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Basic Principles N928 > Anesthesia Monitoring > Flashcards

Anesthesia Monitoring Flashcards

1
Q

Why do we monitor patients?

A

assess data indicating:
patient’s physiologic status (homeostasis)
patient response to therapeutic intervention

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2
Q

What AANA standard is monitoring?

A

Standard 9:
monitoring, evaluate and document patient’s physiologic condition as appropriate for the procedure and anesthetic technique.
Alarms are turned on and audible
Document blood pressure, heart rate, and respiration at least every 5 minutes for all anesthetics

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3
Q

What is standard 9?

A

monitor ventilation, continously (O2 and continous ETCO2)
monitor cardiovascular status continously
monitor thermoregulation continously
monitor neuromuscular function
monitor and assess patient positioning

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4
Q

How long do CRNAs stay with their patients?

A

remain with patients until care is responsibly transferred to another qualified healthcare provider

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5
Q

Alarm Settings

A

alarms reflect changes in patient or equipment status
variable pitch
threshold alarms on and audible

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6
Q

Alarm fatigue

A

National patient safety goal 2017

goal 6: reduce harm associated with clinical alarm systems

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7
Q

What is Vigilance?

A

a state of clinical awareness whereby dangerous conditions are anticipated or recognized and promptly corrected

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8
Q

What is more important then monitors?

A

Look
Listen
Feel
Smell

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9
Q

Look

A

inspection

retractions, color, mucous membranes

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10
Q

Listen

A

Ausculate
heart and lung sounds, wheezing
continous suction intraoperatively

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11
Q

Feel

A

palpate

pulses, color, edema, crepitus, muscle tension, resistance and compliance

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12
Q

Smeel

A

smoke/burning, volatile anesthetic

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13
Q

List of Monitors

A 
pulse oximeter
capnography
NIBP or arterial line
EKG
Temperature
oxygen analyzer
stethoscope
PA catether
ICP urine output
Peripheral nerve stimulator
BIS
Precordial Doppler
TEE/TTE
SSEPs
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14
Q

Oxygenation

A

continously monitor oxygenation by clinical observation and pulse oximetry
the surgical or procedure team communicates and collaborates to migate the risk of fire

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15
Q

Most important aspect of anesthesia

A

AIRWAY

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16
Q

ventilation

A

continously monitor ventilation by clinical observation and confirmation of continous expired CO2 during moderate sedation, deep sedation or general anesthesia

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17
Q

Oxygenation implies

A 
oxygen analyzer
pulse oximetry
skin color
color of blood
ABG (when indicated)
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18
Q

O2 analyzer

A 
Measures FiO2 (inspired gas/inspiratory limb)
low concentration alarm <30%
calibrate to room air and 100%
required for any general anesthetic
useful for calculating PaO2
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19
Q

Alveolar Gas Equation

A

PAO2= FiO2 x (Pb-47)-PaCO2

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20
Q

Oxgen analyzer

A

electrochemical sensor (Cathode and anode embedded in electrolyte gel)
separated from O2 gas by oxygen permeable membrane
o2 reacts with electrodes, generates electrical signal proportional to O2 pressure in sample gas

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21
Q

Pulse oximetry

A

standard of care for continous non-invasive monitoring of oxygenation
provides early warning of hypoxemia; cynaosis= late sign
measures arterial O2 saturation coming principles of oximetry and plethysymography

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22
Q

What does pulse oximetry require

A

pulsatile arterial bed
plethysmography, pulsatile measurement
finger, toe, ear lobe, bridge of nose, palm of foot in children
continuous measurement of pulse rate and oxygen saturation of peripheral hemoglobin

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23
Q

Lambert-Beer Law of spectrophotometry

A

absorption of red and infrared light differs in oxygenated and reduced Hgb

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24
Q

HbO2 absorbs

A

more infrared 960nm

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25
Q

Reduced HbO2 absorbs more

A

red at 660nm

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26
Q

How does oximeter calculate O2 saturation

A

ratio of infrared and red transmitted to a photodetector) by comparison of absorbances of these wavelengths

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27
Q

What is the basis of oximetry?

A

change of light in absorption during arterial pulsations

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28
Q

Factors that effect pulse ox accuracy

A 
high intensity light
patient movement
electrocautery
peripheral vasoconstriction
hypothermia
cardiopulmonary bypass (need pulsatile bed)
presence of other hemoglobins
IV injected dyes
Hemoglobin less <5
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29
Q

What does CoHb do to the pulse ox reading?

A

false increase in reading

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30
Q

What does MetHb do to pulse ox reading?

A

depends can increase or decrease

depends on SaO2

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31
Q

What dye causes the largest decrease in SpO2?

A

methylene blue

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32
Q

PO2 30=

A

SaO2 60

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33
Q

PO2 60=

A

SaO2 90

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34
Q

PO2 of 40

A

SaO2 75

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35
Q

What is ventilation?

A

movement of volume; inhalation/exhalation
Minute volume
elimination of CO2

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36
Q

Ventilation Monitors include

A

continuous ausculation (stethoscope)
chest excursion
end tidal capnography
spirometry

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37
Q

Precodial stethoscope

A

suprasternal notch or apex left lung (where heart and lung sounds are audible)
easily detects changes in breath sounds or heart sounds

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38
Q

What do you hear with a pericordial stethoscope?

A

airway/circuit disconnect
endobronchial intubation
anesthetic depth/increase HR, contractility

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39
Q

Esophageal Stethoscope

A 
soft plastic catheter
balloon covered distal opening
limited to intubated patients
better quality heart & breath sounds
incorporated temperature probe
place through mouth or nose into esophagus (distal 1/3)
ONLY in general anesthesia
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40
Q

C/A with esophageal stethoscope

A

esophageal varices or structures

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41
Q

Respiratory Gas Analysis

A

gas sampling line
allows measurement of volatile anesthetics
non-dispersive infrared (NDIR) most common

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42
Q

What are characteristics of nondispersive infrared?

A

side streaming sampling
gas absorbs infrared energy at specific wavelength
complex algorithm and micropressor
rate of absorbance
many gases absorb at different wavelengths and the microchip can determine what the gas

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43
Q

Modern gas analyzer rate

A

250ml/min

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44
Q

Principles of Capnography

A

confirms ETT placement and adequate ventilation

average adult produces 250ml CO2/min

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45
Q

Capnography changes d/t

A

patient’s condition
anesthetic depth
temperature

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46
Q

Sidestream sampling

A

most common
airway gas aspirated and pumped into measuring device
sample flow rates of 50-250ml/min

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47
Q

limitations of side streaming

A

H20 condensation can contaminate the system and falsely increase readings
lay time between sample aspiration and reading
kinked line

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48
Q

PACO2-PaCO2 gradient

A

normal 2-10mmHg

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49
Q

Abnormal PA-Pa Co2 gradient

A 
gas sampling errors
prolonged expiratory phase
V/Q mismatch
airway obstruction
embolic states
COPD
hypoperfusion
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50
Q

Phase 1 of Capnograph

A

corresponds to inspiration
anatomic/apparatis dead space devoid of CO2
level should be zero unless re-breathing

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51
Q

When is the baseline elevation of phase 1 of capnograph elevated?

A

CO2 absorbent exhausted
expiratory valve is missing/incompetent
bain circuit

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52
Q

Phase 2 of Capnograph

A

early exhalation/ steep upstroke

mixing of dead-space with alveolar gas

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53
Q

What cause a prolonged upstroke in phase 2 of caphnograph?

A

mechanical obstruction (kinked ETT)
COPD
bronchospasm
This indicates CO2 isn’t able to escape as readily

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54
Q

Phase 3 of capnograph

A

CO2 rich alveolar air

horizontal with mild upslope

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55
Q

What disrupts the 3rd phase of the capnograph

A

steepness is function of expiratory resistance
COPD, Bronchospasm
Not able to release CO2 due to airway resistance or diffusion issue

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56
Q

Low plateau

A

low CO2, decrease CO, increase RR rate increase dead space

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57
Q

High Plateau

A 
hypoventilation
increase CO2 (ie MH)
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58
Q

Important alarms for the mechanical ventilator

A

tidal volume- integrated spirometry
airway pressure: in-circuit pressure gauge, peak inspiratory pressure, sustained elevated pressure
Disconnect alarm: low airway pressure

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59
Q

Electrocardiogram

A

standard of care requires continuous monitoring and display

heart rate with audible indicator

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60
Q

Heart rate detects

A 
cardiac dysrhythmias
conduction abnormalities
myocardial ischemia/ST Depression
electrolyte changes
pacemaker function/malfunction
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61
Q

three lead EKG system

A

typically monitor in lead 2

limited in detection of myocardial ischemia

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62
Q

Five lead EKG system

A

allows recording of six standard limb leads (1,2,3, avr, avf, avl)
better in detecting myocardial ischemia
allows better differiental diagnosis of atrial and ventricular dysrhythmias

63
Q

Lead 2

A

yields max P wave voltages
superior detection of atrial dysrhythmias
detects inferior wall ischemia/ ST depression

64
Q

V5

A

5 ICS/ anterior axillary line

detection of anterior and lateral wall ischemia

65
Q

Lead One

A

Patient’s

R hand negative L hand positive

66
Q

Lead 2

A

Patient’s

R hand negative and Foot positive

67
Q

Lead 3

A

Patient’s L hand negative

foot position

68
Q

Avr

A

patient R hand positive

foot negative

69
Q

AvL

A

patient’s L hand positive

foot negative

70
Q

5 lead EKG placement

A

white: 2nd ICS R mid clavicular line
green: 6-7th ICS R midclavicular line
Brown: 4 ICS R sternal border
Black: 2nd ICS L midclavicular line
Red: 6-7 ICS L midclavicular line

71
Q

Arterial Blood Pressure

A

palpation

ausculation (korotkoff sounds)

72
Q

automated indirect blood pressure (NIBPM)

A 
oscillometry
easy, accurate, versatile in children and obses
may be used no calf or thigh
oscillometric device
air pump inflates cuff
micropressor open deflation valve 
oscillations are sampled
73
Q

NIBP Errors

A 
surgeon leans on cuff
inappropriate cuff size
large cuff to low reading
small cuff to high reading
shivering or excessive motion
74
Q

atherosclerosis and HTN with NIBP

A

systolic low

diastolic too high compared with invasive arterial pressure

75
Q

Indications for arterial monitoring

A

any patient requiring BP measurement > minute to minute
critically ill
anticipated rapid blood loss
major procedures: cardiopulmonary bypass aortic cross clamping
intracranial surgery
carotid sinus manipulation
Frequent ABG

76
Q

Arterial Line Site Selection

A 
radial artery
ulnar artery (technically more difficult/ more tortuous)
brachial artery (complications, predisposed to kinking)
femoral artery (prone to pseudoaneurysm & atheroma formation)
dorsalis pedis(may have distorted waveform)
axillary artery (potential for plexus/nerve damage from hematoma or traumatic cannulation
77
Q

Indications for CVP

A

fluid management of hypovolemia and shock
infusion of caustic drugs
aspiration of air emboli
insertion of pacing leads
TPN
venous access in patients with poor peripheral veins

78
Q

Site selection

A

IJ (R)
subclavian
external jugular
antecubital (special kit with long catether)

79
Q

Pulmonary Artery Catheterization

A 
via CVL
poor LV function
EF <0.4, CI <2L/min
evaluate response to: fluid administration, vasopressors, vasodilators, inotropes
Potential indications
valvular heart disease
recent MI
ARDS
Massive trauma
Major vascular surgery
80
Q

RA

A

2-6mmHg

81
Q

RV 20-

A

20-30mmHg/0-5mmHg

82
Q

PA

A

20-30mmHg/5-15mmHg

83
Q

PCWP

A

4-12 mmHg

84
Q

Factors effecting thermoregulation

A

ambient room temperature (cool or tropical)
scope and length of surgery (open or laproscopic)
Hypothalamic depression
intraoperative fluid replacement (blood and IVF being warmed)
viligiance in maintaining core temperature

85
Q

RT RBCs decrease body temp by

A

0.2 degrees C

86
Q

RT Crystalloids decrease body temp by

A

0.4 degrees C

87
Q

4 Methods of heat loss

A

evaporation
radiation
convection
conduction

88
Q

List the methods of heat loss from greatest to least

A

radiation> convection> conduction> evaporation

89
Q

Radiation

A

heat radiated from patient into room

90
Q

Convection

A

heat loss due to air velocity

91
Q

Conduction

A

contact with OR table, black, touch

92
Q

Evaporation

A

heat loss to dry inspired gases

93
Q

Unintentional Hypothermia

A

GA can’t regulate temperature
Phase 1-3
Phase 2- altered perception by dermatones (hours1-4)

94
Q

hypothalamus

A

controls temperature by intrathreshold range

inhibited by anesthetics

95
Q

Hypothermia

A

heat loss outpaces metabolic heat production
anesthesia impairs normal response
body temperature may decrease 1C to 4C
may delay awakening
may cause shivering (increase O2 consumption by what %)

96
Q

Who is greatest risk of hypothermia?

A

elderly, burn patients, neonates and patient’s with spinal cord injuries

97
Q

Mild hypothermia

A

33-36 degrees
reduced enzyme function
coagulopathy

98
Q

Moderate hypothermia

A

= to 32C

fibrillatory threshold

99
Q

Hyperthermia

A

rarely develops under anesthesia

late sign of malignant hyperthermia

100
Q

Other causes of hyperthermia

A

endogenous pyrogens
thyrotoxicosis or pheochromocytoma (increase metabolic rate)
anticholinergic blockade of sweating
excessive environmental warming

101
Q

Monitoring Temperature Sites

A 
esophagus (lower 1/3) accurately reflects blood temperature (most often, trended)
nasopharynx
rectum
bladder
tympanic
blood (PA catheter)
skin
102
Q

Superifical warming modalities

A

Active warming
forced air warmer
most effective
warming blanket (water circulates, miniminally effective)
radiant heat unit (no impact on body temp)
heated liquids (IV bags or bottles on patient-very dangerous; burns
Watch with joint surgeries because heat can cause infection

103
Q

Core warming modalities

A

Active warming
intravenous fluid warmers
warmed liquid transfer of heat (hotline) to infusate
delivers fluids at highest temperature of any technology
Gastric lavage- warms body core, impractical in surgery
peritoneal irrigation- encourage use of warm irrigation during intra-abdominal procedures

104
Q

Passive warming modalities

A

ambient temperature- highest effect on maintaining body heat
ambient tem > 24C
insulation (head and extremities)
heat and moisture exchanger (artificial nose, retains moisture)
coaxial breathing circuit

105
Q

Ambient temperature >24

A

most adults remain normotheramic w/o requiring other measures

106
Q

coaxial breathing circuit

A

warms and humidifies inspiratory gases

107
Q

Neuromuscular function

A

monitor NM response and assess depth of blockade and degree of recovery

108
Q

Peripheral Nerve Stimulator

A

monitors effect of NM blocking agent on NM junction
- know and compare to baseline
-quantify by feel
Delivers electrical stimulation to a peripheral motor nerve
evokes mechanical response
permits titration of drug to optimal effect
quantifies recovery from NM blockade

109
Q

Monitoring sites of PNS

A 
ulnar nerve
facial nerve
posterior tibial nerve
peroneal nerve
place electrode near nerves to avoid direct muscle stimulation
110
Q

Ulnar Nerve

A

innervates the adductor pollicis muscle
-adducts thumb
electrodes placed at wrist or elbow
- negative (depolarizing) placed distally
common monitoring site
inaccurate reflection of degree of block (diaphragm or airway muscles)
- these muscles less sensitive to ND block
-adductor pollicis paralysis and still have coughing, breathing, vocal cord movment

111
Q

When is it best to utilize the ulnar nerve?

A

onset of recovery

112
Q

Facial Nerve

A

lies within the parotid gland
electrodes in front of tragus of ear and below
avoid direct muscle stimulation
-negative electrode placed over nerve
-facial hair contact interference
Better indicator and ND blockade of diaphragm and airway then peripheral muscle
monitor contraction of orbicularis oculi

113
Q

orbicularis oculi controls

A

closes eyelid

114
Q

currugator supercilli

A

furrows brow

115
Q

Posterior Tibial Nerve

A

places electrodes behind medial malleolus of tibia

results in plantar flexion

116
Q

flexor hallucis brevis muscle

A

sole of foot

flexes big toe

117
Q

Peroneal nerve

A

electrodes on lateral aspect of knee

response= dorsiflexion of the foot

118
Q

Patterns of Stimulation

A 
single twitch
TOF
tetanic stimulation
Post tetanic stimulation
double-burst stimulation
119
Q

Singel twitch stimulation

A

single pulse delivered every 10 seconds at 0.1-1Hz
increasing block results in diminishing response
Twitch heights will be normal til 75% Nachr receptors are blocked
90% no twitch

120
Q

TOF

A

most common
4 repetitive stimuli
twitches progressively fade as relaxation increases
2Hz every 0.5 seconds for 5 seconds
ration of responses to 1st adn 4th are sensitive indicator of ND relaxation

121
Q

Loss of 4th twitch

A

75% receptors blocked

122
Q

Loss of 3rd twitch

A

80% of receptors blocked

123
Q

Loss of 2nd twitch

A

90% of receptors blocked

124
Q

Clinical relaxation requires

A

75-95% block

125
Q

Depolaring NM

A

every twitch will be same height

126
Q

Partial NMB

A

inversely proportional to degree of block

127
Q

Tetanic Stimulation

A

tetany at 50-100Hz
-50 Hz Q5seconds evoked tension approximates tension developed during maximal voluntary effort
in presence of NM Relaxants, fade occurs
sustained response occurs when TOF >70%

128
Q

Post Tetanic Count

A

apply tetanus @ 50Hz for 5 seconds
wait 3 seconds
apply single twitches every second up to 20
# of twitches inversely related to depth of block

129
Q

When is post tetanic count useful?

A

when all twitches are suppressed

130
Q

Double Burst Stimulation

A

less painful than tetany

more sensitive than TOF for visual evaluation of fade

131
Q

DBS3,3

A

3 short 50 hz impulses followed by 750msec by another 3 burst

132
Q

PNS method during Induction

A

Single twitch

TOF

133
Q

PNS method intraop

A

TOF

Post tetanic cound

134
Q

PNS method for Emergence

A

TOF

double burst stimulation

135
Q

Relative Sensitivities of muscle groups to ND muscle relaxants

A 
Most sensitive: extraocular
pharyngeal
masseter
adductor pollicis
abdominal rectus
Orbicularis oculi
diaphragm
vocal cord- most resistant (least sensitive)
136
Q

Orbicularis occuli measures

A

onset

137
Q

Adductor pollicis measure

A

recovery

138
Q

In TOF, 1 of 4 twitches indicates reversal will be

A

as long as 30 minutes

139
Q

In TOF, 2-3 twitch indicates reversal will be

A

10-12 minutes following a long acting relaxants, 4-5 minutes after immediate relaxants

140
Q

In TOF, 4 of 4 twitches indicates

A

adequate recovery within 5 minutes of neostigmine, within 2-3 minutes of edrophonium

141
Q

Limitations of NM monitoring

A

responses may appear normal despite receptor occupancy
wide variabiltiy in evoked responses, some exhibit weakness at TOF ration of 0.8-0.9
valves of adequate recovery do not guarantee adequate ventilatory function or airway protection
perioperative hypothermia increases skin impedence, limiting interpretation of evoked responses

142
Q

Unreliable signs of clinical recovery

A 
sustained eye openign
tongue protrusion
arm life to opposite shoulder
normal tidal volume
normal or near normal vital capacity
max insp pressure <40-50cmH20
143
Q

Most reliable signs of clinical recovery

A

sustained headlift x 5 seconds
sustained leg lift for 5 seconds
sustained handgrip x 5 seconds
max inspiratory pressure 40-50 cm H20 or >

144
Q

Quantitative Nerve Monitoring

A

device that quantifies the degree of NM blockade
reliable, accurate, objective
post stimulation, muscle response objectively quantified

145
Q

Acceleromyography (AMG)

A

piezoelectric sensor measures muscle acceleration (voltage generated upon muscle contraction)

146
Q

Electromyography (EMG)

A

muscle action potentials recorded, electrical activity proportional to the force of contraction
- more specific then mechanical

147
Q

Kinemyography

A

quanitifies muscle movement with motion sensor strip containing piezoelectric sensors

148
Q

Mechanomyography

A

detects contraction force, converts to electrical signal, signal amplitude reflects contraction strength

149
Q

Phonomyography

A

muscle contraction produces low-frequency sounds, calculates muscle response

150
Q

Bispectral Index Score

A 
used to assess depth of anesthesia (optional)
EEG signal
index ranges from 0-100
100=awake CNS
>70 greater recall risk
40-60 general anesthesia
0= isoelectic EEG
151
Q

Advantage of BIS score

A

reduced risk of awareness
better management of responses to surgical stimulation
faster wake up (controversial)
more cost effective use of anesthetics

152
Q

BIS readings are affected by

A 
electrocautery
EMG
pacer spikes
patient movement
#s asosciated with reduced risk of recall
levels >70 associated with less recall
153
Q

Cerebral Oximetry

A

assess cerebral oxygen saturation using near infrared spectrophotometry (NIRS)
noninvasive monitor
detects decreases in CBF in relation to CMRO2
intensity difference between transmitted and received light, determines regional oxygen saturation (similar to oximetry and Beer lambert law
light source adheres to forehead, light transmits through tissue adn cranium

Basic Principles N928 (10 decks)

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