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2-General Anesthesia Exam 2 > Cardiac Monitoring > Flashcards

Cardiac Monitoring Flashcards

1
Q

What should be done if you are unable to place the ECG lead properly? What needs to be documented?

A

When unable to place chest or limb lead optimally due to surgical constraints, document appropriately:

  • Rationale for lead modification
  • Location of adjusted lead
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2
Q

What is a J point?

A

Repolarization

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3
Q

What is sensitivity?

A

The ability of a test to correctly identify those with the disease

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4
Q

What is specificity?

A

The ability of the test to correctly identify those without the disease

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5
Q

What is true about analyzing the ST segment?

A

Elevation or depression assessed relative to the PR interval (isoelectric line).

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6
Q

Where is the ST junction measured?

A
  • ST junction measured from where the QRS complex ends and the ST segment begin
  • Synonymous with the J point
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7
Q

What is the sensitivity and specificity of ST segment analysis?

A
  • Average sensitivity of 74%
  • 73% specificity in detecting myocardial ischemia
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8
Q

Which chest lead have the best ST junction?

A

V2 and V3 chest leads have greatest shift of the ST junction

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9
Q

What are the preferred leads for ST analysis?

A

V3, V4, V5, limb lead III and aVF (in this order)

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10
Q

What is the default for most ECG leads?

A
  • Research from 1988 suggested leads II and V5 were optimal and many still default to this option
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11
Q

More recent literature suggests _______ detects ischemia the earliest and most frequently

A

V3

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12
Q

What is the threshold value for abnormal J-point elevation, for men 40 years or older?

A

should be 0.2 mV (2 mm) in leads V2 and V3 and 0.1 mV (1 mm) in all other leads.

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13
Q

What is the threshold value for abnormal J-point elevation, for men 40 years or younger?

A

the threshold values for abnormal J-point elevation in leads V2 and V3 should be 0.25 mV (2.5 mm).

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14
Q

What is the threshold value for abnormal J-point elevation, for women?

A

the threshold value for abnormal J-point elevation should be 0.15 mV (1.5 mm) in leads V2 and V3 and greater than 0.1 mV (1 mm) in all other leads.

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15
Q

What is the threshold value for abnormal J-point elevation, for men and women in V3R and V4R?

A

the threshold for abnormal J-point elevation in V3R and V4R should be 0.05 mV (0.5 mm), except for males less than 30 years of age, for whom 0.1 mV (1 mm) is more appropriate

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16
Q

What is the threshold value for abnormal J-point elevation, for men and women for V7-V9?

A

the threshold value for abnormal J- point elevation in V7 through V9 should be 0.05 mV (0.5 mm).

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17
Q

What is the threshold value for abnormal J-point depression, for men and women of all ages in V2 and V3?

A

For men and women of all ages, the threshold value for abnormal J-point depression should be −0.05 mV (−0.5 mm) in leads V2 and V3 and −0.1 mV (−1 mm) in all other leads.

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18
Q

What is ocurring with ST segment depression?

A

Imbalance between oxygen supply and demand

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19
Q

What leads are most important in st segment depression analysis?

A
  • Leads V2 and V3 (males and females)
  • -0.5mm (-0.05mV)
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20
Q

What is the measurement for ST segment depression?

A
  • All ECG leads except V2 and V3
  • -1.0mm (-0.1mV)
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21
Q

What is EASI?

A
  • Utilizes a 5 cable ECG lead system to derive a 12 lead ECG
  • Comparable but not equivalent
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22
Q

EASI: Where is the LA lead placed?

A

placed over the manubrium

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23
Q

EASI: Where is the V lead placed?

A

(chest lead) placed over the lower body of the sternum

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24
Q

EASI: Where is the LL lead placed?

A

left midaxillary, horizontal to the chest electrode

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25
Q

EASI: Where is the RA lead placed?

A

right midaxillary, horizontal to the chest electrode

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26
Q

EASI: Where is the RL lead placed?

A

in any convenient location

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27
Q

What is the characteristics of the radial aline cannulation?

A

Preferred site; Allen’s test necessary

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28
Q

What is the characteristics of the ulnar aline cannulation?

A

Allen’s test necessary as this is primary source of hand blood flow

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29
Q

What is the characteristics of the brachial aline cannulation?

A

Insert medial to biceps tendon; median nerve damage possible

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30
Q

What is the characteristics of the axillary aline cannulation?

A

•Insert at junction of pectoralis and deltoid muscles

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31
Q

What is the characteristics of the dorsalis pedis aline cannulation?

A

Collateral circulation is posterior tibial artery; shows systolic pressure readings higher than radial (means likely comparable)

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32
Q

What is the characteristics of the umbilical aline cannulation?

A

Used in critically ill newborns; may require a cutdown; risk of aortic thrombosis

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33
Q

Identify the aortic, brachial artery, radial artery, femoral artery and dorsalis artery waveform.

A
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34
Q

Arterial waveform: what is the anacrotic limb?

A

The anacrotic limb marks the waveform’s inital upstroke, which occurs as blood is rapidly ejected from the ventricle through the open aortic valve into the aorta

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35
Q

Arterial waveform: what is the systolic peak?

A

Arterial pressure then rises sharply, resulting in the systolic peak-the waveform’s highest point.

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36
Q

Arterial waveform: what is the dicrotic limb?

A

as blood continues into the peripheral vessels, arterial pressure falls and the waveform begins a downward trend called the dicrotic limb. Arterial pressure usually keeps falling until pressure in the ventricle is less than pressure in the aortic root

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37
Q

Arterial waveform: what is the dicrotic notch?

A

when ventricular pressure is lower than aortic root pressure, the aortic valve closes. This event appears as a small notch on the waveform’s downside.

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38
Q

Arterial waveform: what is the end diastole?

A

when the aortic valve closes, diastole begins, progressing until aortic root pressure gradually falls to its lowest point. On the waveform, this is known as end diastole

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39
Q

What are the results of a normal allen’s test?

A

Return of color within 6 seconds

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40
Q

What are the results of a slow arch filling allen’s test?

A

Return of color delayed 7 to 15 seconds

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41
Q

What are the results of a incomplete arch allen’s test?

A

Return of color greater than 15 seconds

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42
Q

What are the different techniques of arterial line cannulation?

A
  • Direct arterial puncture
  • Guidewire assisted cannulation (Seldinger technique)
  • Transfixion withdrawl
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43
Q

What is the appropriate sizing for an adult NIBP monitoring?

A

width of the bladder should be roughly 40% the circumference of the arm and length of the bladder should cover about 80% of the circumference of the arm

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44
Q

What is the appropriate sizing for an child NIBP monitoring?

A

cuff should cover approximately 2/3 upper arm or thigh

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45
Q

What is a source of most error for NIBP monitoring?

A

Inappropriate cuff size or too rapid deflation

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46
Q

What can cause a false high on bp cuff?

A

Too narrow

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47
Q

What can cause a false low on bp cuff?

A

Too wide

48
Q

What is true about central lines and PA catheters in general surgery?

A

Rarely use, Less invasive means now available

49
Q

What is needed when placing lines?

A
  • Basic anatomy must be understood when placing lines, e.g. distance from entry to point of measure
50
Q

Wbat should be done if the PA catheter is advanced beyond 10 cm of expected distance?

A

provider should withdraw catheter (with balloon deflated in the case of PA catheter) and reinsert)

51
Q

What occurs in the a part of the RA waveform (CVP)?

A

Contraction of the RA

52
Q

What occurs in the C part of the RA waveform (CVP)?

A

Closure of the tricuspid valve

53
Q

What occurs in the V part of the RA waveform (CVP)?

A

Passive filling of the RA

54
Q

What occurs in the X part of the RA waveform (CVP)?

A

Start of atrial diastole

55
Q

What occurs in the y part of the RA waveform (CVP)?

A

Opening of tricuspid valve

56
Q

Id the components of the RA waveform.

A
57
Q

What are causes of loss of a waves or only v waves? (2)

A
  • Atrial fibrillation
  • Ventricular pacing in the setting of asystole
58
Q

What are causes of cannon A waves? (8)

A
  • Junctional rhythms
  • Complete AV block
  • PVCs
  • Ventricular pacing (asynchronous)
  • Tricuspid or mitral stenosis
  • Diastolic dysfunction
  • Myocardial ischemia
  • Ventricular hypertrophy
59
Q

What are causes of large V waves? (2)

A
  • Tricuspid or mitral regurgitation
  • Acute increase in intravascular volume
60
Q

How many types of pulmonary artery catheters are there?

A

Two:

  • one measures Continuous Cardiac Output & Mixed Venous Oxygenation
  • standard PA catheter
61
Q

What can be used to help determine PA catheter placement?

A

West zones

62
Q

What is West zone 1?

A

PA>Pa>Pv

  • Zone 1
  • No blood flow
63
Q

What is West zone 2?

A

Pa>PA>Pv

  • Zone 2
  • moderate blood flow
64
Q

What is West zone 3?

A

Pa>PV>PA

  • Zone 3
  • Greatest blood flow
65
Q

Which zone is where the PA catheter should be?

A

Zone 3

66
Q

Identify the PA catheter waveform.

A

Slide 76

67
Q

What is mixed venous oxygen saturation (SVO2)?

A

the percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart.

68
Q

What does the mixed venous oxygen saturation (SVO2) reflect?

A

Reflects the amount of oxygen “left over” after the tissues remove what they need

69
Q

Wbat are the three cardiac output analysis devices? (3)

A
  • FloTrac
  • PiCCO
  • LiDCOrapid
70
Q

What do cardiac output anaylsis devices measure?

A
  • Directly measure fluctuations in arterial pressure and the heart rate
  • From this they estimate the beat-to-beat stroke volume
71
Q

What is cardiac output?

A

HR x SV

72
Q

What is flotrac?

A
  • Less invasive than PA catheter – requires arterial line but not central line
  • Insufficient evidence showing decreased mortality with more invasive measures
73
Q

What is clearsight?

A
  • Uses a noninvasive finger blood pressure cuff rather than an arterial line
  • Cuff dynamically inflated/deflated to track brachial artery BP while also assessing the absorption of infrared light
74
Q

What is function of the TEE based on?

A

Uses piezoelectric elements to absorb, reflect or scatter light

75
Q

TEE: How is abnormal wall motion described?

A

Hypokinesia, Akinesia, Dyskinesia

76
Q

Define hypokinesia.

A

Contraction that is less vigorous than normal

77
Q

Define akinesia.

A

Absences of wall motion; May be associated with MI

78
Q

Define dyskinesia.

A
  • Correlates with paradoxical movement (outward motion during systole)
  • Hallmark of MI and ventricular aneurysm
79
Q

RA ECG placement

A

Over the outer right clavicle

80
Q

LA EKG placement

A

Over the outer left clavicle

81
Q

LL EKG placement

A

Near the left ilia crest or midway between the costal margin and left illiac crest, anterior axillary line

82
Q

RL EKG placement

A

any convient location on the body

83
Q

V1 EKG placement

A

4th intercostal space right of the sternal border

84
Q

V2 EKG placement

A

4th intercostal space left of the sternal border

85
Q

V3 EKG placement

A

Equal distance between V2 and V4

86
Q

V4 EKG placement

A

Midclavicular line at 5th intercostal space

87
Q

V5 EKG placement

A

Horizontal to V4 on the anterior axillary line

88
Q

V6 EKG placement

A

Horizontal to V5 on the midaxillary line

89
Q

V7 EKG placement

A

Horizontal to V6 on the posterior axillary line

90
Q

V8 EKG placement

A

Horizontal to V7 below the left scapula

91
Q

V9 EKG placement

A

Horizontal to V8 at the left paravertebral border

92
Q

V3R EKG placement

A

right side of chest wall in mirror image to chest lead V3

93
Q

V4R

A

right side of chest wall in mirror image to chest V4

94
Q

What is the distance from the insertion site of the subclavian to the right atrium?

A

10 cm

95
Q

What is the distance from the insertion site of the right internal jugular vein to the right atrium?

A

15 cm

96
Q

What is the distance from the insertion site of the left internal jugular vein to the right atrium?

A

20 cm

97
Q

What is the distance from the insertion site of the femoral vein to the right atrium?

A

40 cm

98
Q

What is the distance from the insertion site of the right median basilic vein to the right atrium?

A

40 cm

99
Q

What is the distance from the insertion site of the left median basilic vein to the right atrium?

A

50 cm

100
Q

What is the distance of the right internal jugular to the junction venae cave and right atrium?

A

15 cm

101
Q

What is the distance of the right internal jugular to the right atrium?

A

15-25 cm

102
Q

What is the distance of the right internal jugular to the right ventricle?

A

25-35 cm

103
Q

What is the distance of the right internal jugular to the pulmonary artery?

A

35-45 cm

104
Q

What is the distance of the right internal jugular to the pulmonary artery wedge position?

A

40-50 cm

105
Q

What is the absolute value and range of normal MRAP?

A

Absolute: 5 mmHg

Range: 1-10 mmHg

106
Q

What is the absolute value and range of normal RV?

A

Absolute: 25/5

Range: 15-30/0-8

107
Q

What is the absolute value and range of normal PA S/D?

A

A: 25/10 mmHg

Range: 15-30/5-15 mmHg

108
Q

What is the absolute value and range of normal MPAP?

A

A: 15 mmHg

R: 10-20 mmHg

109
Q

What is the absolute value and range of normal PAOP?

A

A: 10 mmHg

R: 5-15 mmHg

110
Q

What is the absolute value and range of normal MLAP?

A

A: 8 mmHg

R: 4-12 mmHg

111
Q

What is the absolute value and range of normal LVEDP?

A

A: 8 mmHg

R: 4-12 mmHg

112
Q

What are causes of High CO and High SvO2?

A

Sepsis, Eccessive blood flow (hypervolemia, excessive vasoactive therapy)

113
Q

What are causes of High CO and Low SvO2?

A

Anemia, hypoxia, high VO2 = inadequate cardiac output???

114
Q

What are causes of low CO and high SvO2?

A

Low VO2 (anesthesia, hypothermia) = adequate cardiac output

115
Q

What are causes of low CO and low SvO2?

A

low output syndrome (hypervolemia, heart failure and pulmonary embolism)

116
Q

What is femoral aline cannulation?

A

•Ideal in low flow states; long catheter optimal; potential for local and retroperitoneal hemorrhage

2-General Anesthesia Exam 2 (11 decks)

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