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Intro to Anesthesia Main > Hemodynamic monitoring > Flashcards

Hemodynamic monitoring Flashcards

1
Q

IABP complications

A
  1. Nerve damage
  2. hemorrhage/hematoma
  3. infection
  4. thrombosis
  5. air embolus
  6. skin necrosis
  7. loss of digits
  8. vasospasm
  9. arterial aneurysm
  10. retained guidewire
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2
Q

ECG complex

A
  • each box, 0.04 seconds
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3
Q

CVC contraindications

A
  1. R atrial tumor
  2. Infection at site
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4
Q

ECG indicators of acute Ischemia

A
  1. ST segment elevation >/= 1mm
  2. T wave inversion
  3. Development of Q waves
  4. ST segment depression, flat or downslope of > or equal to 1mm
  5. Peaked T waves
  6. Arrhythmias
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5
Q

CVC size

A

7 french

20 cm length

*not confirmed by xray in OR, aspirate blood from all ports

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6
Q

SaO2

A

ratio of oxyhemoglobin to all functional hemoglobin.

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7
Q

dichrotic notch

A

aortic valve closure

happens later in waveform the further art line is

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8
Q

Distance from RIJ to Wedge (pulmonary artery)

A

40-50 cm

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9
Q

PAP waveforms

A

Same as CVP but for left side

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10
Q

Cardiac output monitoring techniques

A
  1. thermodilution
  2. continuous thermodilution
  3. mixed venous oximetry
  4. ultrasound
  5. pulse contour
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11
Q

Pulmonary artery pressure monitoring

A

Measures left side of heart. Line goes through SVC, RA, RV to PA

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12
Q

Transesophageal echocardiography Complications

A
  1. esophageal trauma
  2. dysrhythmias
  3. hoarseness
  4. dysphagia

*more complications in awake patients

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13
Q

Changes in lead V1-V4

A

Anterioseptal ischemia

left descending coronary artery

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14
Q

Leveling art line

A
  • Mid axillary line in supine pts
  • level of ear (circle of willis) in sitting patients
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15
Q

Anterior view of heart

A

V3, V4

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16
Q

5 Lead ECG

A
  • Leads I, II, III, aVR, aVL, aVF, V
  • Electrodes RA, LA, LL, RL, chest lead
  • 7 views of the heart (adds anterior view)
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17
Q

Risks of CVC

A

air or thrombo-embolism

dysrhythmia

hematoma

Carotid puncture

pneumo/hemothorax

vascular damage

cardiac tamponade

infection

guidewire embolism

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18
Q

Complications of NIBP

A
  1. edema of extremity
  2. petechiae/bruising
  3. ulnar neuropathy
  4. interference of IV flow
  5. altered timing of IV drug administration
  6. pain
  7. compartment syndrome
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19
Q

Transesophageal echocardiography

7 cardiac parameters observed:

A
  1. ventricular wall characteristics and motion (look for ischemia)
  2. valve structure and function
  3. Estimation of end-diastolic and end-systolic pressures and volumes (EF)
  4. CO
  5. blood flow characteristics
  6. intracardiac air
  7. intracardiac masses
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20
Q

CVC location

A

Tip within the Superior Vena Cava (SVC), just above the junction of SVC and RA

  • below the inferior border of clavicle and above the level of 3rd rib
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21
Q

Things that can distort CVP and PCWP

A
  • loss of waves
    • afib, ventricular pacing
  • Giant a waves“cannon” a waves
    • junctional rhythms
    • complete HB
    • mitral stenosis
    • diastolic dysfunction
    • myocardial ischemia
    • ventricular hypertrophy
  • Large v waves
    • mitral/tricuspid regurgitation and acute increase in intravascular volume
    • tamponade/pericarditis (both squeezing the heart)
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22
Q

Distance from RIJ to RV

A

25-35 cm

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23
Q

NIBP cuffs

A
  • bladder width should be approximately 40% of the circumference of the extremity
  • Bladder length should encircle 80% of extremity
  • applied snugly, bladder centered over the arter and residual air removed.
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24
Q

DBP

A
  • trough pressure during diastolic ventricular relaxation
    • changes reflect coronary perfusion pressure
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25
Q

PAP assessment

A
  • Intracardiac pressures (CVP, PAP, PCWP/PAWP)
  • estimate LV fillin gpressures
  • assess LV function
  • CO
  • mixed venous oxygen saturation
  • Pulmonary Vascular resistance (PVR) Systemic vascular resistance (SVR)
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26
Q

CVP monitoring

A

Right atrial pressure = Right ventricle preload

normal = 1-7 mmHg

with mechanical ventilation = 4-10 mmHg

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27
Q

Distance from RIJ to PA

A

35-45 cm

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28
Q

CVP waveform

A
  • “a” wave is point of maximal filling of RV and should be used for RVEDP
    • machines “average” the measurement
    • Should be measured at end-expiration.
  • “c” closure of tricuspid valve and V contraction, tricuspid “bulges” back into the atrium slightly increasing the pressure
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29
Q

Changes in Lead I, AVL, V5-V6

A

Lateral wall ischemia

circumflex branch of left coronary artery

30
Q

Thermodilution

A

Using known amount of known temperatured solution to inject in catheter in RA. Thermister on cathether (swan-ganz) measures change in temperature. Used to assess cardiac output

31
Q

AANA minimal standard required monitors and monitoring information (on graphic display)

A
  1. ECG (HR and rhythm)
  2. Blood pressure
  3. pulse ox
  4. Oxygen analyzer
  5. end tidal carbon dioxide
  • ECG
  • BP
  • HR
  • ventilation status
  • O2 sat

*Must document minimum of every 5 minutes!!

**Variable pitch tone must be audible with use of Pulse ox

32
Q

Insertion sites of Central venous catheters

A
  • right internal jugular (most common for anesthesia)
  • left internal jugular vein
  • subclavian veins
  • external jugular veins
  • femoral veins
33
Q

Septal view of heart

A

V1, V2

34
Q

3 Lead ECG

A
  • Electrodes RA, LA, LL
  • Leads I, II, III
  • 3 views of the heart, no anterior view
35
Q

most important lead for ischemia

A

V

*all V leads

36
Q

PCWP

A

Pulmonary Capilary wedge pressure

a wave: contraction of Left atrium

*usually a small deflection unless there is resistance moving blood into LV like in mitral stenosis.

c wave: rapid rise in LV pressure in early systole, causing mitral valve to bulge backward into LA, so atrial pressure increases momentarily

v wave: blood entering LA during late systole

*prominent v wave reflects mitral insufficiency causing large amounts of blood to reflux into the LA during systole

37
Q

distance from RIJ to RA

A

15-25 cm

38
Q

BP Oscillometry

A

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

  • 1st oscillation correlates with SBP
  • maximum/peak oscillations occurs at MAP
  • oscillations cease at DBP
39
Q

Transesophageal echocardiography uses:

A
  1. unusual causes of acute hypotension
  2. pericardial tamponade
  3. pulmonary embolism
  4. aortic dissection
  5. myocardial ischemia
  6. valvular dysfunction
40
Q

most important lead for rhythm changes

A

II

41
Q

Falsely high PB

A
  • cuff too small
  • cuff too loose
  • extremity below level of heart
  • arterial stiffness- HTN, PVD
42
Q

Changes in Lead I, AVL, V1-V4

A

Anterior wall ischemia

Left coronary artery

43
Q

Lateral view of heart

A

I, aVL, V5, V6

Lead I = RA-LA

44
Q

Pulse pressure

A

SBP-DBP

As location of BP moves out peripherally, you get exaggerated SBP and wider pulse pressure.

45
Q

PAP catheters

A
  • 7 or 9 french
  • 110 cm length
  • 4 lumens
    • distal port PAP
    • second port 30 cm more proximal CVP
    • third lumen balloon
    • fourth wires for temp
46
Q

Distance from RIJ to Vena cava and RA junction

A

15 cm

47
Q

Calculate MAP

A

SBP+2(DBP) / 3

48
Q

low CVP reading

A

hypovolemia/shock

49
Q

CVC indications

A
  1. measuring right heart filling pressures
  2. assess fluid status/blood volume
  3. rapid administration of bolus
  4. administration of vasoactive drugs
  5. removal of air emboli
  6. insertion of transvenous pacing leads
  7. vascular access
  8. sample central venous blood
50
Q

Standard 2

A
  1. Oxygenation
  2. ventialtion
  3. circulation
  4. temperature

*Continually evaluated

51
Q

inferior view of heart

A

II -RA-LL

III - LA-LL

aVF- LA+LL-RA

52
Q

PAP complications

A
  1. arrhythmias
  2. catheter knotting
  3. balloon rupture (can rupture pulmonary vasculature
  4. thromboembolism; air embolism
  5. pneumothorax
  6. pulmonary infarction
  7. PA rupture
  8. infection
  9. damage to cardiac structures (valves, etc)
    10.
53
Q

SBP

A
  • peak pressure generated during systolic ventricular contraction
    • changes correlate to changes in myocardial O2 requirements
54
Q

Indications for Art line

A
  1. elective deliberate hypotension
  2. wide swings in BP
  3. rapid fluid shifts
  4. titration of vasoactive drugs
  5. end organ disease
  6. repeated blood sampling
  7. failure of NIBP
55
Q

Standard 1

A

Qualified provider must be with pt the entire time

SRNA

CRNA

MDNA

AA- need direct in room supervision

56
Q

Allen test

A

block radial and ulnar arteries, pt pump fist, release ulner artery first to make sure it can refill hand if radial artery gets “trashed” by art line.

57
Q

Falsely low BP

A
  • Cuff too large
  • extremity above level of heart
  • poor tissue perfustion
  • too quick deflation

*improper cuff placement, dysrhythmias, tremors/shivering

58
Q

Arterial pressure waveform

A

*the more distal the art line, the SBP will increase, DBP will decrease, MAP same, dichrotic arch is later

59
Q

Art line sites

A
  1. radial
  2. ulnar
  3. brachial
  4. femoral
  5. dorsalis pedis
  6. axillary
60
Q

to improve accuracy of art line

and forms of erro

A
  1. minimize tubing length
  2. limit stopcocks
  3. no air bubbles
  4. use non-compliant stiff tubing
  5. calibrated

forms of error: Dampening and overshooting

61
Q

PAC indications

A

LV dysfunction

valve disease

Pulm HTN

CAD

ARDS/resp failure

shock/sepsis

AFR

Cardiac sugeries

62
Q

high CVP readings

A

fluid overload

right heart failure

PE

tension pneumo

63
Q

Pulse Oximeter

A
  • measures hemoglobin saturation
  • pulses red and intrared LED on and off several hundred times per second
    • absorption of intrared light in blood–algorithm used to compute ration of infrared light signal and saturation
64
Q

Changes in Lead II, III, AVF

A

(posterior)/ Inferior wall ischemia

Right coronary artery

65
Q

Purpose of ECG

A
  1. detect arrhythmias
  2. monitor heart rate
  3. detect ischemia
  4. detect electrolyte change
  5. monitor pacemaker function
66
Q

Standards for Basic Anesthetic Monitoring

A
  • Oxygenation
  • Ventilation
  • Circulation
  • Temperature

Contiuous monitor

67
Q

Basic Monitoring Technique

A
  • Inspection
  • Auscultation
  • Palpation
68
Q

Stethoscope

A
  • Continual assessment of breath sounds and heart tones
  • Precordial placed on chest surface
  • Esophageal placed 28-30cm into esophagus
  • Very sensitive monitor for bronchospasm, airway, obstruction, changes in HR/rhythm
69
Q

Gain Setting and Frequency Bandwith

A
  • Gain should be set at standardization
    • 1 mV signal produces 10-mm calibration pulse
    • Therefore, a 1-mm ST segment change is accurately assessed
  • Filtering capacity should be set to diagnostic mode
    • Filtering out the low end of frequency bandwidth can distort ST segment
70
Q
A
71
Q

Myocardial Ishchemia: Coronary Anatomy and ECG

A
  • Inferior wall ischemia (right coronary artery) Changes in Lead II, III, AVF
  • Lateral wall ischemia (circumflex branch of left coronary artery) Changes in Lead I, AVL, V5-V6
  • Anterior wall ischemia (left coronary artery) Changes in V3-V4
  • Septal ischemia (left descending coronary artery) Changes in Lead V1-V2

Intro to Anesthesia Main (7 decks)

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