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Basic Principles of Anesthesia - CP > Anesthesia Monitoring > Flashcards

Anesthesia Monitoring Flashcards

1
Q

Which AANA Standard is related to monitoring?

A

Standard 9: Monitoring, Alarms

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2
Q

According to standard 9 which monitors do we need to document and how often do we need to document them?

A

blood pressure, heart rate, and respirations at least every 5 minutes

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3
Q

National patient safety goals 2017: goal 6 refers to

A

reduce harm associated with clinical alarm systems

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4
Q

Definition of vigilance

A

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

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5
Q

Which is the most important monitor?

A

We are! :-)

vigilant CRNAs develop intuitive sense through education and experience

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6
Q

Examples of things we are looking/inspecting at/for

A

retractions, color, mucous membranes, chest movement, facial expression of patient, reservoir bag

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7
Q

Examples of things we are listening/auscultating for

A

heart and lung sounds, wheezing, continuous suction, the patient’s voice

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8
Q

Examples of things we are feeling/palpating

A

pulses, edema, crepitus, muscle tension, resistance, compliance, temperature

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9
Q

Examples of things we can smell

A

smoke, burning, volatile anesthetic

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10
Q

List the various monitors we may use

A

pulse oximeter, capnography, NIBP/aline, EKG, temperature, oxygen analyzer, stethoscope, PA catheter, ICP, urine output, PNS, BIS, precordial doppler, TEE/TTE, SSEPs

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11
Q

What is standard 8?

A

positioning

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12
Q

What is standard 11?

A

transfer of care

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13
Q

What are the subcategories under standard 9?

A

oxygenation, ventilation, cardiovascular, thermoregulation, neuromuscular function

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14
Q

The most important aspect of anesthesia

A

AIRWAY

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15
Q

what is the fundamental goal for anesthesia?

A

avoid hypoxia

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16
Q

Alveolar gas equation

A

PAO2 = FiO2 x (Pb - 47) - PaCO2

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17
Q

What does the O2 analyzer measure?

A

FiO2

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18
Q

How does the pulse oximeter determine the saturation?

A

compares the absorbances of the infrared wavelength to the red wavelength

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19
Q

infrared

A

960 nm

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20
Q

red

A

660 nm

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21
Q

Factors affecting accuracy of pulse oximeter

A

high intensity light, patient movement, electrocautery, peripheral vasoconstriction, hypothermia, cardiopulmonary bypass, presence of COHb, MetHb, IV injected dyes (methylene blue), Hb <5

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22
Q

A PaO2 of 30 is a SaO2 of

A

60

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23
Q

A PaO2 of 60 is a SaO2 of

A

90

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24
Q

A PaO2 of 40 is a SaO2 of

A

75

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25
Q

On the oxyhemoglobin dissociation curve which is the dependent variable? independent variable?

A

Dependent: O2 saturation
Independent: O2 content

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26
Q

Hypoxia is when the O2 sat is …

A

< 90%

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27
Q

What is ventilation?

A

movement of volume, inhalation and exhalation, elimination of CO2

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28
Q

What are our ventilation monitors?

A

continuous auscultation (stethoscope), chest excursion (observation), end tidal capnography, spirometry

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29
Q

Where do we typically place the precordial stethoscope?

A

at the apex of the lung or suprasternal notch or wherever you hear best

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30
Q

When would an esophageal stethoscope be contraindicated?

A

esophageal varices, strictures

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31
Q

Dispersive method for respiratory gas analysis

A

uses single optical filter (prism) to separate the component wavelengths for each of our agents

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32
Q

Nondispersive method for respiratory gas analysis

A

multiple narrow band, optical filters through which that infrared emission is past to determine which gas is present in the mixture; more common method

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33
Q

Modified analyzers gas sampling rate

A

50 - 250mL/min, can show up as a leak source

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34
Q

How much CO2/min does an average adult produce?

A

250mL CO2/min

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35
Q

Sidestream sampling

A

airway gas is aspirated and pumped to measuring device

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36
Q

Limitations of sidestream sampling

A

H2O condensation can contaminate the system and falsely elevate reading
Lag time between sample aspiration and reading

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37
Q

Normal PACO2 - PaCO2 gradient

A

2 - 10 mmHg

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38
Q

Things that cause an abnormal PACO2 - PaCO2 gradient

A

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

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39
Q

At a CO2 of 40 mmHg you have

A

normal CO2 production, adequate circulation, adequate alveolar ventilation

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40
Q

Beta angle on ETCO2 waveform

A

top right corner, actual ETCO2 reading because it is end exhalation

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41
Q

Phase 1 on ETCO2 waveform

A

corresponds to inhalation
anatomic and apparatus dead space
should be 0 unless rebreathing

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42
Q

what causes an elevation in the baseline on ETCO2 waveform

A

CO2 absorbent exhausted, expiratory valve is missing/incompetent, bain circuit

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43
Q

phase 2 on ETCO2 waveform

A

early exhalation, upstroke

mixing of dead space and alveolar gas

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44
Q

things that prolong the upstroke on ETCO2 waveform

A

mechanical obstruction/kinked, slow emptying (COPD, bronchospasm)

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45
Q

phase 3 on ETCO2 waveform

A

CO2 rich alveolar air
plateau with mild upstroke at end
steepness is function of expiratory resistance

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46
Q

bare minimum urine output in the OR

A

0.5 mL/kg/hr

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47
Q

what do bubbles in a urine sample mean?

A

protein in the urine, seen in pre-eclampsia/eclampsia

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48
Q

phase 4 on ETCO2 waveform

A

inspiration of fresh gas, returning to baseline

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49
Q

things that decrease amplitude on ETCO2 waveform

A

increased BMR, leak, hyperventilation, temperature/shivering

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50
Q

how much does shivering increase o2 consumption by?

A

up to 400%!!

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51
Q

what factors do we look at when assessing an ETCO2 waveform?

A

time, frequency, slope, amplitude, baseline

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52
Q

What can curare cliffs be mistaken for on ETCO2 waveforms?

A

cardiac/cardiogenic oscillations which are synchronous with heart beat in thin patients or pediatrics

53
Q

What do electrocardiograms detect?

A

cardiac dysrhythmias, conduction abnormalities, myocardial ischemia/ST depression, electrolyte changes, pacemaker function/malfunction

54
Q

Which lead does a three electrode monitor?

A

lead II

55
Q

Which leads can the five electrode monitor?

A

allows recording of 6 standard leads (I, II, III, aVR, aVL, aVF) and 1 precordial lead (V5)

56
Q

Which lead system is better for diagnosing atrial and ventricular arrhythmias

A

five electrode

57
Q

Lead II

A

yields max P wave voltages, best at detecting atrial dysrhythmias, detects inferior wall MI

58
Q

V5

A

detects anterior and lateral wall MI

lies at 5th intercostal space/anterior axillary line

59
Q

Inferior MI lead detection

A

II, III, aVF

60
Q

Lateral MI lead detection

A

I, aVL, V5, V6

61
Q

Anterior/septal MI lead detection

A

V1 - V4

62
Q

Determining BP cuff

A

20% > mean diameter of the extremity

63
Q

if BP cuff is too narrow that indicates

A

falsely high reading

64
Q

if BP cuff is too wide that indicates

A

falsely low reading

65
Q

Things that can cause errors with BP cuff

A

surgeon leaning on cuff, inappropriate cuff size, shivering, excessive movement, athersclerosis, HTN

66
Q

indications for an invasive arterial BP monitor

A

requiring BP measurement minute to minute, critically ill, anticipated rapid blood loss, major procedures (bypass, aortic cross clamping, intracranial surgery, carotid sinus manipulation), frequent ABGs

67
Q

Sites used for arterial lines

A

radial, ulnar, brachial, femoral, dorsalis pedis, axillary

68
Q

indications for CVP monitoring

A

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

69
Q

indications for pulmonary artery cath

A

valvular heart disease, recent MI, ARDS, massive trauma, major vascular surgery, poor LV function (EF < .4, Cl <2 L/min/m2

70
Q

normal RA pressures

A

2-6 mmHg

71
Q

normal RV pressures

A

20-30/0-5 mmHg

72
Q

normal PA pressures

A

20-30/5-15 mmHg

73
Q

normal PCWP pressures

A

4 - 12 mmHg

74
Q

in a 70 kg patient, 1 L crystalloid at room temp will lower body temp by about

A

0.4 degrees C

75
Q

in a 70 kg patient, 1 unit of PRBCs will lower temperature by about

A

0.2 degrees C

76
Q

Mechanisms of heat loss

A

evaporation, radiation, convection, conduction

77
Q

radiation

A

most common

heat radiated from patient into room

78
Q

convection

A

heat loss d/t air velocity

KE to air molecules on skin replaced with cool molecules

79
Q

conduction

A

contact with OR table, blanket

80
Q

evaporation

A

heat loss to dry inspired gases

81
Q

why can’t our body compensate for hypothermia during GA?

A

because our anesthetics inhibit our central thermoregulation by interfering with the hypothalamus function, which normally maintains core body temp

82
Q

How can we prevent phase 1 in unintentional hypothermia?

A

prewarm patients for 30 minutes prior

83
Q

hypothermia

A

heat loss outpaces metabolic heat production
< 36 degrees C
mild: 33 to 36 (reduced enzyme function, coagulopathy)
moderate: < or equal to 32 (fibrillatory threshold)

84
Q

symptoms of hypothermia

A

shivering, dizziness, feeling hungry, nausea, rapid breathing, problems speaking, confusion, coordination difficulties, fatigue, rapid heart rate, drowsiness, weak pulse, shallow breathing

85
Q

patients at greatest risk for hypothermia?

A

elderly, burn patients, neonates, patients with spin cord injuries

86
Q

causes of hyperthermia

A

MH (late sign), endogenous pyrogens, thyrotoxicosis or pheochromocytoma, anticholinergic blockade of sweating, excessive environmental warming

87
Q

monitoring sites for temperature

A

esophagus (lower 1/3), nasopharynx, rectum, bladder, tympanic membrane, blood (PA cath), skin

88
Q

which is the most effective active warming modalities?

A

bair hugger, it decreases radiant and convective losses and decreases postop shivering/pacu stay

89
Q

monitoring sites for PNS

A

ulnar nerve/adductor pollicis, facial, posterior tibial, peroneal nerve

90
Q

ulnar nerve PNS

A

innervates adductor pollicis and adducts thumb

place negative electrode distally (black)

91
Q

facial nerve PNS

A

monitor contraction of orbicularis oculi (eyelid), or corrugator supercilii (furrows brow)

92
Q

posterior tibial PNS

A

behind medial malleolus of tibia and results in plantar flexion

93
Q

peroneal nerve PNS

A

electrodes on lateral aspect of knee

response = dorsiflexion of the foot

94
Q

What do we see with depolarizing blockade in phase 1 block?

A

constant but diminished, no fade

95
Q

patterns of stimulation

A

single twitch, TOF, tetanic stimulation, post-tetanic stimulation, double burst stimulation

96
Q

single twitch

A

single pulse delivered every 10 seconds

increasing block results in diminished response

97
Q

train of four

A

4 repetitive stimuli, twitches progressively fade as relaxation increases
expressed at T4/T1 ratio

98
Q

T4/T1 ratio for train of four

A

loss of 4th twitch = 75% receptors blocked
loss of 3rd twitch = 80% receptors blocked
loss of 2nd twitch = 90% receptors blocked

99
Q

tetanic stimulation

A

tetany at 50-100 Hz
5 seconds at 50 Hz evoked tension approximates tension developed during maximal voluntary effort

in presence of ND relaxants, fade occurs
sustained response occurs when TOF > 70%

100
Q

post tetanic count

A

is useful when all twitches are suppressed
apply tetanus at 50 Hz for 5 seconds, wait 3 seconds, apply single twitches every second up to 20

the number of twitches inversely related to depth of block

101
Q

double burst stimulation

A

less painful, can use this because a ratio of <0.2-0.3 is difficult to detect
3 short 50 Hz impulses followed by 750 msec period of relaxation and then another 3 bursts

102
Q

what would we use for induction in terms of PNS?

A

single twitch, train of four

103
Q

what would we use for PNS during maintenance?

A

train of four, post tetanic count

104
Q

what would we use for PNS during emergence?

A

train of four, double burst stimulation

105
Q

what muscle is the most sensitive to nondepolarizing relaxants?

A

extraocular

106
Q

what muscle group is the least sensitive to nondepolarizing relaxants?

A

vocal cords

107
Q

what muscle group should we monitor PNS during onset?

A

facial nerve

108
Q

what muscle group should we monitor PNS during recovery?

A

ulnar nerve

109
Q

TOF 1 of 4 twitches indicates

A

reversal may take as long as 30 minutes

110
Q

TOF 2-3 of 4 twitches indicates

A

reversal may take 10-12 minutes following long acting relaxants, 4-5 minutes after intermediate relaxants

111
Q

TOF 4 of 4 twitches indicates

A

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

112
Q

limitations of NM monitoring

A

responses may appear normal despite receptor occupancy
wide variability in evoked responses
values do not guarantee adequate ventilatory function or airway protection
perioperative hypothermia increases skin impedance which limits interpretation

113
Q

unreliable clinical signs of recovery

A

sustained eye opening, tongue protrusion, arm lift to opposite shoulder, normal tidal volume, normal or near normal vital capacity, max inspiratory pressure <40-50 cmH20

114
Q

reliable clinical signs of recovery

A

sustained head lift for 5 seconds, sustained leg lift for 5 seconds, sustained handgrip for 5 seconds, max inspiratory pressure 40-50 cm H2O or greater

115
Q

4 types of quantitative assessment nerve monitoring

A

visual, tactile, mechanical, electrical

116
Q

quantitative nerve monitoring

A

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

117
Q

acceleromyography

A

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

118
Q

electromyography

A

muscle action potentials recorded, electrical activity proportional to the force of contraction

119
Q

kinemyography

A

quantifies muscle movement with motion sensor strip containing piezoelectric sensors

120
Q

mechanomyography

A

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

121
Q

phonomyography

A

muscle contraction produces low frequency sounds, calculates muscle response

122
Q

bispectral index score

A

used to assess depth of anesthesia

advantages: reduced risk of awareness, better management of responses to surgical stimulation, faster wake up, more cost effective use of anesthetics

123
Q

EEG signal index range

A

0-100

100 = awake CNS
>70 = greater recall risk
40-60 = general anesthesia
0 = isoelectric EEG
124
Q

What are BIS readings affected by?

A

electrocautery, EMG, pacer spikes, EKG signal, patient movement

125
Q

if SQI is ____ and EMG is ____ then BIS is ____

A

increased; decreased; likely more accurate

126
Q

cerebral oximetry

A

assesses cerebral oxygen saturation using near infrared spectrophotometry
detects decreases in CBF in relation to CMRO2

127
Q

conditions that can decrease cerebral oximetry reading

A

change in BP, partial pressure CO2 in arterial blood, regional blood volume, hemoglobin concentration

128
Q

if >20% reduction in cerebral oximeter reading …

A

regional and global ischemia

129
Q

goal of cerebral oximetry

A

keep within 75% of our baseline reading

Basic Principles of Anesthesia - CP (7 decks)

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