbance

Shows signal quality

138
Q

How does the pulse ox account for ambient light?

A

Detector reads red, IR and ambient light
Pulse ox rapidly switches LEDs on/off in specific sequence (100/s)
Red on: detect red and ambient
Red off, IR on: detect IR and ambient
Both off: detect ambient only which can then be subtracted

139
Q

What are some problems with pulse oximetry?

A 
Movement
Incorrect placement
Too much ambient light
Electromagnetic interference - diathermy
Poor perfusion affects pulsation
Nail polish, IV dyes and some drugs interfere with wavelength
Carbon monoxide joins Hb and detected as oxyHb 
Below 70% not accurate 
Change site 2 hourly - pressure sore
Venous pulsation eg valsalva
140
Q

What are the generals steps to a pulse ox measurement?

A

Detector detects light from LED
Ratio of red to IR calculated
Pulsatile vs non-pulsatile
Flicking on/off to remove ambient

141
Q

What is a capnograph?

A

A device that records and displays waveform and value of end of expiration

142
Q

What is a capnogram?

A

Graphical plot of carbon dioxide partial pressure or percentage vs time

143
Q

What is a capnometer?

A

A device that shows numerical concentration without a waveform

144
Q

How does end tidal carbon dioxide analysis work?

A

CO2 absorbs IR
Amount absorbed is related to amount of CO2 in sample chamber
Remaining IR goes to photodetector which produces heat
Heat is measured by a temp sensor and the temp is inversely proportional to amount of CO2 in sample chamber
Light also passes reference chamber of room air to compare
RR measured from rise/fall

145
Q

Describe a side stream analyser?

A

1.2mm ID tube samples gas at a constant rate of 150-200ml/min
Tube connects to adaptor near pt and delivers to sample chamber
Teflon so impermeable to CO2 and unreactive to agents
Moisture trap and exhaust allows humid gas to be vented or returned
Tube needs to be close as possible
Time delays

146
Q

What is a main stream analyser?

A 
Sample chamber within patient gas stream
High dead space
Heated to 41 degrees to prevent condensation
No time delay
Can't measure other gases
Only with intubated patients 
No gas removed from system
147
Q

Compare side stream and main stream analyser.

A

Side: time delay, moisture trap, sample other gases, removes gas - return, leak risk, need calibration, use on non-intubated
Main: no time delay, heat chamber, doesn’t remove gas, dead space, can’t measure others, can’t use on non-intubated, no calibration

148
Q

What are cardiogenic oscillations?

A

If sample line aspirates gas due to prolonged pause or expiration
Ripples appear on the trace during alveolar plateau in sync with the heart beat
Smoothed by high lung volume and peep

149
Q

How is oxygen analysed?

A

Measure of FiO2

Galvanic, polarographic and paramagnetic method

150
Q

How does the paramagnetic analyser work?

A

O2 attracted to magnetic field
The O2 is attracted and agitated leading to a change in pressure in both chambers
The pressure difference is proportional to pp difference between the chambers

151
Q

What are the benefits of the paramagnetic analyser?

A 
Very accurate
Most common
Most rapid and can be breath-by-breath 
Continuous
High and low alarms 
Displays pp and %
(Pauling)
Needs water trap - affected by vapour
152
Q

What are the components of nitrous and agent analyser?

A 
Sample tube
Sample chamber
IR light source
Optical filters
Photodetector
153
Q

What is the mechanism of the nitrous and agent analyser?

A

Sample enters chamber and exposed to IR
Photodetector measures the light reaching it across correct wavelength
Absorption of IR proportional to concentration
Electrical signal analysed and process
Optical filters used to select correct wavelength

154
Q

How are shapes used to identify agents in the analyser?

A

Can measure up to 3 agents
5 sensors produce spectral shape which represents spectral signal of agent in sample
This is compared with spectral shapes stored in memory to ID
Amplitude of shape is inversely proportional to the amount of agent
Optical filter used to filter desirable wavelengths

155
Q

How do piezoelectric crystals work in analysis?

A

Can measure agent concentration
Lipophilic coated crystal undergoes changes in natural resonant frequency when exposed to lipid soluble agents
Change in frequency proportional to pp of agent
Lacks agent specificity
Sensitive to vapour

156
Q

What is mass spectrometry?

A

Breath-to-breath
Charge particles of sample with beam and then separate components into a spectrum according to their mass to charge ratio
Done in high vacuum avoids interference
Abundance of ions at certain mass:charge ratios is determined and relates to composition of mixture
Magnet used to separate ion beam into spectrum
(Sample hit with high energy electrons and exposed to MF to sort ions)
High expense

157
Q

What systems can measure oxygen?

A 
Paramagnetic
Polarographic
Galvanic
Mass spec
Raman spec
158
Q

What systems can measure CO2?

A

IR
Mass spec
Raman spec

159
Q

What systems can measure agent concentration?

A

IR
Mass spec
Raman spec
Piezoelectric

160
Q

What is a pneumotachograph?

A

Measure gas flow and calculates flow rate, TV and MV
Component: tube with fixed resistance from a bundle of parallel tubes, 2 P transducers either side
Sense a change of P across resistance
(Gas flow through is laminar)
Change in P proportional to flow rate
TV summated over minute - MV
Bi directional
Water vapour at resistor affects accuracy - hearing tubes help

161
Q

What factors affect pneumotachograph readings?

A 
Location
Gas composition 
Gas temperature 
Humidity
Dead space
162
Q

What is a peripheral nerve stimulator for?

A

Monitor transmission across neuromuscular junction

Establishes depth, reversal and type of block

163
Q

What is EMG and NMT?

A

Electromyography
- electrical activity

Neuromuscular transmitter
- transmission across junction

164
Q

What nerves can be stimulated?

A

Ulna
Common peroneal- at fibula neck
Posterior tibial - at ankle
Facial

165
Q

What is the tetanic stimulation mode?

A

A tetanus of 50-100Hz is used to detect residual block

Fade will be apparent

166
Q

What is TOF mode?

A 
Assess degree of block
Ratio of 4th to 1st twitch
4x 2Hz twitches over 2s
Fade noticed first, then lose 4th then 3rd etc twitch
2 twitches to reverse
>3 absent for ideal abdo surgery
167
Q

What is the double burst function?

A

More accurate assessment of residual block
2x short 50Hz tetanus
Each twitch comprises of 2-3 square wave impulses

168
Q

What safety considerations should be thought of for nerve stimulators?

A

Awake can hurt

Hand muscles small in comparison to diaphragm therefore result at hand doesn’t reflect true depth of diaphragm block

169
Q

What is BIS?

A

Bispectral index
Monitor electrical activity and sedation of the brain
Assess the risk of awareness
Allows titration of hypnotics based on individual needs
Measures hypnotic component but less sensitive to analgesic components

170
Q

What are the components of BIS?

A

Display: BIS value, facial EMG, eeg suppression, signal quality index
Forehead sensor with 4 electrodes and a smart chip
Small tines in electrode part outer skin layers and hydrogel to make contact
Reduces impedance and optimise
Flexible design fits most

171
Q

How does BIS work?

A

BIS is a statistic analysis, empirical method that quantifies the level of synchronisation of underlying frequencies
Value derived mathematically using info from EEG, frequency and BIS info
Produces linear scale 1-100

172
Q

What are the values for BIS?

A 
100 - awake
0 - electrical silence
65 - 85 sedation
40 - 60 GA
60 return of conscious state
173
Q

What are some safety features of BIS?

A

Inaccurate at low temperatures
Ketamine is dissociative so cannot monitor
Insufficient data for use with neuro disease
Interference with diathermy and EMG

174
Q

What is entropy?

A

Measure anaesthetic depth by amount of disorder of eeg signal
Forehead sensors
Calculates the frequency of voltages for each time sample and converts into normalised spectrum
SE: 0-91; RE: 0-100

175
Q

What is state and response entropy?

A

State: calculated from low frequency range corresponding to EEG
Response: calculated from high frequencies and EMG from frontal muscle

176
Q

What are the components of invasive arterial monitoring?

A

In-dwelling Teflon cannula
Has parallel walls to reduce effect of flow to distal limb
Column of NaCl (hep) at 300mmHg in flushing device
Connects to transducer which connects to amp and oscilloscope
Strain gauge variable resistor used
Thin membrane diaphragm is interface between fluid and transducer
Low compliance tubing so doesn’t move with each pulse

177
Q

How does invasive arterial monitoring work?

A

Transducer changes R in response to change in P
NaCl column goes up/down with arterial pulse causing movement of diaphragm
Transducer connects to Wheatstone bridge
Changes in R and I are converted and displayed as systolic, diastolic, MAP
3-4ml/Hr flush cannula to prevent back flow and clotting

178
Q

How does a Wheatstone bride in the arterial transducer work?

A

Electrical circuit for comparison of resistors
Galvanometer, 4 resistors in 2 parallel branches
2 known R, 1 Variable and 1 Unknown
The ratio of the 2 branches are compared and a current will flow through the galvanometer if there is an imbalance and therefore a reading

179
Q

Draw the waves for an optimal, under and over damped pressure wave and for a square wave test.

A

See notes

180
Q

What are some safety features of arterial monitors?

A

Transducer should be at RA level as reference point; every 10cm out gives a 7.5mmHg error
Haematoma, infection, nerve damage, thrombosis, ischemia, bleeding
More peripheral arteries are narrower and less compliant therefore increased amplitude
Narrow/bifurcate arteries impede flow so backward reflect of P wave
Drug injection = occlusion, gangrene
Re-zeroing to reduce baseline drift

181
Q

Why is zeroing an arterial line important?

A

Eliminates atmospheric pressure effects

Ensure monitor indicates zero in the absence of applied pressure therefore eliminating drift

182
Q

How is a CVC placed?

A

Jugular, subclavian or basilic vein
Sterile with landmark or ultrasound guidance
Seldinger technique
J-shaped soft tip wire inserted through into needle. Tip lessens trauma. Needle removed. Small incision in skin. Dilate. Railroad catheter over wire then remove wire. Aspirate and flush each port. Secure and check with X-ray

183
Q

What is a PICC line?

A

Inserted via ACF
Prolonged drug therapy which may be vein irritant
Several months

184
Q

What is a Hickman line?

A

Inserted via subclavian vein with proximal end tunnelled under the skin. Cuffed to hold in place and reduce infection
Long term therapy
Months - years

185
Q

What are some safety features of a CVC?

A 
Too far in - arrhythmia 
Blocked, failure
Pneumothorax
Infection, bleeding, nerve damage
Air embolism
Haematoma
Tracheal puncture
186
Q

What are ways to reduce CVC infection rate?

A 
Sterile method
Subclavian site
Ultrasound guide to reduce number of attempts
Minimal number of ports
Remove ASAP
AB coated lines
Sterile, clear dressings
187
Q

What are the components of a PA catheter?

A 
5-8G 
Upto 5 ports
Distal lumen is PA
Proximal lumen in RA 
Other proximals can infuse drugs 
Another lumen houses wires for thermistor - 3.7cm from tip
Lumen to inflate balloon up to 1.5ml air
Can be inflated to float with blood or when wanted PCWP 
Lumen to connect to P transducer 
Some can measure mixed venous O2 sats
188
Q

What is the mechanism of the PA catheter?

A

Flush lines, test balloon
Connect to P transducer
Partially inflate balloon to get to RA
Watch waveform!
Fully inflate balloon to get tip to pulmonary artery branch where it will wedge. This measurement reflects Left atrial filling pressure
Deflate balloon so catheter floats back to PA. Keep deflated until PCWP wanted

189
Q

How does thermodilution work?

A

10ml of cold injectate administered upstream. Thermistor in PA measures change in temperature of blood downstream and a temperature time curve is created. This can then calculate CO. Volume of injectate must be accurate and quick. Mean of 3 readings used.
Low blood = high temperature change
High blood = low temperature change

190
Q

What are the safety concerns of a PA catheter?

A 
Arrhythmia
VT
Heart block
Valve damage
Perforate PA
Don't advance >10cm without a change in waveform 
Thrombosis, infection, pulmonary infarction
Whip artifacts
191
Q

What is the LiDCOrapid?

A

CO monitor uses arterial waveform analysis to generate cardiac output
Assess fluid and inotrope affects
Algorithms used
Can assess SV and its response to fluid challenges

192
Q

How does a thermistor work?

A

A temperature dependant semi conductor and a Wheatstone bridge
A change in temp = change in R
Small and cheap

193
Q

How does an IR tympanic temperature probe work?

A

Small probe inserted into external auditory meatus
Detected by a series of thermocouples (thermopile)
Detector receives IR from tympanic membrane
IR signal converted to electrical signal
Must be accurately timed
False low; wax

194
Q

How does a thermocouple work?

A

2 strips of different metals in contact from both ends and galvanometer
One junction for measure and one for reference
Metals expand and contract to different degrees with changing temp which produces a voltage compared with reference
Generate a voltage which is temperature dependant
Accurate to 0.1

195
Q

What are the measurable sites for temperature?

A 
Rectal 
Oesophageal (core)
Tympanic (core)
Bladder (accurate if output normal)
Skin
Axillary
196
Q

What is the oesophageal Doppler?

A

Quick estimate of CO
Probe in Oesophagus
Close to aorta; minimal interference
Adequate sedation needed

197
Q

How does an oesophageal Doppler work?

A

Principle: high frequency when approach and low when travelling away
Ultrasound waves encounter moving RBC. Frequency determines flow
Probe inserted in mouth with bevel facing up at back of throat
Probe rotated and slowly pulled back
Position: 5-6 thoracic vertebrae adjacent to aorta

198
Q

What is the mechanism of action of a hot water bath?

A

Water heated 45-60 degrees
Dry/cold gases enter container where some pass close to surface of water = max saturation
Container has ^ SA for vaporisation which ensures gas is fully saturated
Tubing has poor thermal insulation causing a drop in temp
By ^ temp > body temp it’s possible to deliver it at 37 degrees, fully saturated
Temp measured at pt end and feedback to control water temp

199
Q

What are the safety features of hot water bath?

A 
Need electricity 
Potential shock/burn
2nd thermostat if first malfunctions
Water trap should be lower than pt to prevent flooding of airway by condensed water
Water may be colonised
Microbe risk drops with higher temp but burns risk then increases
Large, expensive
Leak risk
200
Q

Define relative humidity.

A

Ratio of the amount of water vapour in the air at a specific temp compared to the maximum it could hold

201
Q

Define absolute humidity.

A

Measure of the amount of water vapour in the air. Measured as partial pressure
g H2O vapour/ cm3

202
Q

What is the minimum humidification outcome for an HME?

A

30 degrees

30gm-3

203
Q

What are some comments regarding the position of the filter in the system?

A

Should be higher than lung level and in a vertical position to reduce chance of a complete block. A block on pt side stops exp but allows insp.

Should be after lime to prevent drying and therefore not encourage compound A/monoxide production

204
Q

What are the effects from theatre pollution?

A 
Abortion
Low fertility
Haematological malignancy
Renal/liver dysfunction
Low mental performance
205
Q

Describe the collection system for AGSS?

A

Gather from APL or from ventilator exhaust valve
30/19mm connection
This mustn’t cause R to expiration

206
Q

What are safety features of the unidirectional valves?

A

Clear housing
Hydrophobic
Sit on knife edge to avoid sticking

207
Q

How does colorimetric CO2 work?

A

It contains paper which changes colour in the presence of CO2 based on pH

208
Q

What is the conversion between kPa and water?

A

1 kPa = 10 cmH20

209
Q

What is a port-a-Cath?

A

SC port attached to a central catheter
Surgically placed
Prolonged intermittent therapy
Months - years

210
Q

What is a CVC?

A

Resuscitation or pressure monitoring

Up to 14 days

211
Q

What are the indications for central lines?

A 
Chemo
Long term AB
TPN
Haemodialysis
Repeated transfusions or samples
Peripheral irritant
212
Q

What are the correct DLT sizes?

A

41/39 male

37 female

Anaesthesia (8 decks)

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