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Principles of Anesthesia II - Fall 2024 > CV monitoring - Exam 1 > Flashcards

CV monitoring - Exam 1 Flashcards

1
Q

Impulses traveling toward the lead “eyeball” are ________.

A

positive

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2
Q

Impulses traveling away from the lead “eyeball” are ________.

A

negative

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3
Q

How many limb leads do we have?

A

4
* commonly only use 3

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4
Q

Augmented Limb Leads

aVR
pos:
neg:

A
  • pos: right arm
  • neg: b/w LA & RL
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5
Q

Augmented limb leads

aVL
pos:
neg:

A
  • pos: LA
  • neg: RA & LL
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6
Q

Augmented Limb leads

aVF
pos:
neg:

A
  • pos: LL
  • neg: RA & LA
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7
Q

Precordial Leads

V1 placement & view of heart:

A
  • placement: 4th ICS, R sternum
  • view: septal
    should be negative
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8
Q

Precordial Leads

V2 placement and view of heart:

A
  • placement: 4th ICS, L sternum
  • view: septal
    should be negative
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9
Q

Precordial Leads

V3 placement and view of heart:

A
  • placement: b/w V4 and V2
  • view: anterior
    should be even/positive
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10
Q

Precordial Leads

V4 placement & view of the heart:

A
  • placement: 5th ICS, L sternum @ mid clavicular line
  • view: anterior
    should be the most positive lead
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11
Q

Precordial Leads

V5 placement & view of the heart

A
  • placement: 5th ICS, anterior axillary line
  • view: lateral
    should be positive
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12
Q

Precordial leads

V6 placement & view of the heart:

A
  • placement: 5th ICS mid axillary line
  • view: lateral
    should be positive
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13
Q

12-lead EKG

What leads give an inferior view of the heart?

A

II, III, aVF

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14
Q

12-lead EKG

What views give a lateral view of the heart?

A

V5 & V6
I & avL = high lateral

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15
Q

12-lead EKG

What leads give an anterior view of the heart?

A

V3 & V4

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16
Q

12-lead EKG

What views give a septal view of the heart?

A

V1 & V2

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17
Q

12-lead EKG

what does a 12 lead help identify? (4 things)

A
  1. rhythm
  2. conduction delays
  3. infection
  4. damage
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18
Q

12-lead EKG

What EKG change is indicative of heart damage/problem?

A

> 2mm change in contiguous leads!

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19
Q

12-lead EKG

What is the turn signal rule?

A

helps identify BBB
1. find the J point in V1
2. look back into the complex (to the left)
3. positive deflection = RBBB
4. negative deflection = LBBB
5. QRS must be >0.12s

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20
Q

Axis Deviation

What leads do we look @ to determine axis deviations?

A

I, II, III

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21
Q

Axis Deviations

What is a normal axis deviation?

A

0-90 degrees
* I, II, III upright (positive)

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22
Q

Axis Deviation

What is a physiologic L axis deviation?

A
  • 0 - (-40) degrees
  • I: positive
  • II: positive or =
  • III: negative

Cause: hypertrophy (obese and athletic)

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23
Q

Axis Deviation

What is a pathological L Axis deviation?

A
  • (-40) to (-90) degrees
  • I: pos
  • II: negative
  • III: neg
  • anterior hemiblock
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24
Q

Axis Deviation

What is a R axis deviation?

A
  • 90-180 degrees
  • always pathologic in adults
  • I: neg
  • II: pos/=/neg
  • III: pos
  • posterior hemiblock
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25
Q

Axis Deviations

What is an extreme R axis deviation?

A
  • V-tach
  • I: neg
  • II: neg
  • III: neg
  • ventricular in origin
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26
Q

Axis Deviation Chart

A
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27
Q

12-lead EKG

Diagnosis for R atrial hypertrophy

A
  • initial component of “P” larger in V1
  • height > 2.5mm in any limb lead
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28
Q

12-lead EKG

Diagnosis for L atrial hypertrophy

A
  • terminal portion of dipahsic P larger in V1
  • occurs w/ mitral stenosis, systemic HTN
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29
Q

12-lead EKG

Diagnosis for R Ventricular hypertrophy

A
  • more depolarization toward V1
  • QRS in V1 positive, R waves get smaller
  • concentric hypertrophy - more depolarization toward V1
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30
Q

12-lead EKG

Diagnosis/EKG for LV hypertrophy

A
  • large S wave in V1
  • larger R wave in V5
  • depth of V1 and height of V5 = 35mm
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31
Q

12-lead EKG

Diagnosis/EKG in myocardial ischemia

A
  • reduced supply of O2 from coronary arteries
  • inverted, symmetrical T wave
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32
Q

12-lead EKG

myocardial injury

A
  • acute MI
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33
Q

12-lead EKG

Myocardial Infarct (transmural)

A
  • Q indicated necrosis, and makes diagnosis of old infarct
  • > 1mm wide or 1/3 QRS tall & 2 related leads
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34
Q

Pacemakers

What are PM the treatment of choice for?

A
  • disturbances in cardiac impulse conduction (brady or tachy)
  • causes: excessive BB (elderly), SSS
  • also used after cardiac surgery s/a valve replacement/CABG
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35
Q

What are the 3 types of PM?

A
  • transthoracic (permanent)
  • transcutaneous (pads)
  • transvenous (similar to PA cath)
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36
Q

Pacemakers

Ex: pt has high degree block not responding to meds (atropine)
What do we do??

A
  • transcutaneous pacer
  • set HR 60-80
  • slowly increase voltage until electrical capture seen
  • monitor for mechanical capture (heart responding to impulse)
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37
Q

Pacemakers

What are the 2 main parts of the pacemaker?

A
  1. pulse generator: provides electricity through the leads (zoll, external device, implantable device)
  2. electrode leads
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38
Q

Pacemaker definitions

Generator:

A
  • energy source & electrical circuits
  • provides current to go through leads
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39
Q

Pacemaker definitions

Lead:

A
  • insulated wire from generator to electrode
  • insulated: wire comes into contact w/ other things before it gets to place it is supposed to be
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40
Q

Pacemaker definitions

Electrode:

A
  • exposed metal end in contact w/ endocardium or epicardium (epicardial leads)
  • where energy is exposed to the heart
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41
Q

Pacemaker definitions

Unipolar electrodes

A
  • neg. electrode in chamber
  • pos. electrode (grounding)
  • more sensitive to electromagnetic interference (EMI)
  • requires more energy
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42
Q

Pacemaker definitions

Bipolar electrodes:

A
  • both electrodes in chamber being paced (going from point A to point B)
  • more common & uses less energy
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43
Q

Pacemaker definitions

Multipolar leads

A
  • multiple electrodes within 1 lead but multiple chambers
  • ex: biatrial/biventricular electrodes
  • electrode transverses the septum
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44
Q

Pacemaker Codes

What is I?

0:
A:
V:
D:

A

chamber that is paced
* 0: none
* A: atrial
* V: ventricular
* D: dual (A+V)

0 = no pacer, not programmed/active

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45
Q

Pacemaker Codes

What is II?
0:
A:
V:
D:

A

chamber that is sensed: on-demand device (watches what HR is doing and that determines the response)

0: none
A: atrial
V: ventricular
D: dual (A+V)

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46
Q

Pacemaker Codes

What is III?
0:
T:
I:
D:

A

response to sensing
* 0: does nothing different when it senses
* T: triggered - if pt falls outside of set parameters (bradycardic) the PM responds to the low HR
* I: inhibit - if PM senses traditional/spontaneous depolarization it will not activate
* D: dual - does both most common response to sensing

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47
Q

Pacemaker Codes

What is IV?
0:
R:

A

rate modulation – artifact setting
* may mean it is able to adapt
* not common - response to overdrive pacing usually
* 0: none
* R: rate modulation

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48
Q

Pacemaker Codes

What is V?
O:
A:
V:
D:

A

multisite pacing
* biatrial/biventricular or both atrial and ventricular
* O: none
* A: atrium
* V: ventricle
* D: dual (A+V)

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49
Q

Pacemaker Codes

What is inhibition?

A
  • intrinsic activity perceived - chamber is NOT PACED
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50
Q

Pacemaker Codes

What is Triggered?
What is it used for?

A
  • Pacemaker discharges if intrinsic activity is sensed
  • used for testing devices - make pt bradycardic/tachycardic to prove good capture
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51
Q

Pacemaker Codes

What is Rate Modulation?

A
  • artifact setting
  • tailored for pt
  • vibration
  • motion
  • Vm
  • R Ventricular pressure
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52
Q

Pacemaker Codes

What pt population do we see the use of biventricular pacers in?

A
  • horrible cardiomyopathies
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53
Q

PM- EKG examples

Traditional QRS

A
  • both atria/ventricles working
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54
Q

PM Codes - EKG examples

Normal atrial impulse & Ventricles not working

A
  • pacer spike then QRS complex
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55
Q

PM - EKG examples

AV pacer

A
  • atrial spike followed by impulse
  • ventricular spike followed by depolarization
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56
Q

Peri-op Care of PM:

What 2 main things do we need to consider w/ PMs?

A
  1. how can we safely manage the pt?
  2. do we need to change anything?
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57
Q

Peri-op care of PM

Is interrogation needed?

A
  • pre-op: not routinely
  • post-op: maybe to ensure it was not influenced by electrocautery
58
Q

Peri-op Care of PM

What precautions shall be taken w/ the grounding pad for electrocautery?

A
  • do not put pad near PM
  • avoid use of monopolar cautery near device
59
Q

Peri-op care of PM

What happens when you put a magnet on the device?

A
  • turns it into a non-demand mode
  • goes to regular settings (HR 60-80)
  • some newer devices don’t do this!
60
Q

Bi Ventricular pacing

Where are the leads? (3 chamber)

A
  • lead in RA
  • Lead in both ventricles (trans-septal)
61
Q

What is the goal of bi-ventricular pacing?

A
  • increase synchronization b/w ventricles in pts w/ cardiomyopathy = improved CO
    improves RV-LV activation time
    increases EF %
62
Q

What are the 3 main requirements for Bi-V pacing?

A
  1. moderate/severe HF w/ EF (30-35% now 10-20%)
  2. intraventricular conduction delays - resynchronization needed
  3. Hx of cardiomyopathy induced cardiac arrest (young athletes w/ OOH cardiac arrest)
63
Q

What is the typical anesthesia plan for PM placement?

A
  • GETA - always default (pts don’t tolerate)
  • sedation w/ local
64
Q

What are blocks we can do for pacemaker placement?

A
  • periclavicular block
  • cervical plexus block
  • surgeon - local @ site
65
Q

What is the procedure for PM placement?

A
  1. incision below clavicle
  2. create pouch where generator will live
  3. put electrodes into subclavian and run them down to the heart
66
Q

Magnets and PM

What does placing a magnet on a PM do?

A
  • puts it into an asynchronous pacing mode w/ no rate modulation
  • takes it to default rate
  • devices have changed
67
Q

Magnets and PM

If we put a magnet on a PM what do we need to do post-operatively?

A
  • have it interrogated
68
Q

What is the peri-op care of a AICD/BiV?

A
  • optimize pt condition
  • turn filter OFF on cardiac monitor
  • bipolar cautery
  • back-up pacing ability available
  • interrogation post-op
69
Q

What does an implantable cardioverter-defibrillator do?

A
  • can terminate VF or VT
  • measures R-R intervals & if it’s too short = shock delivered
  • can inappropriately shock SVT
70
Q

Pacemakers

What can cause malfunctioning of an AICD?

A
  • old batteries
  • cracked wires
  • pt moves wrong way, HR goes too high
  • irregular rhythms - can’t measure R-R
71
Q

Where is CVP measured?

What is the measurement dependent on?

What is the measurement used to assess?

A
  • junction of vena cava and right atrium
  • d/o blood volume and vascular tone
  • assessment of blood vol. and R heart function
72
Q

Reasons CVP will increase

A
  • pericardial effusion
  • fluid overload
73
Q

Reasons CVP will decrease?

A
  • vol. depleted
74
Q

Normal CVP

A

1-7mmHg in a spont. breathing pt

75
Q

How does PPV alter CVP?

A
  • artificially increases CVP
  • intrathoracic pressure increases & squeezes vessels
76
Q

What are 9 Indications for CVP lines?

A
  1. CVP monitoring
  2. PA cath placement
  3. Transvenous cardiac pacing
  4. Temporary hemodialysis
  5. Drug admin
  6. Rapid transfusion of fluids/blood
  7. Aspiration of air emboli
  8. inadequate peripheral access (PICC, midline)
  9. repeated blood testing
77
Q

CVP waveforms

“a wave”

A
  • represents atrial contraction
  • occurs after the “P wave”
  • atrial depolarization - increased atrial pressure
  • provides atrial kick

easy to see

78
Q

CVP Waveforms

“C wave”

A
  • ending of atrial involvement
  • isovolumetric contraction of ventricle
  • TV closed and ventricle bulges back toward atria
  • indirect eval of what’s happening in RV
  • follows R wave
79
Q

CVP Waveform

“X descent”

A
  • decrease in atrial pressure from “a wave”
  • called systolic collapse
  • RV starts to collapse - decrease in pressure
  • blood fills RA again
  • called X and X1

easy to see

80
Q

CVP Waveform

“V wave”

A
  • venous filling of the atrium
  • during late systole - TV closed
  • peaks just after “T wave”

hard to see

81
Q

CVP Waveforms

“Y descent”

A
  • TV opens - initial blood flow into ventricle
  • diastolic collapse
  • hard to see
82
Q

Abnormal CVP Waveforms

A-fib:

A
  • absence of “a” wave b/c atria aren’t contracting well
  • larger “c” wave - more vol. when it finally contracts
83
Q

Abnormal CVP Waveforms

Tricuspid Regurgitation

A
  • no “x” descent - valve is incompetent blood leaking back into RA & poor filling of RV
  • don’t have consistent filling
84
Q

Abnormal CVP Waveforms

Tricuspid Stenosis

A
  • tall “a” wave b/c of back pressure - inability for RA to effectively contract
  • “Y” descent masked by tall a wave
85
Q

PA catheter

What is the purpose of the balloon?

A
  • used to float catheter down through PA where it can be wedged in place
86
Q

PA Cath

What does the PA cath tell us info about when the balloon is inflated?

A
  • the balloon isolates everything behind it
  • tells us what the left heart is doing
  • TEE may be more effective though!
87
Q

PA Cath

Which lumen monitors the PAP?

A
  • distal lumen
88
Q

PA cath

which lumen monitors the CVP?

A
  • proximal lumen
89
Q

PA cath

What lumen leads to the balloon?

90
Q

PA Cath

what lumen leads to the temperature thermistor?

A
  • 4th lumen - proximal to the balloon
91
Q

What is the preferred insertion site for a PA cath?

92
Q

PA cath

At what point upon insertion is the balloon inflated?

A
  • once you reach the RA
93
Q

PA cath

How long is the cath?

What intervals is it marked in?

A
  • 110cm long
  • marked @ 10cm intervals
  • thin line = 10cm
  • thick line = 50cm
94
Q

PA Cath Depth

What is the depth at the RA?

95
Q

PA cath depth

What is the depth at the RV?

96
Q

PA Cath Depth

What is the depth at the PA?

97
Q

PA Cath Depth

What is the depth when the PA cath is wedged?

98
Q

Complications of PAC

Are dysrhythmias, PVCs, V-tach considered complications?

A
  • no; we know it is going to happen b/c myocytes are irritated
99
Q

Complications of PAC

What are 6 associated complications?

A
  1. transient RBBB/complete heart block
  2. catheter knots (open cardiac procedures)
  3. pulmonary infarct if PA cath inadvertently inflated = tissue not being perfused beyond this
  4. PA rupture (tissue under pressure)
  5. Endocarditis
  6. Valve injury
100
Q

Complications of PAC

What are symptoms of PA rupture?

A
  • hemoptysis - coughing up blood
  • hypotension
101
Q

Complications of PAC

How can we prevent endocarditis and valve injuries?

A
  • remove cath in 1st 12-24 hours post surgery
102
Q

Complications of PAC

What is the treatment for PA rupture?

A
  1. adequate oxygenation (endobronchial intubation w/ SLT or DLT)
  2. PEEP (tamponade bleeding - stops adequate perfusion to heart)
  3. reverse anticoagulation - protamine do not do if on bypass
  4. float baloon into rupture/withdraw catheter
  5. defintive surgical therapy (oversew PA or resection)
103
Q

PA cath

What pressures are monitored w/ the PA cath?

A
  1. Pulm artery pressure (PAP)
  2. Pulm. Artery Wedge Pressure (PAWP)
  3. Left Ventricular End-diastolic Pressure (LVEDP)
104
Q

PA cath

The PAWP provides an indirect measurement of what?

What pressure can be used as an alternative to a wedge pressure?

A
  • LA pressure
  • PAD pressure can be used if you can’t get cath to wedge
  • PAD = more consistent monitoring of “wedge”
105
Q

PA cath

Where should the PAC tip be located?

A
  • zone 3: Pa>Pv>PA
  • arterial pressure > venous pressure > alveolar pressure
  • blood present throughout entire cardiac cycle!
106
Q

PA Cath

What things can lead to a poor estimate of LVEDP?

A
  1. compliance
  2. aortic regurg: artifificially increases #s (blood leaking back into LV during systole)
  3. PEEP: increasing thoracic pressure & pressure on heart
  4. VSD - altered flow
  5. mitral stenosis/regurg

important to know pts valvular status - TEE

107
Q

Abnormal PAC Waveforms

Mitral Regurg:

A
  • Tall “V” wave
  • “C” wave fused w/ “V” wave
  • No “X” descent
  • no sensitivity to severity of MR
108
Q

Abnormal PAC Waveforms

Mitral Stenosis

A
  • slurred, early “y” descent
  • “a” wave may be absent (associated w/ a-fib)
  • cardioversion may be necessary for pts w/ mitral valve replacements
109
Q

Abnormal PAC Waveforms

Acute LV MI

A
  • tall “a” waves d/t non-compliant LV (kid w/ fixed ventricular vol)
  • LV systolic dysfunction = increased LVEDV and LVEDP
  • PAWP increases
110
Q

What did mixed venous oximetry use to be used for?

A
  • monitor of CO and shock states
  • now we use non-invasives/TEE/lactate
111
Q

Mixed Venous Oximetry

Fick Equation Rearranged

A

SvO2 = SaO2 - VO2/Q x 1.34 x Hgb

  • If Hb, arterial sat, and oxygen consumption stay the same = mixed venous sat an indirect indicator of CO

problem: these are all changing

112
Q

CO =

113
Q

CO (L/min)
avg:
range:
formula:

A
  • avg: 5.0
  • range: 4.0-6.5

CO = HR x SV

114
Q

SV (mL)
Avg:
Range:
Formula:

A
  • avg: 75mL
  • range: 60-90mL
    SV = EDV - ESV
115
Q

SVR (dynes/sec/cm5 or cgs)
avg:
range:
formula:

A
  • avg: 1200 dynes/sec/cm5
  • range: 800-1600 dynes/sec/cm5
    SVR = (MAP-CVP/CO(L/min)) x 80
    or SVR = (MAP - RAP/CO(mL/sec)) pru
116
Q

PVR (dynes/sec/cm5)
avg:
range:
formula:

A
  • avg: 80 dynes/sec/cm5
  • range: 40-180 dynes/sec/cm5
    (PVR = MPAP - PAWP/CO) x 80
117
Q

Mixed Venous O2 Sat (SvO2)
avg:
range:
formula:

A
  • avg: 75
  • range: 70-80
    SvO2 = (SaO2 - VO2/Q x 1.34g/dL x Hb)
118
Q

PA cath

How do we perform bolus thermodilution CO measurement?

A
  • inject 10mL of cold fluid
  • change in temp measured downstream
  • 3 avg. attempts
  • CO inversely proportionate to degree of change
119
Q

Bolus thermodilution

results
low CO:
high CO:

A
  • low CO: takes longer to get back to normal temp
  • high CO: gets back to normal temp quicker
120
Q

Bolus Thermodilution:

What 5 things can cause inaccuracies?

A
  1. intracardiac shunts
  2. tricuspid/pulmonic regurg
  3. mishandling of injectate (not done consistently)
  4. fluctuations in body temp
  5. rapid fluid infusion (cold blood)
121
Q

PA Cath

How do continous CO devices work?

A
  • still uses a thermistor
  • releases heat from filament in RV
  • temp change measured @ thermistor
  • updated q 30-60sec - gives avg over 3-6 min
122
Q

PA Cath

Compared to thermodilution, continous CO devices are more ________ & ________. And they are more accurate during ____.

A
  • accurate and precise
  • PPV
123
Q

How do pulse contour devices work?
What 3 things do they measure?

A
  • they use AUC arterial pressure tracings
  • estimate CO, pulse pressure, and SVV
124
Q

What treatment can pulse contour devices guide?

A
  • if hypotension is more likely to respond to fluid or medications (SVV > 10% = fluid)
125
Q

How accurate are pulse contour devices compared to thermodilution when estimating CO?

A
  • +/- 0.5L/min compared to thermodilution
126
Q

What 3 things can cause inaccuracies with pulse contour devices?

A
  • A-fib
  • site of arterial puncture
  • quality of arterial tracing (vasopressors, vasodilators, vascular abnormalities in the artery)
127
Q

Echo

What is m-mode used for?

A
  • narrow beams to measure tissue planes
  • ex: ventricular wall mass
128
Q

Echo

what does the 2-D image provide?

What does doppler allow?

A
  • 2-D: shows real time motion & function
  • doppler: can determine speed and direction of flow
129
Q

Echo

What are potential problems in using a transthoracic issue?

A
  • obesity
  • pt does not tolerate lying flat
130
Q

Echo

When using a TTE - what structures will be at the top of the image?

A
  • anterior structures
  • they are closest to the transducer
131
Q

Echo Windows

Where anatomically is the parasternal view?

132
Q

Echo Windows

Where anatomically is the apical view?

A
  • at the PMI
133
Q

Echo Windows

Where anatomically is the subcostal view?

A
  • just below the xiphoid
134
Q

Echo FOCUS views

What does the parasternal long axis view look at?

A
  • measures LA, LV and Ao Root
  • provides a great overall view
135
Q

Echo FOCUS views

What does the parasternal short axis view assess?

A
  • LV function
  • LV volume assessment
136
Q

Echo FOCUS views

What does the Apical 4 chamber view assess?

A
  • RV & LV size
  • TV and MV function
  • Descending Ao
137
Q

Echo FOCUS views

What does the Subcostal 4 chamber view assess?

A
  • all 4 heart chambers
  • can see fluid around the heart
138
Q

Echo FOCUS views

What is the subcostal IVC view assessing?

A
  • the diameter and collapsibility of the IVC (fluid status)
139
Q

What can an intra-op TEE be used for?

A
  • rescue tool
  • determines valve/volume issues
  • aids in decision making
140
Q

What structures are at the top of the image when doing a TEE?

A
  • posterior structures b/c they are closer to the transducer
141
Q

What are 2 contraindications to TEE?

A
  • esophageal varices
  • laparoscopic banding

Principles of Anesthesia II - Fall 2024 (10 decks)

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