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Intro to Anesthesia: Part A > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

Purpose of hemodynamic monitoring (5 items)

A
  1. Assess homeostasis, trends
  2. Observe for adverse reactions
  3. Assess therapeutic interventions
  4. Manage anesthetic depth
  5. Evaluate equipment function
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2
Q

How we monitor oxygenation (4 items)

A
  1. Pulse ox
  2. Skin color
  3. ABGs
  4. 02 analyzer on machine
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3
Q

How we monitor ventilation (5 items)

A
  1. End tidal CO2
  2. breath sounds,
  3. flow volume loop,
  4. chest rise,
  5. movement of respiratory bag
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4
Q

How we monitor circulation (7 items)

A
  1. Pulse ox,
  2. capillary refill,
  3. pulses,
  4. a line,
  5. skin color,
  6. BP,
  7. HR, heart sounds
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5
Q

Minimal standard for monitoring (5 items)

A
  1. EKG
  2. BP
  3. Temperature
  4. SaO2
  5. ETCO2
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6
Q

Considerations when choosing monitoring (7 items)

A
  1. Indications
  2. Contraindications
  3. Risks/benefits
  4. Techniques
  5. Alternatives
  6. Complications
  7. Cost
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7
Q

Hemodynamic monitoring tools (6 items)

A
  1. Stethoscope
  2. EKG
  3. BP
  4. CVP
  5. PAP
  6. TEE
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8
Q

Types of stethoscopes:

  1. Precordial
  2. Esophageal
A
  1. Placed on surface of chest to read continuously; placement depends on what structure of the heart you want to hear
  2. Only used with intubated pts; goes down esophagus 28-30cm; sensitive for brochospams, obsturction, changes in HR/rhythm
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9
Q

Purpose of EKG (5 items)

A
  1. Monitor HR
  2. Arrythmia detection
  3. detect ischemia
  4. detect lyte changes
  5. monitor pacemaker function
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10
Q

3 lead EKG:

  1. Electrodes
  2. Leads
  3. Views
A

RA, LA, LL.
Leads I, II, III.
3 views, no anterior. No LAD view

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11
Q

5 lead EKG

  1. Electrodes,
  2. Leads
  3. Views
A

RA, LA, LL, RL, chest lead (ususally V1 or V5).
I, II, III aVR, aVL, aVF, V.
7 views

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12
Q

Best lead for

  1. Arrythmia,
  2. Ischemia
A

II.

V5.

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13
Q

Monitor settings for:

  1. Gain
  2. Filtering Capacity
A
  1. Standardization: 1mv signal produces 10mm calibration pulse; will accurately depict 1mm ST changes
  2. Diagnostic Mode: filters out low ECG bandwith, electrical interference
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14
Q

Indicators of acute ischemia on ECG (5 items)

A
  1. ST elevation >1 mm,
  2. Peak T wave/ inversion,
  3. Pathological Q waves,
  4. ST depression, flat or downslope >1 mm.
  5. Arrhythmias
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15
Q

Where inferior wall ischemia shows, artery

A

II, III, AVF

Supplied by Right Coronary Artery

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16
Q

Where lateral wall ischemia shows, artery

A

I, AVL, V5-V6

Circumflex of Left Coronary Artery

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17
Q

Anterior wall ischemia:

  1. Leads
  2. Artery
A
  1. V3-4

2. Left Coronary Artery

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18
Q

Where anteroseptal ischemia shows, artery

A

V1-V2

Left Anterior Descending

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19
Q

Blood pressure correlations:

  1. SBP
  2. DBP
  3. PP
  4. MAP
A
  1. Peak systolic contraction; changes correlate with myocardial O2 demand
  2. Trough pressure during diastole; changes correlate with coronary perfusion pressure
  3. SBP-DBP; correlates with conraction force; narrows in tamponade, widens in hypovolemia
  4. Correlates with organ perfusion; weighted arterial pressure during cardiac cycle
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20
Q

MAP calculation

A

SBP + 2DBP/3

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21
Q

Proper NIBP:

  1. Width
  2. Length
  3. Placement
  4. Limitations
A
  1. 40% of circumference of extremity
  2. Must encircle at least 80% of extremity
  3. Snugly, bladder centered over artery w/ residual air removed
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22
Q

What creates a falsely high BP (3 items)

A
  1. Cuff too small or loose,
  2. extremity below heart,
  3. arterial stiffness in htn or PVD.
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23
Q

What creates a falsely low bp (4 items)

A
  1. Cuff too big,
  2. above heart,
  3. poor tissue perfusion,
  4. too quick of deflation
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24
Q

Complication of NIBP (6 items)

A
  1. Edema of arm,
  2. bruising,
  3. ulnar neuropathy,
  4. interferes IV flow,
  5. pain,
  6. compartment syndrome
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25
Q

Indications for Arterial Line (7 items)

A
  1. Elective hypotension
  2. Unstable BP
  3. Severe fluid shifts
  4. Titration of vasoactive drugs
  5. End Organ Disease
  6. Frequent ABG sampling
  7. NIBP failure
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26
Q

How to improve A-line accuracy (6 items)

A
  1. Remove air bubbles,
  2. limit tube length,
  3. limit stop cocks,
  4. small mass of fluid,
  5. Use stiff tubing,
  6. calibrate at heart
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27
Q

Where to zero a line when monitoring:

  1. BP
  2. CPP
A
  1. Supine- mid axillary line (RA).

2. Meatus of ear (circle of Willis)

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28
Q

A line Waveform Components (6 items)

A
  1. Systolic upstroke (slope=heart contractility)
  2. Systolic peak pressure
  3. Systolic Decline
  4. Diacrotic notch (aortic valve closure)
  5. Diacrotic runoff
  6. End diastolic pressure

*Area under curve=MAP

29
Q

Distal pulse amplification does what

A

For a line. SBP peak increases, DBP wave decreases, MAP same. Dicrotic notch becomes less and appears later
Due to narrowing and stiffening and vessels

30
Q

Arterial Line Complications (6 items)

A
  1. Hematoma
  2. Nerve Damage
  3. Infection
  4. Thrombosis/embolus
  5. Vasospasm
  6. Retained Guide Wire
31
Q

Indications for CVL (7 items)

A
  1. Measure R heart filling
  2. assess fluid status,
  3. rapid admin fluids,
  4. give vasoactives,
  5. remove air emboli,
  6. insert transcutaneous pacing leads
  7. frequent blood samples
32
Q

CVL:

  1. Size, length
  2. Insertion points
  3. Correct tip positioning
  4. Placement confirmation
A
  1. 7 French (apx 14 gauge), 20 cm length
  2. RIJ (most common), LIJ, Sublavian, external jugular, femoral
  3. Within SVC above junction of SVC and RA; below inferior border of clavicle, above level of 3rd rib, T4 (carina, or RMB)
  4. Blood aspiration from all ports, xray (not done in OR)
33
Q

Contraindications to CVL (3 items)

A
  1. Contralateral pneumo
  2. RA tumor
  3. Infection at site
34
Q

Risks of CVL (8 items)

A
  1. Air or thromboembolism
  2. Dysrhythmias,
  3. Hematoma,
  4. Carotid puncture, vascular damage
  5. Pneumo/hemothorax,
  6. Tamponade,
  7. Infection,
  8. Guidewire embolism
35
Q

Normal RAP/Vented RAP

A

1-7 mmHg in spontaneous breathing; 3-5 mmHg rise w vent

RAP=CVP=RV preload

36
Q

CVP Waveform: A wave

A

Atrial contraction (follows EKG P); atrial kick; End of diastole

37
Q

CVP Waveform: C wave

A

Tricuspid valve bluges into atrium during ventricle contraction; occurs early in systole (after QRS on EKG)

38
Q

CVP Waveform: X descent

A

Systolic collapse in atrial pressure; mid-systolic even

39
Q

CVP Waveform: V wave

A

Filling of the atrium from the VC; occurs late systole while tricuspid closed (after T wave on EKG)

40
Q

CVP Waveform: Y descent

A

Diastolic collapse in atrial pressure; drop in atrial pressure as tricuspid OPENS

41
Q

CVP Wave to Cardiac Cycle:

  1. A Wave
  2. C Wave
  3. X Descent
  4. V Wave
  5. Y Descent
A
  1. End diastole
  2. Early Systole
  3. Mid Systole
  4. Late Systole
  5. Early Diastole
42
Q

Pulmonary Artery Catheter Can Assess… (6 items)

A
  1. Intracardiac pressures (PAP, PCWP)
  2. Estimate LV pressures
  3. Assess LV function
  4. CO
  5. Mixed venous saturation
  6. PVR/SVR
43
Q

PA Catheter:

  1. French
  2. Length
  3. Lumens (4)
A
  1. 7 French (introducer 8.5)
  2. 110 cm, marked at 10cm intervals
  3. Distal (measures PAP), Proximal (Blue, measures CVP), Balloon, Thermistor port (wires, cant inject)
44
Q

Indications for PA monitoring (5 items)

A
  1. LV dysfunction,
  2. valvular disease,
  3. pulm htn,
  4. CAD, ARDS, shock, sepsis, ARF,
  5. cardiac/aortic/OB procedures
45
Q

Complications of PA Catheter (8 items)

A
  1. Arrhythmias (V fib, RBBB, heart block)
  2. PA rupture
  3. Catheter knotting
  4. Balloon rupture
  5. Embolism (air/thrombus)
  6. Pneumothorax
  7. Valve or myocardial damage
  8. Infection
46
Q

Contraindications to PA insertion (2 items)

A

Wpw syndrome, complete LBBB

47
Q

What happens to wave form as PA inserted

A

CVP wave in RA, more turbulent and higher pressure in RV, SBP same and DBP rises in PA, more compact pressure when wedged

48
Q

PA Catheter Cm Length at:

  1. RA junction
  2. RA
  3. RV
  4. PA
  5. PA wedge
A
  1. 15
  2. 15-25
  3. 25-35
  4. 35-45
  5. > 45 (40-50)

*Catheter usually secured at skin between 50-60cm

49
Q

PCWP a wave

A

contraction of the left atrium. small deflection unless there is resistance in moving blood into the left ventricle as mitral stenosis.

50
Q

What c wave is PCWP

A

rapid rise in the left ventricular pressure in early systole, causing the mitral valve to bulge backward into the left atrium, so that the atrialpressure increases momentarily.

51
Q

What v wave is PCWP.

A

Blood enters LA in late systole; high v wave is mitral insufficiency due to blood reflux during systole

52
Q

CO Monitoring Techniques (5 items)

A
  1. Thermodilution
  2. Continuous Thermdilution
  3. Mixed Venous Oximetry
  4. Ultrasound
  5. Pulse Contour
53
Q

What can cause

  1. Loss of A-waves (2 items)
  2. Low A-waves
  3. High A-waves (4 items)
A
  1. Atrial fibrilation, Ventricular Pacing
  2. Hypovolemia
  3. Valve insuficency (regurg/stenosis), heart block, JHR, decreases ventricular compliance
54
Q

Causes of large V-waves

A
  1. Valve insufficiency: tricuspid (CVP) or Mitral (PAOP) regurg/stenosis
  2. Fluid Overload
55
Q

What does a TEE observe (6 items)

A
  1. Ventricular wall motion/traits
  2. Valve structure/function
  3. EF
  4. CO
  5. Blood Flow
  6. Intracardiac air/masses
56
Q

Most common things a TEE is used to detect (7 items)

A
  1. Unexpected causes of hypotension
  2. Myocardial ischemia
  3. PE
  4. Aortic dissections
  5. Tamponade
  6. Valve dysfunction
  7. Air embolism
57
Q

TEE complicaitons (4 items)

A
  1. Esophageal trauama
  2. Dysrhythmias
  3. Dysphagia
  4. Hoarsness
58
Q

Types of NIBP (4 items)

A
  1. Palpation
  2. Doppler
  3. Auscultation
  4. Oscillometry
59
Q

NIBP Palpation:

  1. Technique
  2. Considerations
A
  1. Palpating a pulse while deflating cuff

2. Only measures SBP but usually UNDERestimates; is cheap, simple

60
Q

NIBP Doppler:

  1. Technique
  2. Considerations
A
  1. Use dopler on artery w/ cuff

2. Measures only SBP reliably

61
Q

NIBP Auscultation:

  1. Technique
  2. Considerations
A
  1. Listen for Korotkoff sounds

2. Can estimate SBP and DBP; usually underestimates in HTN patients

62
Q

NIBP Oscillometry:

  1. Technique
  2. Considerations
A
  1. Senses fluctuations in cuff pressure produced by arterial pulsations during deflation:
    1st is SBP
    Max is MAP
    Cease at DBP
  2. Dysrhythmias/, tremors/shivering will give erroneous readings
63
Q

Pulse Oximeter:

  1. Mechanism
  2. Uses
  3. Sites
A
  1. Measures hemoglobin saturation through algorithm to compute absorption of red and infared light in blood; must have VARIABLE PITCH tone when used
  2. Detects hyoxemia, perfusion
  3. Fingers, toes, nose, ear, forehead
64
Q

Common SaO2 Complications (6 items)

A
  1. Electrical interference
  2. Nail polish
  3. CO poisoning; methhemoglobinemia
  4. Dye (methylene blue)
  5. Malpolisitioning
  6. Cold extremity, shivering
65
Q

EKG Lead (Poles and Direction)

  1. I
  2. II
  3. III
  4. aVF
  5. aVL
  6. aVR
A
  1. Positive voltage from RA to LA
  2. Positive voltage from RA to LL
  3. Positive voltage from LA to LL
  4. Positive from GCT to LL (+ QRS)
  5. Positive from GCT to LA (+/- QRS)
  6. Positive from GCT RA (- QRS)

*Goldbergs Central Terminal: average of the two remaining leads

66
Q

Components of EKG:

  1. P wave
  2. PR interval
  3. QRS Complex
  4. ST interval
  5. QT interval
  6. T wave
  7. RR interval
A
  1. Atrial depolarization; 0.08-0.10 sec
  2. Conduction from SA/AV node; 0.12-0.20 sec
  3. Contraction of ventricle; 0.08-0.10 sec (under 0.12)
  4. Isoelectric line between ventricular depolarization and
    re-polarization
  5. Time taken for ventricular depolarization and
    re-polarization; 0.40-0.43 sec
  6. Ventricular repolarization
  7. Represents heart rate; 0.6-1.0 sec
67
Q

Lead Placement:

  1. RA, LA
  2. V1, V2
  3. V3
  4. V4
  5. V5
  6. V6
A
  1. 2nd ICS
  2. 4th ICS, R and L of sternum
  3. Between V2/V4
  4. 5th ICS, MCL
  5. Level w/ V4, anterior axillary line
  6. Level with v4/v5 at midaxillary line
68
Q

Benefits of A-line

A
  1. Generates realtime beat to beat BP
  2. Allows of ABG samples
  3. Can calculate CO/CI/SVR

Intro to Anesthesia: Part A (6 decks)

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