Cardiac Monitoring

Question 1

Every monitor we use really mointors cellular metabolism at the cellular level so that we can respond quickly so the patient can have a ____ _______

Answer 1

full recovery

Question 2

Continuous or repeated observation + vigilance in order to maintain homeostasis

Answer 2

definition of monitoring

Question 3

What are the ASA standards for delivery of an anesthetic

Answer 3

qualified personnel (CRNA, AA, MDA), oxygenation (Sa02, Fi02), Ventilation (ETC02, stethescope, disconnect alarm), Circulation (BP, pulse, ECG)

Question 4

Other monitors

Answer 4

temp, peak airway pressure (PAW), Vt, ABG

Question 5

Arterial line indications

Answer 5

beat-to-beat monitoring, frequent blood sampling, circulatory therapies (IABP, bypass, vasoactive drugs, deliberate hypotension), failure of indirect BP (due to burns or morbid obesity)

Question 6

Complications of radial artery cannulation are uncommon except in

Answer 6

vasospasmotic disease, prolonged shock, high dose vasopressors, prolonged cannulation

Question 7

The radial artery is ______ in true anatomical position

Answer 7

lateral

Question 8

The more proximal you go with an arterial catheter placement, the higher chance of _______

Answer 8

thrombosis

Question 9

When placing a brachial arterial line you have to use a _________ catheter to traverse the elbow joint, postoperative the arm needs to be kept ________, and ________ circulation is not as good as in hand

Answer 9

longer / extended / collateral

Question 10

When placing a femoral arterial line you should puncture the femoral artery below the ______ ______ because it’s easier to ________ if required

Answer 10

inguinal ligament / compress

Question 11

The difference in maximal and minimal values of systolic BP during postive pressure ventilation

Answer 11

systolic pressure variation

Question 12

SPV > ____ mmHg or change down > ____mmHg is highly predictive of HYPOVOLEMIA. Is this an early or late sign?

Answer 12

15 / 15 / Early

Question 13

Central venous line indications

Answer 13

CVP monitoring, advanced CV disease + major operation, secure vascular access for drugs (TLC), secure access for fluids (inroducer sheath), aspiration of entrained air for sitting craniotomies, inadequate peripheral IV access, pacer, Swan-Ganz

Question 14

The IJ vein lies in groove between the _______ and ______ _______ of the sternocledomastoid muscle

Answer 14

sternal / clavicular heads

Question 15

The IJ vein is _______ and slightly ______ to the carotid

Answer 15

lateral / anterior

Question 16

Best position for IJ line placement

Answer 16

trendelenburg because it helps dilate the IJ

Question 17

Of note when inserting a IJ central line, if the patient has a LBBB can cause a ________. If any ectopy or change in ECG noted what should you do?

Answer 17

RBBB / pull the wire back

Question 18

In the OR, we place the line, use it and then get a _____

Answer 18

CXR

Question 19

Advantages of RIJ

Answer 19

consistent and predictable anatomic location, readily identifiable landmarks, short straight course to the SVC, easy intraop access for anesthetist at patient’s head, high success rate (90-99%)

Question 20

Subclavian central line notes

Answer 20

easier to insert vs. IJ if c-spine precautions, better patient comfort than IJ, risk of pneumo is 2%

Question 21

External jugular notes

Answer 21

easy to cannulate if visible and no risk of pneumo, does not put them in adults but does put them in kids if needed

Question 22

Serious complications of double-cannulation of same vein (RIJ)

Answer 22

vein avulsion (shearing), obstruction to head, you wouldn’t put one on each side, catheter entanglement, catheter fracture,

Question 23

CVP monitoring reflects the pressure at junction of ____ _____ OR _____

Answer 23

vena cava / RA

Question 24

CVP is driving force for filling the ____ and ____

Answer 24

RA and RV

Question 25

CVP provides estimate of _____ _____ _____ and ____ preload

Answer 25

intravascular blood volume / RV

Question 26

When considering using a CVP, _____ in CVP monitoring are useful. Must consider the patient and conditions

Answer 26

trends

Question 27

When do you measure CVP

Answer 27

end expiration

Question 28

Where do you zero CVP (I know we all know)

Answer 28

zero and mid-axillary line

Question 29

The PAC allows accurate bedside measurement of important clinical variables including CO, PAP, PCWP, CVP to estimate ____ filling volume and to help guide _____ and _____ drug therapy

Answer 29

LV / fluid / vasoactive

Question 30

PAC discloses pertinent CV data that cannot be accurately predicted from standard ____ and ____

Answer 30

signs and symptoms

Question 31

Basically, a PAC allows surgeons to treat _______ since they're not at the bedside.

Answer 31

remotely

Question 32

Look at the PAC waveforms on slide

Answer 32

26

Question 33

When inserting a PAC and going from RA to RV, you have a slight bump in your ______ pressure

Answer 33

diastolic

Question 34

The ASA task force indications for PAC

Answer 34

High risk patient with severe cariopulmonary dz, intended surgery palces patient at risk because of magnitude or extent of operation, practice setting suitable for PAC monitoring which would require MD familiarity, ICU, nursing competence

Question 35

PAC education project webiste for learning how to use PAC

Answer 35

www.pacep.org

Question 36

Early use of PAC to optimize ______ status

Answer 36

volume

Question 37

FYI

Answer 37

PAC is only a MONITOR. It cannot improve outcome if disease has progressed too far, or if intervention based on PAC is unsuccessful or detrimental

Question 38

PAC complications

Answer 38

most common is arrhythmias, Tranisent RBBB, external pacer if pre-existing LBBB, misinformation, serious complications (knotting, pulmonary infarction, PA rupture, endocarditis, structural heart damage

Question 39

Important feature of PAC is it allows calculation of _____ output and calculation of ____

Answer 39

cardiac / D02

Question 40

CO is _______ proportional to area under curve

Answer 40

inversely. This means when you look at two curves the larger curve would indicate LESS cardiac output

Question 41

If a patient has tricuspid regurgitation, what problems may you see when attempting to obtain CO?

Answer 41

recirculation of thermal signal so the CO would be invalid

Question 42

CO from PAC technical problems and facts

Answer 42

use the average of 3 measurements due to variations in respiration (always do and end expiration), blood clot on thermistor tip can cause innaccurate temp, shunts can be problematic, you must enter the computation constant on the machine which varies with each PAC (check the package insert)

Question 43

Normal mixed venous oximetry

Answer 43

normal Sv02 is 60-75%

Question 44

If 02 sat, V02 and Hg remain constant _____ is indirect indicator of CO

Answer 44

Sv02

Question 45

Sv02 can be measured using oximetric Swan or CVP, or send blood gas from ___

Answer 45

PA

Question 46

He said there will be a question on

Answer 46

Mixed venous oximetry

Question 47

A significant decrease in Sv02 may have several causes including (3)

Answer 47

decrease in perfusion (CO) with a higher 02 extraction ratio, increase in metabolic rate (increased 02 extraction), and decrease in arterial oxygen saturation from a decreased 02 supply

Question 48

Increaed Sv02 (>75%) simply means _________ output or low _______

Answer 48

overabudnant / extraction

Question 49

Increased Sv02 >75% could be from inability to extract 02 from _____ ______ or high cardiac output situations like _____, _______, and L-->R shunts or AV fistulas

Answer 49

carbon monoxide / sepsis, burns

Question 50

V02 =

Answer 50

oxygen extraction

Question 51

Decreased Sv02 <60% can be due to HIGH EXTRACTION states.

Answer 51

Decreased CO: MI, CHF, hypovolemia | Decreased Hg: bleeding and shock | Decreased Sa02: hypoxia, resp distress | Increased V02: fever, agitation, thyrotoxic, shivering

Question 52

_____ _____ ______ of the left ventricular cavity can be used as an index of global systolic function on the TEE + TG SAX view

Answer 52

fractional area change

Question 53

FAC measurement is made at the ___-_______ level by calcuating the cross-sectional area of the ____ during systole and diastole

Answer 53

mid-papillary / LV

Question 54

FAC =

Answer 54

(LVAd-LVAs / LVAd)

Question 55

Normal range for FAC is

Answer 55

35-65%

Question 56

Normal FAC

Answer 56

>50%

Question 57

Hypovolemia for estimated diastolic area (EDA)

Answer 57

< 8 cm^2

Question 58

Normal EDA

Answer 58

8 to 14

Question 59

Dilated EDA

Answer 59

> 14