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N928 Basic Principles of Anesthesia > Anesthesia monitoring > Flashcards

Anesthesia monitoring Flashcards

1
Q

Why do we monitor patients?

A

standard of care
detect any early physiological abnormalities
patient safety
guides titration of therapies and medications

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2
Q

What standard addresses monitoring & alarms?

A

standard 9

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3
Q

What must be documented every 5 minutes at a minimum?

A

patient’s blood pressure, heart rate, and respiration

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4
Q

Standard 9 requires the monitoring of

A

ventilation continuously (oxygenation SpO2/continuous EtCo2)
cardiovascular status continuously
thermoregulation continuously (MH triggers)
monitor and assess patient positioning
monitor NMBs

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5
Q

CRNAs must remain vigilant until

A

care is responsibly transferred to another qualified healthcare provider

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6
Q

Alarms should

A

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

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7
Q

The most important monitor is

A

the vigilant CRNA

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8
Q

When inspecting, we are looking at

A

retractions, color, mucous membranes

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9
Q

When listen/auscultating we are listening to

A

heart & lung sounds, wheezing, and continuous suction intraoperatively

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10
Q

When we are palpating, we are feeling for

A

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

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11
Q

When we are smelling, we are smelling for

A

smoke/burning, volatile anesthetic

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12
Q

Standard 11 is responsible for

A

transfer of care to another responsible qualified healthcare provider

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13
Q

Monitors include

A

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

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14
Q

Oxygenation should be

A

continuously monitored via clinical observation and pulse oximetry

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15
Q

The most important aspect of anesthesia is

A

the airway

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16
Q

The fundamental goal of ventilation monitoring is

A

to avoid hypoxia

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17
Q

Ventilation needs to be continuously monitored via

A

expired carbon dioxide during moderate sedation, deep sedation, or general anesthesia

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18
Q

Oxygenation is evaluated through

A

the oxygen analyzer, pulse oximetry, skin color, color of blood, and ABG (when indicated)

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19
Q

The O2 analyzer measures

A

FiO2 of the inspired gas/inspiration
low concentration alarm <30%
required for any general anesthetic

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20
Q

The O2 analyzer can be used to

A

calculate PAO2 because it gives us PaO2

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21
Q

The oxygen analyzer is a

A

electrochemical sensor
cathode and anode embedded in electrolyte gel
O2 reacts w/ electrodes, generates electrical signal proportional to O2 pressure (mmHg) in sample gas

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22
Q

Pulse oximetry is useful for

A

provides early warning sign of hypoxemia; cyanosis= late sign

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23
Q

Pulse oximetry measures

A

arterial oxygen saturation combining principles of oximetry and plethysmography

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24
Q

Pulse oximetry requires a

A

pulsatile arterial bed

can be assessed at finger, toe, ear lobe, bridge of nose, palm, and foot in children

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25
Q

_____ is responsible for the mechanism of pulse oximetry

A

Beer-Lambert law of spectrophotometry

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26
Q

Pulse oximetry works by

A

absorption of red and infrared light differs in oxygenated and reduced Hgb
HbO2 absorbs more infrared (960 nm)
Reduced Hb absorbs more red (660 nm)
calculates O2 saturation by comparison of absorbances of these wavelengths

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27
Q

Factors that affect the accuracy of pulse oximetry include

A

high intensity light, patient movement, electrocautery, peripheral vasoconstriction, hypothermia, cardiopulmonary bypass (need pulsatile bed), presence of other hemoglobins including carbon monoxide hemoglobin (increased false reading), met hemoglobin (false decrease/increase)

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28
Q

Methylene blue gives the largest

A

decrease in accuracy of the pulse oximeter

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29
Q

With a hemoglobin of <5,

A

the pulse oximeter will not read

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30
Q

The oxyhemoglobin dissociation curve

A

allows us to estimate arterial O2 content

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31
Q

When PaO2 is 30

A

SaO2 is 60

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32
Q

When PaO2 is 60

A

SaO2 is 90

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33
Q

When PaO2 is 40

A

SaO2 is 75

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34
Q

What is ventilation?

A

movement of volume; inhalation/exhalation- minute volume

elimination of CO2

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35
Q

Ventilation monitors include

A

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

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36
Q

The precordial stethoscope is placed at

A

the suprasternal notch or apex of the left lung & it is where heart/lung sounds are audible

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37
Q

The precordial stethoscope allows for

A

early detection of changes in breath or heart sounds & indicates
airway/circuit disconnect, endobronchial intubation, anesthetic depth/increased heart rate, contractility

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38
Q

The esophageal stethoscope is a

A

soft plastic catheter that is placed into intubated patients and allows for better quality heart and breath sounds

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39
Q

The esophageal stethoscope is contraindicated in patients with

A

esophageal varices or strictures

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40
Q

The esophageal stethoscope is placed thorugh

A

mouth or nose into distal 1/3rd of the esophagus

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41
Q

The respiratory gas analysis is

A

the gas sampling line and allows for measurement of volatile anesthetics

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42
Q

The most common respiratory gas analysis is the

A

non-dispersive infrared

side=stream sampling where gas absorbs infrared energy at specific wavelength

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43
Q

Capnography confirms

A

ETT placement and adequate vetilation

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44
Q

The average adult produces ____ mL Co2/min.

A

250

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45
Q

CO2 production changes with

A

patient’s condition, anesthetic depth, and temperature

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46
Q

Limitations of the sidestream sampling include

A

H2O condensation can contaminate the system and falsely increase readings
lag time between sample aspiration and reading

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47
Q

The sidestream sampling works by

A

aspirating airway gas and pumping it to the measuring device

sampling flow rates of 50-250 mL/min.

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48
Q

An end tidal CO2 of 40 mmHg suggests

A

adequate circulation, adequate alveolar ventilation, and adequate PaCO2 production

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49
Q

The normal PACO2-PaCO2 gradient is

A

2-10 mmHg

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50
Q

An abnormal PACO2 to PaCO2 gradient can be from

A

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

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51
Q

Phase 1 of the end tidal CO2 corresponds to

A

inspiration

anatomic/apparatus dead space devoid of CO2 and the levels should be zero unless rebreathing

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52
Q

If there are elevated CO2 baseline levels at phase 1, it is indicative of

A

Bain circuit, expiratory valve is missing/incompetent, and CO2 absorbent is exhausted

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53
Q

Phase 2 of the capnograph corresponds to

A

early exhalation/steep upstroke

mixing of dead space w/ alveolar gas leads to rapid rise

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54
Q

A prolonged upstroke in phase II is indicative of

A

mechanical obstruction (kinked ETT), slow emptying of lungs (COPD, broncospasm)

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55
Q

Phase IV is caused by

A

inspiration of fresh gas and a return to baseline

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56
Q

Phase III of the capnograph is a

A

horizontal line with mild upstroke
CO2 rich alveolar air
steepness is function of expiratory resistance (COPD, bronchospasm)

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57
Q

The mechanical ventilator senses

A

disconnect alarm (low airway pressure), tidal volume (integrated spirometry), and airway pressure (in-circuit pressure gauge, sustained elevated pressure, peak inspiratory pressure)

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58
Q

The electrocardiogram detects

A

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

59
Q

The electrocardiogram is used to

A

display continuous heart rate with audible indicator

60
Q

With the three electrode EKG system,

A

typically monitor lead II

limited in detection of myocardial ischemia

61
Q

With the five electrode EKG system,

A

better in detecting myocardial ischemia, allows better differential diagnosis of atrial and ventricular dysrhythmias, and allows recording of six standard limb leads (I, II, III, aVR, aVL, and aVF) and one precordial lead usually V5

62
Q

Lead V5 is located at

A

the 5th ICS/anterior axillary line and detects anterior and lateral wall ischemia

63
Q

Lead II yields max

A

P wave voltages, superior detection of atrial dysrhythmias, and detects inferior wall ischemia/ST depression

64
Q

With the 5 lead EKG placement,

A

the white lead is located in the 2nd intercostal space on the right (mid-clavicular) and the black lead opposite on the left; the green lead is located in the 8th intercostal space mid clavicular and the red on the left, and the brown is located (V5) to the right of the sternal border in intercostal space 4

65
Q

Leads V3 and V4 are used to detect

A

anterior MI

66
Q

Leads V1 & V2 are used to detect

A

septal MI

67
Q

Leads II, III, and aVF are used to detect

A

inferior MI

68
Q

Leads I, aVL, V5, and V6 are used to detect

A

lateral MI

69
Q

When auscultating the BP we are listening for

A

korotkoff sounds

70
Q

The oscillometric device is

A

a non-invasive form of BP monitoring and the air pump inflates cuff–> microprocessor opens deflation valve–> oscillations are sampled

71
Q

Errors with the oscillometric blood pressure can be caused by

A

surgeon leaning on cuff, inappropriate cuff size (large size–> low reading, small cuff–> high reading), shivering or excessive motion, atherosclerosis and HTN

72
Q

Errors with the oscillometric BP as it relates to atherosclerosis and HTN include

A

systolic low and diastolic BP high compared with invasive arterial pressure

73
Q

The cuff width should be

A

> 20% of the mean arm diameter

74
Q

Indications for invasive arterial BP monitoring include

A

any patient requiring minute to minute BP monitoring, critically ill, anticipated rapid blood loss, major procedures including cardiopulmonary bypass, aortic cross-clamping, intracranial surgery, & carotid sinus manipulation
frequent ABG

75
Q

The radial artery is the

A

most common site for arterial line site selection

76
Q

The ulnar artery for arterial line selection is

A

not often used and is technically more difficult/more tortuous

77
Q

The brachial artery for arterial line selection is

A

predisposed to kinking/location and complications may risk limb

78
Q

The femoral artery for arterial line selection is

A

prone to pseudoaneurysm and atheroma formation

79
Q

The dorsalis pedis for arterial line selection

A

may have distorted waveform

80
Q

The axillary artery for arterial line selection

A

has potential for plexus/nerve damage from hematoma or traumatic cannulation

81
Q

Indications for central venous pressure monitoring include

A

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

82
Q

Site selection of central venous pressure includes

A

internal jugular (right is preferred), subclavian, external jugular, antecubital (special kit w/ long catheter)

83
Q

Potential indications for pulmonary artery catheterization include

A

valvular heart disease, recent MI, ARDs, massive trauma, & major vascular surgery

84
Q

Pulmonary artery catheters can be used to evaluate response to

A

fluid administration, vasopressors, vasodilators, and inotropes

85
Q

Pulmonary artery catheters can indicate poor LV function via

A

EF <0.4 and CI <2L/min/m2

86
Q

Factors that affect temperature include

A

ambient room temperature, scope and length of surgery (open or laprascopic approach), hypothalamic depression, intraoperative fluid replacement (warmed?), vigilance in monitoring core temperature

87
Q

Mechanisms of heat loss include

A

radiation>convection>conduction>evaporation

88
Q

Radiation is

A

heat radiated from the patient to the room

89
Q

Convection is

A

heat loss due to air velocity

90
Q

Conduction is

A

contact with OR table, blanket

91
Q

Evaporation is

A

heat loss to dry inspired gases

92
Q

Unintentional hypothermia occurs in

A

phase 1, most drastic heat loss within 1 hour of start time

93
Q

Symptoms of hypothermia include

A

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

94
Q

Hypothermia is considered to be

A

temperature <36 degrees celcius

95
Q

Mild hypothermia is

A

33-36 degrees Celcius and causes coagulopathy and reduced enzyme function

96
Q

Moderate hypothermia is

A

=32 degrees C and causes fibrillatory threshold

97
Q

Hypothermia can cause

A

delayed awakening, cause increased shivering which increases O2 consumption

98
Q

Patients at greatest risk for hypothermia include

A

elderly, burn patients, neonates, and patients with spinal cord injuries

99
Q

Shivering increases O2 consumption by

A

up to 400%

100
Q

Hypothermia occurs when

A

heat loss outpaces metabolic heat production & anesthesia impairs normal response
body temperature may drop 1 to 4 degrees C

101
Q

Causes of hyperthermia include

A

late sign of malignant hyperthermia, endogenous pyrogens, thyrotoxicosis or pheochromocytoma (increases metabolic rate), anticholinergic blockade of sweating, excessive environmental warming

102
Q

Hyperthermia is

A

rarely occurring under anesthesia

103
Q

Temperature monitoring sites include

A 
esophagus (lower 1/3rd) accurately reflects body temperature 
nasopharynx
rectum
bladder (integrated w/ foley catheter)
tympanic membrane (risk of perforation)
Blood (PA cath)
Skin
104
Q

Active warming modalities include

A

forced air warmer (Bair hugger)- most effective
warming blanket- water circulating- minimally effective
radiant heat unit- no impact on mean body temp
heat liquids (IV bags or bottles on patient)- very dangerous, can cause burns

105
Q

Bair huggers are most effective in

A

decreasing radiant and convective losses and decreasing postoperative shivering and PACU stay

106
Q

Gastric lavage is

A

an active warming modality used to warm body core; impractical intraoperatively

107
Q

Peritoneal irrigation is

A

an active warming modality that encourages use of warm irrigation during intra-abdominal procedures

108
Q

Intravenous fluid warming is

A

an active warming modality that allows for warmed liquid transfer of heat (hotline) to infuse (IVF/blood/etc.)
delivers fluids at the highest temperature of any technology

109
Q

Passive warming modalities include

A

insulation of the extremities and head
heat and moisture exchanger- artificial nose, retains moisture
coaxial breathing circuit (“King” circuit)- warms and humidifies inspiratory gases
ambient temperature- hugely important with greatest effect on maintaining body heat- ambient temp >24 degrees

110
Q

The most influential passive warming modality is

A

ambient temperature

ambient temperature >24 degrees C allows most adults to remain normothermic without requiring other measures

111
Q

How many patients still have residual blockade when arriving in PACU?

A

up to 40%

associated with hypoxemia, pulmonary infiltrates, ventilatory insufficiency

112
Q

The peripheral nerve stimulator

A

monitors effect of neuromuscular blocking agents on NM junction- know and compare to baseline, quantify by feel
delivers electrical stimulation to a peripheral motor nerve
permits titration of drug to optimal effect
quantifies recovery from neuromuscular blockade

113
Q

Monitoring sites for the peripheral nerve stimulator include

A

ulnar nerve/adductor pollicis stimulation, facial, posterior tibial nerve, peroneal nerve
place electrodes over nerves to avoid direct muscle stimulation

114
Q

The ulnar nerve innervates the

A

adductor pollicis muscle & adducts thumbs

common monitoring site with electrodes placed at wrist or elbow- negative placed distally

115
Q

The gold standard for peripheral nerve monitoring is

A

the ulnar nerve

116
Q

The facial nerve is monitored by

A

placing electrode in front of tragus of ear and below

better indicator of ND blockade of diaphragm and airway than peripheral muscles

117
Q

The facial nerve is monitoring the

A

contraction of orbicularis oculi (closes eyelid) or corrugator supercili (furrows brow)

118
Q

When monitoring the posterior tibial nerve,

A

place electrodes behind medial malleolus of tibia

results in plantar flexion

119
Q

The peroneal nerve is monitoring the

A

dorsiflexion of the foot by placing electrodes on lateral aspect of knee

120
Q

Patterns of stimulation include

A

single twitch, train of four, tetanic stimulation, post-tetanic stimulation, and double burst suppression

121
Q

Single twitch is

A 
single pulse (0.1 Hz) delivered every 10 seconds
increasing block results in diminished response
122
Q

The train of four is

A

most commonly employed and includes 4 repetitive stimuli of 2Hz over 4 sec.
twitches progressively fade as relaxation increases

123
Q

Describe the # of twitches as compared to how many receptors are blocked (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
0 twitches= 90-98% of receptors blocked

124
Q

Tetanic stimulation is

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%

125
Q

Double burst stimulation is

A

less painful than tetany
more sensitive than TOF for visual evaluation of fade
3 short 50 Hz impulses followed 750 msec by another 3 bursts

126
Q

Post-tetanic count is

A

useful when all twitches are suppressed
apply tetanus @50 Hz for 5 seconds, wait 3 seconds, apply single twitches every second up to 20
# of twitches inversely related to depth of block

127
Q

With induction, PNS used is

A

single twitch and train of four

128
Q

With maintenance, PNS used is

A

train-of-four

post-tetanic count

129
Q

With emergence, PNS used is

A

train-of-four

double-burst stimulation

130
Q

Least sensitive to most sensitive muscle groups to nondepolarizing muscle relaxants is

A

vocal cord, diaphragm, orbicularis oculi, abdominal rectus, adductor pollicis, masseter, pharyngeal, & extraocular

131
Q

For onset ___ should be monitored and ____ should be monitored for recovery

A

onset: facial nerve; recovery ulnar nerve

132
Q

With train of four, timing of reversal is

A

1 of 4 twitches, reversal may take as long as 30 minutes
2-3 twitches, reversal may take 10-12 minutes following long-acting relaxants, 4-5 minutes after intermediate relaxants
4 of 4, adequate recovery within 5 minutes of neostigmine, within 2-3 minutes of edrophonium

133
Q

Unreliable clinical signs of recovery include

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 cm H2O

134
Q

Most reliable clinical signs of recovery include

A

sustained headlift x 5 seconds, sustained leg lift x 5 seconds, sustained handgrip x 5 seconds, max inspiratory pressure 40-50 cm H2o

135
Q

limitations of NM monitoring include

A

responses may appear normal despite receptor occupancy
wide variability in evoked responses–> some exhibit weakness at TOF ratio of 0.8 to 0.9
values for adequate recovery do not guarantee adequate ventilatory function or airway protection
perioperative hypothermia increases skin impedance, limiting interpretation of evoked responses

136
Q

Quantitative nerve monitoring is a

A

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

137
Q

Quantitative nerve monitoring includes

A 
acceleromyography-muscle acceleration
electromyography-electrical activity proportional to the force of contraction
kinemyography
mechanomyography
phonomyography
138
Q

The bispectral index score is used to

A

assess depth of anesthesia

optional monitor/not currently standard of care

139
Q

The reported advantage of BIS is

A

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

140
Q

BIS readings are affected by

A

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

141
Q

Levels > than _____ are associated with _____ with BIS monitoring

A

70; recall

142
Q

BIS index scores

A 
100= awake CNS
>70= greater recall risk
40-60= general anesthesia
0= isoelectric EEG
143
Q

Cerebral oximetry is used to

A

assess cerebral oxygen saturation using near infrared spectrophotometry

144
Q

Cerebral oximetry detects

A

decreases in CBP in relation to CMRO2

N928 Basic Principles of Anesthesia (16 decks)

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