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Foundations of Anesthesia 1 > Cardiac Clinical Monitorin > Flashcards

Cardiac Clinical Monitorin Flashcards

1
Q

Normal CVP aka MRAP (mean right atrial pressure) range

A

1-10 mmHG

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2
Q

Where should the CVP line sit in the heart

A

At the most distal part of the SVC but not in the RA

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3
Q

Normal RV range

A

15-30 / 0-8 mmhg

25/5 average (quarter over a nickel)

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4
Q

Normal PA range

A

15-30 / 5-15 mmhg

25/10 average (quarter of a dime)

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5
Q

Normal mean PA range

A

10-20mmhg

15 avg

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6
Q

Normal PAOP (wedge) range

A

5-15mmhg

10 avg

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7
Q

Normal LVEDP (left ventricular end-diastolic pressure) range

A

4-12 mmHg

Avg 8 mmHg

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8
Q

CVP port on PAC is used to estimate?

A

RVEDP
right ventricular end diastolic pressure

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9
Q

Distal tip of PAC is used to estimate?

A

RV systolic pressure via the PA systolic reading.

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10
Q

The upstroke of the PA tracing is produced by?

A

The opening of the pulmonic valve and is followed by RV ejection.

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11
Q

The downstroke of the PA waveform, which contains the dicrotic notch, is produced by?

A

Sudden closure of the pulmonic valve leaflets (the beginning of diastole)

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12
Q

Similarities and differences between PAOP and CVP waveform/readings

A

Both have a,c,v waves.
PAOP (5-15) is less likely to see c wave. Waveform as a whole should be at a higher baseline pressure because you are measuring LV pressures.

CVP measurements will be 0-10

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13
Q

PAOP waveform - what do a, c, and v represent

A

a = LA systole
c = closure of mitral valve
v = filling of LA as well as volume displacement of mitral valve closure during LV systole

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14
Q

The a wave on the cvp will correlate with what EKG event

A

a wave will follow the P wave (atrial depolarization, contraction)

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15
Q

The c and v wave on the cvp will correlate with what EKG event

A

the c and v waves occur after the beginning of the ventricular contraction (QRS)

the v wave may not occur until shortly after the T wave

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16
Q

What factors can create giant a waves aka cannon a waves?

A

Junctional rhythms
complete AV block
PVCs
ventricular pacing asynchronous
tricuspid or mitral stenosis
diastolic dysfunction
myocardial ischemia
ventricular hypertrophy

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16
Q

What are 2 factors that can create large v waves?

A

Tricuspid or Mitral Regurg
Acute increase in intravascular volume

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16
Q

What are two factors that can cause a loss of a waves or only v waves?

A

atrial fibrillation
ventricular pacing in the setting of asystole

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17
Q

is the CVP a reliable measurement for fluid volume responsiveness?

A

No. But it still has value to it, just not for evaluating fluid responsiveness.

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18
Q

What are better measures of fluid responsiveness than CVP?

A

Dynamic values such as SVV and PPV
stroke volume variant and pressure volume variation

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19
Q

What change in SVV indicates fluid responsiveness

A

Small volume bolus and assess SVV. If there is less SVV occurs after bolus (ex 17% to 15%) the reduction indicates the patient will respond/require further preload augmentation

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20
Q

What criteria must be met for SVV and PPV measurements to be accurate?

A

Patients must be mechanically vented with at least 7-6mL/kg tidal volume with no spontaneous respiratory effort and patients must be in sinus rhythm.

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21
Q

In mechanically vented patients, the normal SVV? Above what % implies fluid admin should be given?

A

range for normal is 10-13%. Values higher than 12-13% imply patients will respond positively to an increase in preload.

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22
Q

Goal PPV range?

A

10-15%. greater than 12% likely fluid responsive.

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23
Q

Potential causes of elevated CVP

A

RV failure
Tricuspid stenosis or regurg
Cardiac Tamponade
Constrictive pericarditis
volume overload
Pulm HTN
chronic LV failure
catheter whip
catheter coiling

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24
Q

Potential causes of elevated PAP

A

LV failure
Mitral stenosis or regurg
L to R Shunt
ASD or VSD
Volume overload
Pulm HTN
“catheter whip”

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25
Q

Potential causes of elevated POAP

A

LV failure
Mitral stenosis or regurg
Cardiac tamponade
Constrictive pericarditis
volume overload
ischemia

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26
Q

The mean or diastolic PA pressure should always be measured when? Why?

A

At the end of expiration.
this the time when pleural pressures are most closely equal to atmospheric pressure (except when PEEP is being used)

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27
Q

LVEDP should be measured at what point the PAP recording?

A

Lowest most point after dicrotic notch. just before the upstroke of the v wave, or c wave if present

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28
Q

What are some circumstances PADP poorly correlates with PAOP?

A

When Pulm Vasc Resistance (PVR) is elevated (COPD, HPV, PE, ARDS, Hypercarbia)
HR > 130bpm
Severe Mitral or Aortic Regurg
When lung zone III has changed to II or I (hypovolemia or PEEP)

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29
Q

Normal SVRI values

A

1760-2600 dynes

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30
Q

Normal SVR values

A

800-1200 dynes

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31
Q

Normal PVRI values

A

45-225 dynes

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32
Q

Normal PVR values

A

40 -225 dynes

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33
Q

Normal svo2

A

65-77%

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34
Q

Normal ScVo2

A

~70%

35
Q

BP cuff that is too small can produce a ?

A

Falsely elevated BP

36
Q

BP cuff that is too big can produce a ?

A

Falsely low BP

37
Q

Transducer below the level of the heart can produce a?

A

Falsely elevated BP

38
Q

Transducer above the level of the heart can produce a?

A

Falsely low BP

39
Q

Which of the following conditions are associated with large ‘v’ waves on the central venous pressure waveform?

A

tricuspid regurg

40
Q

A condition in which individuals exhibit reduced recognition of auditory alarms when subjected to a high visual workload is known as

A

inattentional deafness

41
Q

The degree of ST elevation or depression on an ECG is measured between the isoelectric line and the

A

J point

42
Q

For optimal positioning in an adult, an esophageal temperature probe sensor should be positioned about ______ cm from the nose.

A

45cm

43
Q

Which of the following corresponds to the opening of the tricuspid valve on a central venous pressure waveform?

A

The y descent represents the opening of the tricuspid valve.

44
Q

Most common and required diagnostic tool

A

ECG

45
Q

what two leads to monitor for accurate ST segments

A

V2 and V3

46
Q

where is the J point

A

end of QRS complex and beginning of ST

47
Q

Incidence of perioperative ischemia in patients with CAD

A

20-80%

48
Q

If the pateints Preop EKG was unremarkable, what leads should you monitor intraop?

A

V3-V5, III and aVF

49
Q

What lead monitors narrow WRS rhythms best

A

Lead II

50
Q

Which leads detects ischemia earliest and most frequently

A

V3 (86%), V4 (79%), V5 (65%)

51
Q

What is the gain setting

A

The amplitude at which the ECG monitor is set

52
Q

SVV or PPV more accurate for predicting fluid responsiveness?

A

PPV with the use of an arterial catheter

53
Q

Normal cardiac INdex

A

2.8-3.6 L/min

54
Q

When might you have tricuspid regurg but not have a large v wave on CVP tracing?

A

When RA has become very compliant (large/expanded) due to long term tricuspid regurg.

55
Q

What does the a wave represent in the CVP tracing?

A

Atrial Contraction - End of Ventricular Diastole. P wave on EKG.

When the ventricle is FULLY relaxed - it can receive the remainder of blood in the RA.

56
Q

The size of the a wave on the CVP tracing is dependent on?

A
  1. The volume of blood moving into the atrium
  2. The compliance of the atrium
57
Q

What does compliance of a heart chamber mean?

A

The ease with which the heart expands when filled with blood—the inverse of stiffness.

High compliance = stretchy
Low compliance = small/stiff

58
Q

The x wave on the CVP tracing represents?

A

Start of atrial diastole. Pressure starts to decrease as RA begins to relax.

59
Q

What does the c wave on the CVP tracing represent?

A

Tricuspid valve CLOSURE. the onset of early ventricular contraction. R wave on QRS complex.

60
Q

What is one condition that may result in the loss of the c wave into the a wave?

A

Tachycardia

61
Q

What does the x1 descent represent in a CVP tracing?

A

Downslope represents mid-ventricular systole. R-S EKG.
The tricuspid valve and septum descend towards the apex of the heart as the ventricle squeezes, creating a bigger volume and less pressure in RA.

62
Q

What does the v wave represent on the CVP tracing?

A

Late ventricular systole. T-wave on EKG.
Blood enters RA, hits the CLOSED TV (which is pushing back due to RV contraction). v wave is measuring the back pressure.

63
Q

When might you see a large v wave on a CVP tracing?

A

Suggestive of tricuspid regurg.

64
Q

What is the amplitude of the v wave dependent on?

A
  1. Compliance of RA
  2. Volume filling the RA
65
Q

What does the y descent on the CVP tracing represent?

A

Open tricuspid valve - volume leaving the RA, filling a relaxing RV, thus a drop in RA pressure.
Diastolic EKG trace - after T-wave before P-wave.

66
Q

Describe the arterial line response to this square wave test

A

Normal. 2 oscillations, quick up and downstroke

67
Q

Describe the arterial line response to this square wave test

A

Under damped. too much energy, More than 2 oscillations

68
Q

Describe the arterial line response to this square wave test

A

Over damped. Not enough energy. No oscillations

69
Q

Stroke volume is calculated as

A

end diastolic volume minus the end systolic volume

70
Q

MAP Calculation

A

MAP = DP + [1/3(SP-DP)] AKA
MAP = DP + [1/3(PP)]

71
Q

MAP Calculation

A

MAP = DP + [1/3(SP-DP)] AKA
MAP = DP + [1/3(PP)]

72
Q

What percent of patients scheduled for noncardiac surgery are at risk for CAD?

A

33%

73
Q

What is happening in this arterial waveform? Why might this happen?

A

overdamped. Air bubbles in tubing, thrombus on catheter, catheter kinking, flexed wrist, loss of dicrotic notch. Underestimation of BP

74
Q

What is happening in this arterial waveform? Why might this happen?

A

underdamped - overestimation of SBP. Decreased arterial compliance.

75
Q

An underdamped arterial transducer system produces ?

A

An artificially high systolic BP - overestimated BP

Underestimated DBP

76
Q

Describe where to place your 5 precordial leads for EKG

A

V1: RSB, 4th ICS
V2: LSB, 4th ICS
V3: Equal distance between V2 and V4
V4: Midclavicular line at 5th ICS
V5: Next to V4 along Anterior Axillary Line
V6: Next to V5 along midaxillary line

77
Q

How would you interpret:
CVP - low
PADP - low
PAOP - low

A

hypovolemia
Or transducer not at phlebostatic axis

78
Q

How would you interpret:
CVP - Normal or High
PADP - High
PAOP - High

A

LV Failure

79
Q

PADP and PAOP correlate poorly when?

A

Pulmonary Vascular Resistance is elevated (COPD, PE, ARDS, Hypercarbia)
HR > 130s
Severe MR or AR
When Pulmonary Zone III has changed to Zone II or I due to hypovolemia or PEEP)

80
Q

How would you interpret:
CVP - High
PADP - Normal or Low
PAOP - Normal or Low

A

RV Failure,
TR or TS

81
Q

How would you interpret:
CVP - High
PADP - High
PAOP - Normal or Low

A

PE

82
Q

How would you interpret:
CVP - High
PADP - High
PAOP - Normal

A

Pulmonary HTN

83
Q

How would you interpret:
CVP - High
PADP - High
PAOP - High

A

Cardiac Tamponade

Transducer not leveled

84
Q

How would you interpret:
CVP - Normal
PADP - Normal or High
PAOP - High

A

LV myocardial Ischemia or MR

85
Q

How would you interpret:
CVP - Low
PADP - High
PAOP - Normal

A

ARDS

86
Q

What things can increase SvO2

A

Left to Right Shunt
Hypothermia
Sepsis
Cyanide Toxicity
Wedged PAC
Increased CO

87
Q

What things can decrease SvO2?

A

Hyperthermia
Shivering
Seizures
Hemorrhage
Decreased CO

Foundations of Anesthesia 1 (29 decks)

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