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cardiac constable reading > chapter 3 monitoring > Flashcards

chapter 3 monitoring Flashcards

1
Q

What are indications for EKG in anesthetized patient (4)

A

1)diagnosis of dysrhythmias, 2)diagnosis of ischemia 3)diagnosis of conduction defects 4)diagnosis of electrolyte distrubances

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2
Q

What are best leads for determining an inferior MI

A

II, III, AVF

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3
Q

What are best leads for determining lateral MI

A

I, AVL

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4
Q

Which lead is preferable for cardiac surgical patients

A

V5-single best lead for diagnosis of myocardial ischemia

best when analyzed with lead II (90% of ischemic episodes)

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5
Q

What are limitations of using 3 lead system vs. 5 electrode system

A

3 lead-right arm, left arm, and left leg

limits areas of monitoring to anterior, lateral, and inferior walls

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6
Q

Advantages of 5 lead system

A

5 lead system is all limbs plus unipolar precordial lead(V5 position, or right precordium to monitor Right wall)
7 different leads can be monitored, all but posterior wall can be monitored for ischemia

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7
Q

name bipolar leads, unipolar leads augmented leads

A

Bipolar I, II, III (monitor + and- electrical potential b/t leads
unipolar augmented AVR, AVL, AVF (one is positive, determine absolute electrical potential between 3 leads)

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8
Q

what is esophageal lead sensitive for

A

with esophageal stethoscope, atrial dysrhythmias, posterior ischemia

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9
Q

what is tracheal ECG leads good for

A

pediatric patients for atrial dysrhythmias

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10
Q

what are epicardial electrodes used for

A

ventricular/atrial wires good for weaning off of CPB before sternal closure, recording of atrial or ventricular epicardial EKG, post operatively to diagnosis conduction issues/dysrhythmias

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11
Q

risks associated with ECG

A

minimal-microshock

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12
Q

Will non invasive blood pressure work during CPB?

A

no, must use invasive mechanisms, as pulsatile blood flow is absent in these patients

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13
Q

what are components of invasive BP monitoring

A

intravascular catheter, fluid filled tubing, transducer, electronic analyzer/display system

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14
Q

critically dampened art line, under dampened, over dampened art line correlate to what type of heart rates

A

critically dampened HR >150, under dampened, low HR and overestimation od systolic and underestimation of diastolic, and over dampened underestimate of systolic and overestimate of diastolic

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15
Q

describe most transducer systems in anesthesia

A

under dampened systems with low natural frequency

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16
Q

what effect does air have on invasive BP monitoring

A

leads to over dampening of system (underestimate of systolic, overestimate of diastolic

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17
Q

describe catheter whip

A

noticeable pressure swing in PA or LV catheters

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18
Q

describe radial arterial pressure in relation to aortic pressure

A

radial arterial pressure 20 to 50 mmHG higher than aortic pressure due to decreased peripheral arterial elastane and wave summation

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19
Q

aortic wave form vs. femoral vs.dorsals pedis waveform

A

aortic rounded, definite dicrotic notch
femoral-delay in pulse transmission (higher systolic pressure) and slurring
dorsals-loss of dicrotic notch, second wave due to arterial arteriolar impedance mismatch

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20
Q

where is reference position for transducer in hemodynamic monitoring

A

at the right atrium

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21
Q

what are indications for arterial pressure monitoring in cardiac patient

A

1)small changes in arterial perfusion pressure increase patient risk requiring beat to beat assessment 2)wide variation in BP or intravascular volume is anticipated, 3)frequent blood sampling, 4) assessment of BP can not be performed by other methods (CBP no pulsatile flow) dysrhythmia, or marked obesity)

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22
Q

what are advantages of using femoral artery for invasive BP

A

1)assessment of central venous pressure 2) access for intra aortic balloon pump
if difficult weaning from CPB is expected (depressed EF, severe wall motion abnormalities, or significant CAD)
*seldinger technique

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23
Q

other areas for arterial BP

A

radial, ulnar, femoral, axillary, brachial, dorsalis pedis, posterior tibial arteries can all be used

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24
Q

describe respiratory variation in waveforms in relation to hypovolemia

A

decrease in arterial systolic pressure with PPV (pulses paradox) with PPV impeding venous return to the heart and will seen in hypovolemia

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25
Q

other arterial artery assessments-contractility, SV, vascular resistance-describe

A

contractility(rate of rise during systole effected by preload, and after load and HR), SV(area under curve from onset of systole to dicrotic notch), vascular resistance(position of dicrotic notch with a notch appearing high on downslope of pressure tracing suggesting high resistance, low resistance causes a dicrotic notch that is low not diastolic portion of the pressure tracing)

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26
Q

what are 5 complications of arterial catheterization

A

ischemia, thrombosis, infection, bleeding and false lowering of radial artery pressure may be significantly lower than aortic pressure at completion of CPB with forearm vasodilation secondary to rewarming leading to AV shunting resulting in steal phenomenon

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27
Q

what does CVP measure

A

RA pressure, affected by circulating blood volume, venous tone, and RV function

28
Q

what can CVP monitor

A

fluid and drug therapy, decision to insert CVP to PA catheter

29
Q

most common place for CVP

A

IJ-contraindicated in carotid artery disease, recent cannulation of IJ vein, thyromegaly or prior neck surgery.

30
Q

what should you be careful of in left IJ insertion

A

be careful of inserting left IJ because of close proximity to thoracic duct and laceration of left brachiocephalic vein or SVC is more common

31
Q

IJ landmarks Central technique

A

SCM Apex triangle formed by lateral clavicular and medial sternal head of SCM aim needle caudally and laterally toward ipsilateral nipple

32
Q

why not use EJ for CVP

A

courses superficially along SCM, joins subclavian close to junction of IJ, more tortuous, presence of valves more diffuclt

33
Q

IJ anterior technique

A

medial border of medial head, 5cm above clavicle direct needle toward ipsilateral nipple

34
Q

name 3 positive waves of CVP, 2 negative waves

A

ACV positive

x y negative descents

35
Q

describe A cannon waves

A

when AV disassociation occurs, RA contraction occurs against a closed tricuspid valve

36
Q

describe V waves

A

tricuspid valve insufficiency with retrograde flow across incompetent valve produces an increase in ra pressure during systole

37
Q

CVP

A

RV filling pressure, can be used to estimate LV filling pressures but are distorted in LV dysfunction, decreased LV compliance(ischemia) valvular disease of mitral valve, or pulmonary HTN

38
Q

when does CVP correlate well with PCWP

A

when patients with CAD have good EF >40 and no regional wall abnormalities but compliance of RV is higher than that of lv because RV is thinner walled in comparison

39
Q

Pulmonary artery pressures

A

RV function, pulmonary vascular resistance, left atrial filling pressure

40
Q

PCWP

A

more direct LA filling pressure

41
Q

A, C, V in correlation with ECG

A

A wave-p wave atrial systole
C wave QRS bulging of blood against tricuspid valve during systole
V wave-after the T wave atrial filling

42
Q

Why is the PA diastolic pressure, La pressure and LVEDP greater than RA pressure and RVEDP?

A

during diastole, pulmonic valve is closed

43
Q

patients with differences in RV and LV function

A

volume status difficult to determine because of disparity bt CVP and PCWP-myocardial ischemia, LV dysfunction, PPV

44
Q

Right ventricular failure findings

A

increase in CVP, decrease in CVP to mean PA gradient, and a low CO

45
Q

Left ventricular failure

A

high PA pressures and wedge pressures in the presence of systemic hypotension and low cardiac output

46
Q

tricuspid valve stenosis

A

CVP to RV end diastolic pressure gradient

47
Q

pulmonic valve stenosis

A

rv to pa systolic pressure gradient and CVP waveform morphology

48
Q

mitral valve insufficiency

A

pa and wedge pressure morphology
mitral insufficiency= abnormal v waves and increase in pulmonary venous pressure from regurgitant flow-myocardial ischemia, ventricular pacing, and presence of VSD

49
Q

PA cath with ischemia

A

decrease in ventricular compliance, either an increase in PA pressure or an increase in PCWP, and pathologic V waves from injury to papillary muscles

50
Q

PEEP >10

A

effects PA valves

51
Q

Mixed Venous O2 Saturation normal value

A

normal is 75 with a 5 to 10% increase clinically significant

52
Q

4 things that mixed venous O2 sat can tell you

A

1) decrease in CO
2) decrease in HGB concentration
3) decrease in arterial O2 saturation
4) increased O2 extraction

53
Q

preferred site for PA cath

A

right IJ followed by left subclavian

54
Q

Thermodilution technique

for CO

A

room temp saline injected in RA, temperature sensor in PA cath determines change in temp/time with is a value for PV output, which is equal to CO if no shunts are present 3 measurements, most likely within 10% of true CO

55
Q

increase of thermodilution injectatae by 1 degree C will result in

A

3% overestimate of CO

56
Q

limitations to TEE

A

diseases near distal ascending aorta, proximal aortic arch because airway interferes with TEE signal

57
Q

temps below 32, above 41

A

below 32 irritable myocardium, Vtach, v fib

above 41enzyme desaturation and cell damage

58
Q

acute renal failure

A

2 31% of all cases after CPB

59
Q

use of mannitol during CPB

A

hemodialysis, serum HGB rise maintain urine output to avoid damage to renal tubules
and deliberate hemodilution induced with onset of hypothermic CPB allows removal of excess free water

60
Q

best assessment of renal function during CPB

A

urinary catheter

61
Q

serum electrolytes

A

k and Mg usually decline secondary to mannitol and improved person, cardiopelegia contains K, so replace with caution, and ionized ca replacement may worsen neurological ischemia, only replace ca after reprofusion is established after aortic clamp remove;

62
Q

microshock

A

50-100mA, cardiac patients often have indwelling catheters that lead directly to the heart, pace wires, etc. these patients more at risk, and mocroshock cannot occur unless skin resistance is bypassed-vfib common

63
Q

act

A

heparin monitoring activated clotting time greater than 400 adequate

64
Q

TEG

A

thromboelastography-functional info about platelets, clotting factors, and fibrinolytic processes

65
Q

glucose in period cardiac patient

A

treat when greater than 200 measure q 30-60 min

cardiac constable reading (3 decks)

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