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1: Intro to Anesthesia > Hemodynamics > Flashcards

Hemodynamics Flashcards

1
Q

What is the AANA standard for monitoring and alarms?

A

Standard 9: when monitoring device used, variable pitch and threshold alarms are set and audible, vitals q5 min, cont. pulse ox, etCO2, cont HR monitor, twitch monitor - paralytics, use temperature monitoring and regulation bc pt at risk for MH d/t exposure to anesthetic gas

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2
Q

First duty as CRNA

A

vigilance

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3
Q

Describe Precordial/Esophageal Stethoscope, whats it used for, wheres it placed?

A

continuous monitoring of heart and breath sounds and minimally invasive. use to assess for windmill murmur (VAE) or bronchospasm (peds). Precordial on chest. Esophageal 28-30 cm into esophagus.

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4
Q

Normal PRI

A

0.12-0.2s

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5
Q

Normal QRS

A

0.08 - 0.1s

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6
Q

Normal QT

A

0.4-0.43

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7
Q

Normal RR

A

0.6-1s

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8
Q

What can ECGs detect? (5)

A

arrhythmias, HR (based on R-R wave), ischemia, electrolyte changes, monitor pacemaker function

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9
Q

What view is missing in a 3 lead EKG?

A

anterior view

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10
Q

What are the limitations (4) of a 3 lead EKG and what is needed to be able to detect them?

A

ST monitoring, BBBs, VT, SVT - need a true V1 lead to detect arrhythmias

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11
Q

Majority of dysrhythmias and ischemia can be detected via what two leads?

A

II and V5

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12
Q

Gain should be set at what?

A

standardization, 1 mV produces 10 mm pulse, able to monitor 1 mm ST change

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13
Q

What should filtering capacity be set to, and why?

A

diagnostic mode, filtering out low end can distort ST segment

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14
Q

If monitoring ST segment, what should be done before pt is anesthetized?

A

get baseline ST segment

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15
Q

What are 6 indicators of ischemia?

A

st elevation > 1mm, T wave flat/inverted, q wave, st depression/flat/downslope > 1mm, peaked t wave, arrhythmias

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16
Q

Most common ST change and why?

A

ST depression, indication of demand problem bc heart stressed decreased HR, increased O2 demand

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17
Q

ST elevation is an indication of what?

A

blockage

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18
Q

What are some common causes of ST changes other than ischemia (4)?

A

drugs (digitalis), temp changes (hypo - depression), hyperventilation (elevation), position changes (elevation)

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19
Q

The leads that monitor ST changes in the inferior, lateral, anterior, and septal walls including the artery are:

A

Inferior: II, III, AVF - RCA
Lateral: I, AVL, V5, V6 - CxA (LCA)
Septal: V1, V2 - LCA
Anterior: V3, V4 - LCA

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20
Q

Exercise-related ischemia is most sensitively detected in what leads?

A

V4 V5

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21
Q

When is peak SBP generated?

A

ventricular contraction

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22
Q

Changes in SBP correlate with what?

A

changes in myocardial O2 requirements

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23
Q

DBP is a trough pressure and is generated during

A

ventricular relaxation

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24
Q

Changes in DBP indicate what?

A

coronary perfusion pressure

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25
Q

How to calculate pulse pressure?

A

SBP - DBP

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26
Q

What is MAP?

A

weighted average of arterial pressure during pulse cycle

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27
Q

How is MAP calculated?

A

SBP + 2/3DBP

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28
Q

Intraoperative hypotension is defined as (and its exception)?

A

MAP < 55-60 mmHg (HTN pts may need higher MAPs due to a shift in their autoregulatory curve)

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29
Q

List types of BP measurement (5) and describe

A

palpation - palpate return of pulse when cuff deflated only measure SBP (underestimates),

doppler - underestimates SBP, sound waves

auscultation - steth/cuff/sphygmomanometer uses kortkoff sounds, estimates SBP and DBP (unreliable HTN)

oscillometry - automatic cuff, measures SBP/DBP/MAP

continuous NIBP finger - unreliable

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30
Q

Gold standard for BP measurement?

A

arterial line

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31
Q

What SBP do peripheral and central pulse become weak?

A

peripheral <90, central < 70

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32
Q

Which measurement is most reliable: SBP or DBP or MAP?

A

MAP

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33
Q

What is the ideal circumference and ideal length for a NIBP cuff?

A

40% circumference, 80% circumference

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34
Q

What happens when too small of a cuff is used?

A

false high readings

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35
Q

What can cause false high BP readings? (6)

A

cuff too small, cuff too loose, extremity BELOW level of heart, arterial stiffness (HTN, PVD), dysrhythmias, tremors/shivering

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36
Q

Why does arterial stiffness cause artificially high BP?

A

d/t widening pulse pressure and discrepancy between UE and LE

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37
Q

What can cause falsely low BP? (6)

A

cuff too large, extremity above level of heart, poor tissue perf., quick deflation, dysrhythmias, tremors/shivering

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38
Q

Complications of NIBP measurement? (6)

A

pain, petechiae/ecchymoses, limb edema, venous stasis/thrombophlebitis, peripheral neuropathy, compartment syndrome

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39
Q

What type of patients are vulnerable to complications of NIBP? (5)

A

peripheral neuropathies, arterial/venous insufficiency, coagulopathies, recent thrombolytic therapy, post-mastectomy

40
Q

How is an arterial BP waveform formed?

A

ejection of blood from left vent. into aorta during systole then peripheral run off during diastole

41
Q

Indications of arterial cannulation? (5)

A

cont. real time BP, planned pharmcological/mechanical cardio manip., repeated blood sampling, failure of indirect BP measurement, diagnostic info needed from waveform (valve changes)

42
Q

Extreme dorsiflexion of a wrist where an arterial line is located can cause what complication?

A

median nerve damage

43
Q

What arterial cannulation site is preferred in peds?

A

pedal

44
Q

Complications from arterial line are more likely when (7)? And what is the relative risk over all of arterial line insertion?

A

arterial spasm, previous arterial injury, thrombocytosis, protracted shock, high dose vaso pressor admin., prolonged cannulation, infection

low risk overall

45
Q

Allen test tests for what? What is its predictive value?

A

To see if pt can tolerate arterial line in that extremity.

Predictive value is low.

46
Q

How is allen test done?

A

Compress both radial/ulnar art., pt makes tight fist, pt then opens hands (no hyperextension), release ulnar occlusion, normal color returns w/ in seconds. > 6-10 seconds means reduced flow

47
Q

Indications for Arterial Lines? (8)

A

deliberate hypotension, wide swings in intraop BP, r/o rapid changes in BP, rapid fluid shifts, vasoactive drugs, end organ disease, repeated blood sampling, failure of BP measurement

48
Q

How to make arterial lines more accurate? (6)

A

minimize tube length, limit stop cocks, no air bubbles, mass of fluid small, using stiff tubing, calibrated at level of heart (phlebostatic axis) or at meatus/circle of Willis if concerned at cerebral perfusion

49
Q

What is the rate of passive flushing in an arterial line?

A

1-3 mL

50
Q

The dicrotic notch represents what mechanical event?

A

aortic valve closure

51
Q

Which comes first, mechanical event or electrical event?

A

Electrical, then mechanical

52
Q

The distance from the systolic peak of an arterial line from the dicrotic notch moves _____ the more distal the insertion site is.

A

increases

53
Q

Describe the parts of an arterial waveform.

A

aortic valve opens, slope of systolic upstroke represents contractility, peak of systolic upstroke is SBP/isovolumetric contraction of ventricles, area under curve from peak to dicrotic notch is SV (EDV-ESV) and represents myocardial O2 demand

dicrotic notch is where aortic valve closes, pressure drops as blood flows out of aorta, from dicrotic notch to lowest pressure represents myocardial O2 supply, DBP is the lowest point of the waveform, pulse pressure is the difference from the peak to lowest pressure.

54
Q

Describe underdamped arterial line and what causes are (4)?

A

systolic pressure overshoot; caused by catheter whip or artifact, stiff noncompliant tubing, tachycardia/dysrhythmias

55
Q

Describe overdamped arterial line and what causes are (6)?

A

diminished pulse pressure; loose connections, air bubbles, kinks, blood clots, arterial spasms, narrow tubing

56
Q

What interventions can you try for damped waveforms? (5)

A

pressure bag inflated 300 mm Hg, reposition extremity/pt, verify appropriate scale, flush/aspirate line, check/replace module/cable

57
Q

The square wave test ensures what?

A

arterial line is optimally damped (only two oscillations after a flush)

58
Q

What is the phlebostatic axis?

A

a reference point for zeroing arterial line, 4th intercostal space, midaxillary line

59
Q

What pressure are all physiological pressures referenced to in invasive lines?

A

atmospheric pressure

60
Q

A 20 cm difference in height produces a ___ mmHG difference in pressure.

A

15, aka for every 1cm its 0.75 mmHg difference

61
Q

Examples of arterial line complications are (10)

A

nerve damage, hematoma/hemorrhage, infection, thrombosis, air embolus, skin necrosis, loss of digits, vasospasm, arterial aneurysm, retained guide wire

62
Q 
How does \_\_\_\_ affect arterial waveform?
a aortic stenosis
b aortic regurg
c hypertrophic cardiomyopathy
d systolic LV failure
e cardiac tamponade
A

a pulsus parvus (narrow pp), pulsus tardus (delayed upstroke) - weak pulse

b bisferiens pulse (double peak), wide pulse pressure

c spike and dome, mid systolic obstruction

d pulsus alternans (alt. pp amplitude) alternating strong and weak beats

e pulsus paradoxus - drop in SBP during spont. resp.

63
Q

What does pulse pressure variation (PPV) measure and thresholds?

A

measures pt’s responsiveness to fluid bolus

> 13% fluid responsive, dehydrated

<9% fluid overloaded

64
Q

Whats a way to observe fluid responsiveness via SpO2 pleth?

A

If SpO2 goes down with positive pressure it is bc of increase in intrathoracic pressure, ie overloaded

65
Q

What are the requirements to be able to measure PPV? (4)

A

NSR, intub/mech vent., vent w/ 8 mL/kg of Tv, no sig. alterations to chest compliance (like open chest)

66
Q

Describe how to measure PPV.

A

1.) condense waveform from 25 to 6.25 mm/sec. 2.) find pulse pressure during inspiration and during expiration 3.) enter into formula: (PPmax-PPmin)/mean of the two X 100

67
Q

What law allows SpO2 to be measured via pulse ox, also describe it?

A

Beer Lambert Law; concentration of dissolved substance is directly proportional to absorbance of light

68
Q

What wavelengths are absorbed in a pulse ox?

A

660 nm - deO2Hb

940 nm - O2Hb

69
Q

What causes inaccuracy in pulse ox? (6)

A

dyes, malposition, dark nail polish, different Hb (metHb, carboxy Hb), electrical interference, shivering

70
Q

What is the oxyhemoglobin curve?

A

Describes the nonlinear relationship between SaO2 y-axis (O2 saturated Hb) and PaO2 x-axis (pp of arterial O2). The curve flattens out at 60 mm Hg indicating little change in O2 saturation past this point. Below 60 mmHg the curve is steep indicating small change result in large drop in O2 saturation. Describes O2’s affinity for Hb. Shift toward left increases O2’s affinity for Hb causes hypoxia bc no O2 to cells/tissues, O2 goes back to lungs w/out being used. Shift right decreases O2’s affinity for Hb means more O2 to tissues/cells, but also less O2 picked up from lungs in first place.

71
Q

What causes a LEFT shift on the O2Hb curve?

What causes a RIGHT shift?

A

LEFT: alkalosis, hypocarbia, hypothermia, decreased DPG, COHb, fetal Hb

RIGHT: acidosis, hypercarbia, hyperthermia, increased DPG

72
Q

How does carboxyHb affect SpO2?

A

Falsely elevates SaO2

73
Q

How does metHb affect SpO2?

A

Falsely lowers SaO2

74
Q

Indications for CVC? (8)

A

CVP, admin drugs (vasoactives), temp HD, transvenous pacing, PAC and monitoring, rapid fluid infusion, aspiration of air emboli, inadequate peripheral access, blood sampling

75
Q

Insertion sites and complications of each

A

RIJ - preferred, high accuracy, direct to SVC; LIJ r/o pneumo d/t cupola of pleura higher on left, r/o of carotid cannulation d/t anatomy; subclavian - pneumo and arteial puncture, EJ, femoral

76
Q

Where should a CVC tip be placed?

A

Just above junction of SVC and RA, T4-5, carina, above 3rd rib

77
Q

What are the measurements of a CVC?

A

7 fr, 20 cm length

78
Q

CVC contraindications? (4)

A

R atrial tumor, contralateral pneumo, infection at site, thrombus in intended insertion vein

79
Q

Complications of CVC insertions (9)

A

vascular injury - cardiac tamponade, aw compression from hematoma, pneumo, nerve injury, arrhythmias, thrombus/embolus, infection, misuse of equipment, misinterpreting data

80
Q

Normal CVP, and what it rises to when mech vent?

A

2-7 mmHg, rises by 3-5 mmHg

81
Q

CVP is also know as

A

RAP or RV preload

82
Q

Describe cvp waveform and associated mech events in EKG waveform.

A

a - atrial kick, atrial contraction, end diastole (PQ)
c - isovolumetric contraction (no volume change), tricuspid closed and bulges back into RA, early systole (RS)
x - mid systole, RA relax. (T)
v - systolic filling of RA, ventricular ejection, tricuspid closed, late systole (T)
y - early diastole, tricuspid open early ventricular filling (T)

83
Q

Describe cardiac cycle.

A

0.8 s 1) venous blood return to RA via SVC/IVC, 2) isovolumetric relaxation, all valves closed, 3) passive ventrical filling tricuspid & mitral valves open/atrial & pulmonic valves closed, 70-80% blood, blood flows from atria to ventricles, 3) active ventricular filling, atrial contraction/kick, 20-30% blood, 4) isovolumetric contraction, valves closed 5) ventricular contraction, tricuspid/mitral valves closed, aortic/pulmonic valves open, systole

84
Q

What is the most prominent wave on CVP and whats it represent?

A

a wave, atrial kick/contraction, P wave, end diastole

85
Q

Describe CVP waveform abnorm.

A

afib - loss of a, prom c
av diss. - cannon a
tricuspid regurg - tall c-v wave, no x
tricuspid stenosis - tall a, atten y
RV ischemia - tall a v , steep x y, mw config
pericard constrict - tall a v , steep x y, mw config
card. tamp. - dom x, atten y

86
Q

What does a PAC do? (7)

A

intracardiac press., estim. LV filling press., indirectly assess LV, CO, mixed venous O2 sat., PVR/SVR, pacing

87
Q

Blue port on PAC is ____

Yellow port on PAC is ____

A

proximal,

distal

88
Q

PAC stats

A

7 fr, introducer 8.5fr, 110 cm length (10 cm int), 4 lumens (distal - PAP, second -30 cm prox cvp, 3rd - balloon, fourth - thermistor

89
Q

Indications for PAC (8)

A

LV dysfunction, valve disease, pulm htn, cad, ards/resp fail., shock/sepsis, arf, surgical procedure

90
Q 
PAC complications (9)
relative contraindications (2)
A

arrhythmias, RBB, cath knotting, balloon rupture, thrombus/air embolus, pneumo, pa rupture, infection, dmg to cardiac structures

WPW, LBBB

91
Q

PAC distances from RIJ to:

a) VC, RA junction
b) RA
c) RV
d) PA
e) wedged

A

a) 15 cm
b) 15-25 cm
c) 25-35 cm
d) 35-45 cm
e) 40-50 cm

92
Q

Describe PCWP Waveform w/ pressures

A

RA - acxvy wave (CVP), 2-6 mmHg;
RV - large camel humps, 15-30 mmHg sys, 2-8 mmHg diast;
PA - dicrotic notch returns, 15-30 mmHg sys, 5-15 mmHg diast;
wedge - av waves, small camel humps, 6-12 mmHg

93
Q

Normals:

a) SVR
b) PVR
c) CO
d) EF
e) CI
f) EDV
g) SV
h) PIP
i) Tv
j) etCO2

A

a) 50-100 mL/beat
b) <250 dynes - sec/cm3
c) 4-8 L/min
d) 55-70%
e) 2.4-4 L/min/m3
f) 65-230 mL
g) 50-100 mL/beat
h) 15-20 cmH2O
i) 6-8 mL/kg ideal body wt.
j) 35-40 mmHg

94
Q

What are the 5 types of CO monitoring?

A

thermodilution, cont. thermodilution, mixed venous oximetry, ultrasound, pulse contour

95
Q

TEE for 7:

A

ventr. wall characteristics/motion, valve structure and func., EF, CO, blood flow, intracardiac air, intracardiac masses

96
Q

Uses of TEE (8)

A

unusual hypotension/acute, pericard. tamponade, PE, aortic dissec., myocard ischemia, valve dysfunc.- AL changes, wall motion

97
Q

Complications of TEE (4)

A

esophageal trauma, dysrhythmias, hoarseness, dysphagia

1: Intro to Anesthesia (12 decks)

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