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Spring '14 Advanced Health Assessment > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

What is the purpose of hemodynamic monitoring in anesthesia? (list 5)

A
  • assess homoestasis, trends
  • observe for adverse reactions
  • assess therapeutic interventions
  • manage anesthetic depth
  • evaluate equipment function
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2
Q

Which 2 types of anesthesia providers are considered “qualified” anesthesia providers?

A
  • Anesthesiologists
  • CRNAs
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3
Q

The standards for monitoring include monitoring which 4 things?

A
  • oxygenation
  • ventilation
  • circulation
  • temperature
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4
Q

What are some good ways to monitor oxygenation?

A
  • pulse ox
  • ABG
  • Pt. color
  • O2 analyzer on the machine
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5
Q

What are some good ways to asses ventilation?

A
  • end tidal CO2
  • chest rise
  • breath sounds
  • bag moving
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6
Q

What are some good ways to assess circulation?

A
  • color
  • BP
  • EKG
  • pulse
  • heart tones
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7
Q

Does temperature need to monitored continuously in surgery?

A

Yes in the pediatric population. In adults it needs to be readily available

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8
Q

There are 2 populations in which we do not need to adhere to the complete standard of care surrounding monitors in anesthesia, they are?

A
  • laboring OB patients
  • Chronic pain modalities
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9
Q

How often do you document the information from your monitors?

A

Q5min

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10
Q

Monitors to be used to meet the minimal AANA standard are: (list 6)

A
  • EKG (heart rate and rhythm)
  • BP
  • Precordial stethescope
  • Pulse ox
  • O2 analyzer
  • ETCO2
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11
Q

According to the AANA, which 5 monitors have to be visible on a graphic display?

A
  • EKG
  • BP
  • HR
  • Ventilation status
  • O2 sat
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12
Q

Do all alarms need to be audible?

A

Yes, at all times!

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13
Q

Name 4 basic monitoring techniques that don’t require any fancy equipment.

A
  • Inspection
  • Ausculation
  • Palpation
  • Alert and vigilant providers
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14
Q

What are some considerations you should ponder before applying monitoring modalities to your patient? (list 5)

A
  • Indications/ contraindications
  • Risk/ benefit
  • Techniques/ alternatives
  • Complications
  • Cost
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15
Q

What does the esophageal or precordial stethescope give you?

A

Continual assessment of breath sounds and heart tones

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16
Q

In which patients can you use an esophageal stethescope?

A

In intubated patients only

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17
Q

How far down do you place an esophageal stethescope?

A

28-30cm in the esophagus

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18
Q

What is the esophageal stethescope really good at detecting?

A

Very sensitive monitor for bronchospasm and changes in pediatric patients

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19
Q

What is the added benefit of using an esophageal stethescope?

A

It has a thermistor port for continous temperature monitoring

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20
Q

How long should the patient have continuous EKG monitoring in relation to a surgery?

A

It is standard for every patient to have continuous monitoring from the beginning of anesthesia until the patient leaves the anethetizing location

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21
Q

What is the purpose of continous EKG monitoring during anesthesia? (list 5)

A
  • detect arrhythmias
  • monitor heart rate
  • detect ischemia
  • detect electrolyte changes
  • monitor pacemaker placement
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22
Q

The 3 lead EKG has how many electrodes?

A

It has 3, RA, LA, LL

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23
Q

How many views of the heart do you get with a 3 lead EKG?

A

You get 3 views

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24
Q

With a 3 lead EKG, which view of the heart is missing?

A

anterior view

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25
Q

Is the 3 lead EKG adequate for measuring ischemia?

A

No, you need at least a 5 lead to get some anterior view.

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26
Q

With the 5 lead EKG you get the addition of which 2 areas, which gives you a better view of ischemia?

A

LAD and septum

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27
Q

What are the current recommendations for lead number in EKG monitoring for the perioperative period?

A

3 lead is recommended. This is good for rhythm detection, and it is though that any chest lead will help detect ischemia, V3, V4, and V5 are better for this.

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28
Q

How many electodes are used in a 5 lead EKG?

A

There are 5, RA, RL, LA, LL, and a chest lead.

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29
Q

Which leads are viewed in a 5 lead EKG?

A

I, II, II, aVR, aVF, aVL, and a V lead

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30
Q

How many views of the heart do you get with a 5 lead EKG?

A

7 views

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31
Q

Each little block on the EKG strip reflects how many mV of voltage going up and down?

A

0.1 mV of elevation or depression

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32
Q

What is the 1500 method of calcuating HR?

A

count the little boxes from R to R and divide that number into 1500

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33
Q

If a patient is in a first degree HB, do you care?

A

They are usually stable but you should check their BP and oxygenation

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34
Q

When a patient is in ST, should you treat it with a beta blocker?

A

ST is the most overtreated rhythm in the OR, you should look for the underlying cause of the ST and treat that.

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35
Q

Why should you not change the gain on your EKG monitor in the OR?

A

Changing the gain will alter the ST segment monitoring

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36
Q

When gain is set to standardizaton, how many mm calibration pulse is produced by a 1mV signal?

A

10mm calibration pulse

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37
Q

So in order for a 1mm ST segment change to be monitored accurately, gain should be set at:

A

standardization

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38
Q

Filtering capacity on the EKG monitor should be set at:

A

diagnostic mode

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39
Q

Why should filtering be set at diagnostic mode?

A

because filtering out the end of the bandwidth can distort the ST segment

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40
Q

What are the 5 principal indicators of ischemia on EKG?

A
  • ST segment elevation >1mm
  • T wave inversion
  • Development of Q waves
  • ST segment depression, flat or downslope of > 1mm
  • Peaked T waves
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41
Q

The peak pressure generated by the heart is the:

A

Systolic BP, generated during systolic ventricular contraction

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42
Q

SBP correlates with the time when there is the most:

A

O2 demand on the heart

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43
Q

Changes in SBP correlate with?

A

changes in myocardial O2 requirements

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44
Q

The trough pressure of the heart is the :

A

diastolic BP. it occurs during diastolic ventricular relaxation

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45
Q

Changes in DBP reflect:

A

coronary perfusion pressure

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46
Q

How do you calculate pulse pressure?

A

SBP-DBP

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47
Q

What is MAP

A

It is a time weighted average of arterial pressure during a pulse cycle

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48
Q

What is the formula for calculating MAP?

A

SBP + 2(DBP) / 3

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49
Q

As a pulsation moves peripherally, what happens to the waveform?

A
  • Wave reflection distorts the pressure waveform-
  • exaggerated SBP and
  • wider pulse pressure.
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50
Q

Describe the palpation method for measuring BP?

A

Palpating the return of arterial pulse while an occlusive cuff is deflated.

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51
Q

Does the palpation method of BP measurement give an accurate measurement of BP?

A

No. It underestimates systolic pressure and it only mesures SBP, but it is simple and inexpensive

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52
Q

What is the doppler method of measuring BP?

A

It is based on shift in frequency of sound waves that is reflective of RBCs moving through an artery.

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53
Q

Is the doppler method of measuring BP reliable?

A

It only reliably measures SBP

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54
Q

Is the auscultation method of measuring BP reliable?

A

It is unreliable in hypertensive patients, patients are usually lower than the number it projects. This method permits an estimation of SBP and DBP

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55
Q

Describe the oscillometry method of measuring BP?

A

oscillometry senses oscillations/ fluctuations in cuff pressure produced by arterial pulsations while deflating a BP cuff

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56
Q

The first oscillation, when taking oscillometry BP, reflects what?

A

It correlates with SBP

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57
Q

When measuring BP by oscillometry, the maximal/ peak oscillations occur at?

A

MAP

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58
Q

When measuring BP by oscillometry, oscillations cease at:

A

DBP

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59
Q

How do automated BP cuffs work?

A

By oscillometry. they measure changes in oscillatory amplitude electronically and derives MAP, SBP and DBP by using algorithms

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60
Q

How big should the bladder width of a BP cuff be?

A

40% of the circumfrerence of the extremity

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61
Q

How long should the BP cuff bladder be?

A

It should be sufficient to encircle at least 80% of the extremity

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62
Q

How should the BP cuff be applied?

A

Snugly, with bladder centered over the artery, and resdual air removed.

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63
Q

Name 4 things that will give you a falsely high BP.

A
  • cuff too small
  • cuff too loose
  • extremity below the level of the heart
  • arterial stiffness, HTN, PVD
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64
Q

Name 4 things that will give you a falsely low BP.

A
  • cuff too large
  • extremity above the level of the heart
  • poor tissue perfusion
  • too quick deflation
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65
Q

Will improper placement of cuff, dysrhythmias, and tremors/shivering affect BP?

A

It will affect your BP reading and could give you erroneous values.

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66
Q

Name 7 complications that can occur with non invasive BP measurement.

A
  • edema of the extremity
  • petechiae/ bruising
  • ulnar neuropathy
  • interference with IV flow
  • altering timing of IV drug adminstration
  • pain
  • compartment syndrome
67
Q

How does invasive arterial BP monitoring work?

A

involves percutaneous insertion of catheter into an artery, which is then transduced to convert the generated pressure into a electrical signal to provide a waveform.

68
Q

Name 3 benefits to invasive BP monitoring.

A
  • generates real time beat to beat BP
  • allows access for arterial blood samples
  • measurement of CO/ CI/ and SVR
69
Q

Name 8 indications for using invasive BP monitoring in the OR.

A
  • elective deliberate hypotension
  • wide swings in intra-op BP
  • risk of rapid changes in BP
  • rapid fluid shifts
  • titration of vasoactive drugs
  • end organ disease
  • repeated blood sampling
  • failure of indirect BP measurement
70
Q

What size catheter should be used in an aline?

A

small, even a 20ga angiocath would suffice

71
Q

Name 6 possible sites that you could use for an aline.

A
  • radial
  • ulnar
  • brachial
  • femoral
  • dorsalis pedis
  • axillary
72
Q

What is the most common site for aline placement?

A

radial artery

73
Q

Before using the radial artery, you must peform what test?

A

Allen’s test

74
Q

Describe the transducer system on an aline.

A

It has a continuous flush device, it gives 1-3mL/hr of NS to prevent thrombus formation, it allows for rapid flushing

75
Q

How would your improve the system dynamics and accuracy of an aline transducer system?

A
  • minimize tube length
  • limit stopcocks
  • no air bubbles
  • the mass of fluid should be small
  • use noncompliant stiff tubing
  • calibrate at the level of the heart
76
Q

Aline accuracy depends on what 2 things?

A
  • correct calibration
  • zeroing
77
Q

Where should the aline transducer be leveled?

A
  • at the midaxillary line in supine patients, level with the right atrium
  • Level of the ear (circle of Willis) in sitting patients
78
Q

Name 2 problems that can happen with aline waveforms.

A
  • dampening
  • overshooting
79
Q

The rate of upstroke on the aline waveform is indicative of?

A

contractility

80
Q

The rate of downstroke on the aline waveform is indicative of?

A

SVR

81
Q

You will get exaggerated variations in size of aline waveforms with what 2 conditons?

A
  • naturally with respirations
  • and in hypovolemia
82
Q

The area under the aline curve is reflective of?

A

MAP

83
Q

The dicrotic notch signals that what has occured?

A

aortic valve has closed

84
Q

Describe the 6 phases of the aline waveform.

A
  1. Systolic upstroke
  2. Systolic peak pressure
  3. Systolic decline
  4. Dicrotic notch (aortic valve closure)
  5. diastolic runoff
  6. end diastolic pressure
85
Q

What is distal pulse amplification?

A

it is the changes that occur to arterial BP waveforms as they travel through the arterial tree to the periphery.

86
Q

What happens to the SBP peak as the waveform moves toward the periphery.

A

SBP peak increases

87
Q

What happens to the DBP wave as it moves toward the periphery?

A

The DBP wave decreases

88
Q

What happens to the MAP wave as it moves toward the periphery

A

MAP waves are unchanged

89
Q

What happens to the dicrotic notch as waves move toward the periphery?

A

it becomes less and appears later

90
Q

Where is this waveform likely from?

A

the aorta

91
Q

Where is this waveform likely from?

A

Brachial artery

92
Q

Where is this waveform likely from?

A

Radial artery

93
Q

Where is this waveform likely from?

A

Femoral artery

94
Q

Where is this waveform likely from?

A

Dorsalis Pedis

95
Q

Name the likely locations where these waveforms occur.

A
96
Q

Name 10 complications that can occur with alines.

A
  • nerve damage
  • hemmorhage/ hematoma
  • infection
  • thrombosis
  • air embolus
  • skin necrosis
  • loss of digits
  • vasospasm
  • arterial aneurysm
  • retaines guidewire
97
Q

What is the typical size of a central venous catheter?

A

7 french

98
Q

Name 5 indications for placing central venous catheters.

A
  • measuring right heart filling pressures
  • assess fluid status/ blood volume
  • rapid adminstration of fluids
  • administration of vasoactive drugs
  • removal of air emboli
  • insertion of transvenous pacing leads
  • vascular access
  • sample central venous blood
  • pulmonary artery catheters/ pressure measurement
99
Q

Name 5 common insertion sites for cental venous catheters.

A
  • right IJ
  • left IJ
  • subclavian veins
  • EJs
  • femoral veins
100
Q

What french central venous catheter would you use in a child?

A

4 or 5 french

101
Q

how long is the typical central venous catheter?

A

20cm

102
Q

How do you confirm central line placement in the OR?

A

No x-ray of lines in OR. Aspirate blood from all ports. Get an x-ray after surgery.

103
Q

Where would ideally want the tip of the central line to be, as viewed on x-ray?

A
  • withing the SVC
  • just above the junction of the venae cava and the RA
  • parallel to the vessel walls
  • positioned below the inferior border of the clavicle
  • above the level of the 3rd rib
  • above the T4/T5 interspace
  • above the carina
  • above the takeoff of the right main bronchus
104
Q

Name 2 contraindications to placing a cental venous catheter.

A
  • Right atrial tumor
  • Infection at the insertion site
105
Q

Name 9 risks to placing a central line (most are due to poor technique)

A
  • air or thromboembolism
  • dysrhythmia
  • hematoma
  • carotid puncture
  • pneumo/hemothorax
  • vascular damage
  • cardiac tamponade
  • infection
  • guidewire embolism
106
Q

What is the most commonly recorded risk that occurs in central line placement?

A

carotid puncture

107
Q

What causes the waveforms in central venous monitoring?

A

The ebbs and flows of blood in the right atrium

108
Q

What does CVP also show?

A

CVP is the same as the right atrial pressure (RAP) and RV preload

109
Q

What is the normal value for a mean CVP in a spontaneously breathing patient?

A

1-7 mmHg

110
Q

How does CVP change in a mechanically ventilated patient?

A

It increases 3-5 mmHg

111
Q

the peak of the ‘a’ wave coincides with ?

A

the point of maximal filling of the right ventricle.

112
Q

So, the ‘a’ wave measurement should be read as?

A

RVEDP

113
Q

If you are looking for an accurate RVEDP, why do want to measure it right at the ‘a’ wave.

A

Because the machine just averages pressures, the actual RVEDP is at the peak of the ‘a’ wave.

114
Q

When should you measure RVEDP?

A

at end expiration

115
Q

How many phasic events occur in the CVP waveform?

A

5

116
Q

How many peaks and how many descents?

A

3 peaks, 2 descents

117
Q

What is happening that causes the ‘a’ wave?

A

The a wave occurs due to contraction of the right atrium, which results in increased pressure in the atrium (since there is no pressure difference between the vena cava and the right atrial pressure)

118
Q

When comparing the ‘a’ wave (atrial contraction) where which part of the EKG would it compare to?

A

It would occur right after the P wave.

119
Q

The ‘a’ wave coincides with the end of ventricular diastole and is commonly known as:

A

the atrial kick, which causes the completed filling of the r. ventricle.

120
Q

What does the ‘c’ wave on the CVP waveform indicate?

A

Due to the closure of the tricuspid valve and isovolumetric contraction, this results in the tricuspid valve bulging back into the atrium.

121
Q

Why is the ‘c’ wave a little smaller than the ‘a’ wave?

A

There is now some atrial relaxation and a decrease in atrial pressure after it has pumped out its blood into the right ventricle.

122
Q

Is part of the heart contracting during the ‘c’ wave?

A

Yes, the right ventricle is contracting and causing the tricuspid valve to bulge back a little bit.

123
Q

Where does the ‘c’ wave occur when compared to the EKG?

A

right after the upstroke of the QRS, during early systole.

124
Q

What is happening during the ‘x’ descent of the cvp waveform?

A

atrial pressure continues to decline during ventricular contraction due to atrial relaxation.

125
Q

The ‘x’ wave has also been referred to as:

A

systolic collapse in atrial pressure. It is lowest at midsystole, it is a midsystolic event.

126
Q

What does the ‘v’ wave in the CVP waveform show?

A

It reflects venous return against a closed tricuspid valve (which encompasses a portion of RV systole)

127
Q

The ‘v’ wave is the last atrial pressure increase and is caused by:

A

filling of the atrium with blood from the vena cava.

128
Q

Does the v wave occur after systole?

A

No, it occurs in late systole while the tricuspid valve is still closed

129
Q

where does the v wave occur when compared to the EKG?

A

It occurs just after the T wave

130
Q

What is happening during the ‘y’ descent of the CVP waveform?

A

after ventricular relaxation, the tricuspid valve opens due to the venous pressure, and blood flows from the atrium into the ventricle.

131
Q

What is happening to atrial pressure during the ‘y’ descent?

A

It is falling, following the opening of the tricuspid valve.

132
Q

The y descent is also known as:

A

diastolic collapse in atrial pressure

133
Q

R. sided heart cath (PA cath) monitoring is used for direct bedside assessment of which 6 things?

A
  • intracardiac pressure (CVP, PAP, PCWP)
  • estimate LV filling pressures
  • assess LV function
  • CO
  • Mixed venous O2 saturation
  • PVR and SVR
134
Q

Using a PA catheter, in addition to giving you pressure readings, also gives you the option of:

A

pacing

135
Q

What size are the typical PA caths?

A

7 or 9 french

136
Q

How long is a PA cath?

A

110cm, marked off in 10cm increments

137
Q

How many lumens are there on a PA cath?

A

4 lumens.

138
Q

Describe what the 4 lumen are for in the PA cath?

A
  • distal port for PAP
  • proximal port for CVP (usually 30cm more proximal than PAP)
  • Third lumen for balloon
  • Fourth lumen for thermistor
139
Q

Name 8 indications for which you may want use a PA cath during the procedure?

A
  • LV dysfunction
  • Valvular disease
  • Pulmonary HTN
  • CAD
  • ARDS/ Resp. failure
  • Shock/ sepsis
  • ARF
  • Surgical procedures: cardiac, aortic, OB
140
Q

Name 10 possible complications of PA catheters.

A
  • Arrhythmias (vfib, RBBB, complete HB)
  • catheter knotting
  • balloon rupture
  • thromboembolism/ air embolism
  • pneumothorax
  • pulmonary infarct
  • PA rupture
  • Infection (endocarditis)
  • damage to cardiac structures (valves)
  • relative contraindications (WPW syndrome and complete HB)
141
Q

Where would you expect to see this waveform in your PA cath waves?

A

R. atrium. this is a CVP waveform

142
Q

Where would you expect to see this waveform in your PA cath?

A

in the RV. you will only see this on insertion.

143
Q

Where would you expect to see this waveform in your PA cath?

A

PA

144
Q

What is this waveform reflective of, in your PA waveforms?

A

Wedge

145
Q

What is the typical distance from the RIJ to the Vena cava/ RA junction?

A

15cm

146
Q

What is the typical distance from the RIJ to the R. atrium?

A

15-25 cm

147
Q

What is the typical distance from the RIJ to the RV?

A

25-35 cm

148
Q

What is the distance from the RIJ to the PA?

A

35-45 cm

149
Q

What is the typical distance from RIJ to wedge in the PA?

A

40-50cm

150
Q

Look at these PA waveforms.

A

That is all.

151
Q

What does the ‘a’ wave represent on the PCWP waveform?

A

It represents contraction of the left atrium.

152
Q

The ‘a’ wave of the PCWP waveform is normally a small deflection, if it is enlarged, what does that indicate?

A

There is resistance in moving blood into the left ventricle as in mitral stenosis

153
Q

What causes the ‘c’ wave in the PWCP waveform?

A

The c wave is due to a rapid rise in left ventricular pressure in early systole, causing the mitral valve to bulge backwards into the left atrium, so that the atrial pressure increases momentarily.

154
Q

What causes the ‘v’ wave on the PWCP waveform?

A

It is produced when blood enters the left atrium during late systole.

155
Q

What would a prominent ‘v’ wave mean?

A

mitral insufficiency, causing large amounts of blood to reflux into the left atrium during systole.

156
Q

Look at the wedge compared to the CVP.

A

That is all.

157
Q

Name 5 possible ways to measure cardiac output.

A
  • Thermodilution
  • Continuous thermodilution
  • Mixed venous oximetry
  • Ultrasound
  • Pulse contour (flowtrac)
158
Q

What could cause a loss of the ‘a’ wave in both CVP and PAOP (pulmonary artery occlusive pressure)? (list 2)

A
  • a fib
  • v pacing
159
Q

What could cause giant ‘a’ waves, cannon ‘a’ waves on the CVP, PAOP waveforms? (list 6 )

A
  • junctional rhythms
  • complete HB
  • Mitral stenosis
  • diastolic dysfunction
  • myocardial ischemia
  • vent. hypertrophy
160
Q

What would cause large ‘v’ waves on the CVP or PAOP waveforms? (list 2)

A
  • mitral regurg
  • acute increase in intravascular volume
161
Q

The TEE evaluates which 7 cardiac parameters?

A
  • Ventricular wall characteristics and motion
  • Valve structure and function
  • Estimation of end diastolic and end systolic pressures and volumes (EF)
  • CO
  • Blood flow characteristics
  • Intracardiac air
  • Intracardiac masses
162
Q

Name 6 cases in which you would want to use TEE.

A
  • unusual causes of hypotension
  • pericardial tamponade
  • pulmonary embolism
  • aortic dissection
  • myocardial ischemia
  • valvular dysfunction
163
Q

List 4 complications of TEE.

A
  • Esophageal trauma
  • Dysrhythmias
  • Hoarseness
  • Dysphagia
164
Q

Most of the complications of TEE occur in awake or asleep patients?

A

awake patients

Spring '14 Advanced Health Assessment (5 decks)

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