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Intro Nurse Anesthesia > Hemodynamics Monitoring Review > Flashcards

Hemodynamics Monitoring Review Flashcards

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1
Q

AANA Standard 9 (A-E)

A

Monitoring and Alarms.
- Monitor, evaluate and document patient’s physiologic condition as appropriate for procedure and anesthetic technique
- pitch and threshold alarms are turned on and audible
- document BP, HR RR at least every 5 minutes for all anesthetics
-A. O2- Continou monitor oxygen by observation and pulse oximetry. Talk to surgical team regarding fire
B. Ventilation: Continuous monitor ventilation by clinical observations and expired CO2 during moderate sedation, deep sedation or general. Verify intubation of trache by auscultation, chest rise, and expired CO2.
C. Cardiovascular- monitor pt hemodynamics status HR and invasive monitoring as appropriate
D. Thermoregulations: monitor body temp and active measure to facilitate normothermia. When MH triggering agents used, monitor temp and recognize s/s immediately
E. Neuromuscular- when nMB agent administered, monitor response to assess depth of blockade and degree fo recovery

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2
Q

Required Monitors by AANA

A

EKG, BP, TEMP, PULSE OX, ETCO2

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3
Q

Cornerstone monitoring:

A

Physical assessment. I.e.:

  • Inspection, auscultation, palpation
  • Chest rise/fall
  • Auscultate breath sounds preop, after intubation, and when ventilators parameters change
  • Direct palpating of pulse when monitored value questioned.
  • Direct observation beating heart in cardiac six
  • Inspection of mucous membrane, skin color and turf or
  • Inspect six field for blood loss. UOP observation
  • Evalute JVD
  • pupillary response
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4
Q

Precocial or Esophageal stethoscope

A

Minimally invasive, cost effective and continuous monitor

  • Continual assessment breath and heart sounds
  • sensitive monitor for broncospasm, airway obstruction and changes in hr/rhythm
  • High detection for venous air embolism
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5
Q

Speed EKG paper

A

25 mm/sec

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6
Q

1 SQUARE horizaontal on EKG

A

1 SQUARE= 0.4 sec. 0.5 cm = 0.20 seconds long

1mm or 0.1 mV high

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7
Q

EKG purpose

A 
Detect arrhythmia
Monitor HR
Detect ischemia
Detect electrolyte changes
Monitor pacemaker function
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8
Q

3 lead EKG

A

RA, LA, LL leADS I, II, III. No ANTERIOR view of heart, Only rhythm monitor

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9
Q

Lead I

A

RA TO LA

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10
Q

Lead II

A

RA TO LL

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11
Q

Lead III

A

La to LL

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12
Q

5 lead EKG

A

RA, LA, RL, Chest lead 7 views of heart. V1 preferred for arrhythmia monitoring

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13
Q

AVF

A

Center to LL

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14
Q

AVR

A

CENTER TO RA

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15
Q

AVL

A

CENTER TO LA

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16
Q

V1

A

4TH Intercostal space to right of sternum (septal view of hear)

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17
Q

V2

A

4th intercostal space to left of sternum (septal view of heart)

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18
Q

V3

A

Directly b/w V2 and V4(anterior view of heart)

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19
Q

V4

A

5th intercostal space and L midclavicular line (anterior view of heart)

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20
Q

V5

A

Level with V4 at left anterior ancillary line (lateral view of heart

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21
Q

V6

A

LEVEL with V5 at L midaxillary line (lateral view of heart)

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22
Q

5 principle indicators of Ischemia detection

A

1) ST segment elevation >= 1mm
2) T wave flattening or inversion
3) development of Q waves
4) ST segment depression, flat or downslope >1mm
5) PEAKED T waves
6) Arrhythmias

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23
Q

Inferior Wall ischemia. Which vessel, which leads?

A

RCA. Change in II, III, avf

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24
Q

Lateral wall ischemia. Which vessel/leads?

A

Circumflex branch of LCA,. I, AVL, V5-V6

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25
Q

Anterior wall ischemia

A

LCA, V3-V4

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26
Q

Septal ischemia

A

Left descending coronary artery (LAD) V1, V2

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27
Q

Normal PR

A

0.12-0.2 SEC

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28
Q

QRS

A

0.08-0.10 sec

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29
Q

QT

A

0.4-0.43 sec

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30
Q

RR interval

A

0.6-1sec

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31
Q

Blood pressure based on what law?

A

Ohm’s Law. V=IR. V=blood pressure. Blood flows x resistance

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32
Q

Systolic BP

A

Peak pressure generated with changes in systolic ventricular contractions. Changes reflect myocardial o2 requirements

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33
Q

Diastolic BP

A

Trough pressure during diastolic ventricular relaxation. Changes in DBP reflect coronary perfusion pressure

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34
Q

Pulse pressures

A

SBP-DBP

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35
Q

MAP

A

Weighted average of arterial pressure during pulse cycle. MAP = SBP + 2(DBP)/3 OR MAP DP+(1/3) (SP-DP)

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36
Q

Palpation non-invasive blood pressure measurement

A

Palpating return of arterial pulse when occluded cuff is deflated. Underestimates Sys pressure. Only measures SBP

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37
Q

Doppler BP

A

Based on shift in frequency of sound waves. Only measure SBP

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38
Q

Auscultation

A

Using sphygmomanometer, cuff and stethoscope. Listening to Kortokoff sounds d/t turbulent flow. Estimation of SBP and DMP

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39
Q

Oscillometry

A

Senses oscillations/fluctuations in cuff pressure produced by arterial pulsations when deflating BP cuff. 1st oscillation is SBP. Last is DBP. Automated cuffs work this way.Derives MAP, SBP, DBP by algorithm

SBP and DBP algorithm vary by manufacturer.

Less reliable than values for MAP

Oscillometry methods often underestimate systolic an overestimate diastolic significantly reducing PP calculations

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40
Q

How should the NIBP Cuff fit?

A

Width is 40% circumference of extremity. Length should encircle 80% extremity

Applied snugly, with bladder centered on artery and residual air removed

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41
Q

Falsely high BP MEASUREMENT caused by…

A
  • Cuff too small,
  • too loose,
  • extremity below level of heart.
  • Arterial stiffness- HTN, PVD
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42
Q

Falsely low BP

A
  • Cuff too large
  • Extremity above level of heart
  • Poor tissue perfusion
  • Too quick deflation
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43
Q

Erroneous BP measurements with

A

Dysrhythmia, tremor/shivering

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44
Q

Complications of NIBP measurement

A 
=Pain
-Petechia and ecchymoses
-limb edema
-venous stasis
- peripheral neuropathy
- compartment syndrome
—- pt with peripheral neuropathy, arterial or venous insufficiency, severe coagulopathies or recent use thrombolytics more prone to complications
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45
Q

What does arterial line measure?

A

Systemic arterial pressure waveform from ejection of blood from LV into aorta during systole, with peripheral runoff during diastole

Transducer to convert generated pressure into electiv signal to provide a waveform

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46
Q

Complications Risk of Arterial line

A 
Overall low risk.
Increased risk:
- vasospastic arterial dx
- previous arterial injury
-thrombocytes is
-protracted shock
-high dose vasopressin administration
- prolonged cannulation
-infection
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47
Q

Allen tat

A

Occlude both radial and ulnar arteries, have pt make tight fist. Then have patient open hand, release ulnar artery and watch for color to return to palm with radial artery occluded

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48
Q

Indications for a line

A
  • elective and deliberate hypotension
  • wide swings intra op BP
  • risk of rapid BP changes
  • rapid fluid shifts
  • titration vasoactives
  • end organ dx
  • repeated blood sampling
  • failure of indirect BP measurement
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49
Q

Zeroing a line transducer

A

Phlebostatic axis at 4th intercostal space mid axillary line.

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50
Q

What will Aline reading be if transducer is high/low

A

High transducer= low readings
Low transducer= high reading

20 cm diff makes 15 mmHg difference in arterial line

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51
Q

As arterial line location changes…

A

Further away from heart, more defined systolic peak. Diacritic notch is further out on downslope

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52
Q

What to check for with Overdamped

A 
Looks connections
Air bubbles
Kinks
Blood blots
Arterial spasm
Narrow tubing

Overdamped wave form will appear flat

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53
Q

What to check/look for if Underdamped

A 
Will show peaked wave with whip
Catheter whip or artifact
Stiff non-compliant tubing
Hypothermia
Tachycardia/dysrhythmia
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54
Q

Square wave test

A

2 oscillations only before normal waveform

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55
Q

Aline complications

A 
Distal ischemia, psuedoaneuysm
Hemorrhage
Arterial mobilization
Infection
Peripheral neuropathy
Misuse of equipment
Nerve damage
Thrombosis
Air embolus
Skin necrosis
Loss of digits
Vasopasm
Retained guide wire

ASA closed claims 54% r/t radial artery (ischemic injury, radial nerve or retained wire fragment) others were related to femoral artery (thrombotic/hemorrhagic events)

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56
Q

Aortic stenosis shows as what on a line?

A

Slow upstroke (pulsus tardus) and narrow pulse pressure (pulsus parvus)

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57
Q

Aortic regurgitation shows as what on a line?

A

Double peak (biferiens pulse) with wide PP

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58
Q

Hypertrophic CMP on Aline?

A

Spike and dome

59
Q

Pulsus alternans

A

Alternating pulse pressure amplitude. Seen in sys lV failure

60
Q

Pulsus paradoxes

A

Seen in cardiac tamponade. Exaggerated decreases in sys BP with inspiration

61
Q

Type of law pulse oximeter uses?

A

Beer- Lambert Law

62
Q

Wavelength of pulse ox?

A

660 (unoxygenated) and 940 nm (oxygenated)

63
Q

When in pulse ox inaccurate?

A 
Malposition of probe
Dark nail polish
Different hemoglobin
Dyes
Electrical interference
Shivering
64
Q

Ocyhemoglobin dissociation curve

A

Affinity of o2 to hgb

65
Q

Left shift

A

Wants to hold onto o2 (Alkalosis, hypocardbia, hypothermia,

66
Q

Right shift

A

Let’s go of o2 readily. Acidosis, hypercarbia, hyperthermia

67
Q

CVC indications

A 
CVP monitoring
PA monitoring
Transvenous cardiac pacing
Temporary HD
Drug admin of chemo, vasopressors, hyperalimentation. 
Prolonged abs
Rapid infusion of fluids
Aspiration of air emboli

Basic nursing care
Blood sampling
Diagnostic measurements
PACING

68
Q

Preferred site for cvc

A

RIGHT IJ

69
Q

Where should CVC be?

A

Ideally, tip just within SVC, just above junction of VC and RA, parallel to vessel walls

Inferior border of clavicle, above level of 3rd rib. T4/T5 interspace. Carina

70
Q

Contraindications of CVC

A

R atrial tumor
Contralateral pneumothorax
Infection at site

71
Q

Complications of CVP monitoring

A 
Mechanical injury (vascular injury , arterial and venous, CARDIAC TAMPONADE)
Respiratory compromise (airway compression, pneumonia)
Nerve injury
Arrhythmia
Thromboembolic (PE, VT)
Infection
Misinterpretation of data
RETAINED GUIDEWIRE

Captain CV

72
Q

Normal CVP in awake, breathing

A

2-7 mmHg

73
Q

Normal CVP with mechanical ventilation

A

Rises 3-5 mmHg

5-12 normal

74
Q

CVP waveform peaks?

A

A,c,v

75
Q

CVP waveform descents?

A

X,y

76
Q

Cardiac cycle phases

A 
Atrial contraction
Isovolumetric contraction
Ventricular ejection
Isovolumetric relaxation
Ventricular filling
77
Q

“A” wave on CVP

A
  • Caused by atrial contraction. -Follows p wave on EKG.
  • At end diastole.
  • Corresponds with atrial kick and causes filling of RV
78
Q

“C” wave CVP

A
  • Due to isovolumetric contraction (right side) which causes closing of tricuspid valve and bulges back into right atrium.
  • Occurs in early systole
79
Q

“X” descent in cvp

A
  • Systolic decrease in atrial pressure due to atrial relaxation
  • Mid-systolic event
80
Q

“V” wave in CVP

A
  • Ventricular ejection which drives venous filling of atrium.
  • Late systole with triscupid valve CLOSED
  • Occurs just after t wave in EKG
81
Q

Y Descent in CVP

A

Diastolic decrease in atrial pressure due to flow across open tricuspid valve
-early diastole

82
Q

Size of pA cath

A

7 for. 110 cm in length with 4 lumens

83
Q

Indications of PA cath

A
  • LV Dysfunction
  • valvular dx
  • plum htn
  • CAD
  • ARDS
  • Shock/sepsis
  • ARF
  • Sx procedures
84
Q

PA cath complication

A 
-Arrhythmia (vfib, RBBB, CHB)
Catheter knotting
Balloon rupture
Pneumonia
Pa rupture
Infection
Damage to cardiac structures
85
Q

Normal vena cava distance with PA

A

15

86
Q

RA distance with PA

A

15-25

87
Q

RV distance

A

25-35

88
Q

PA distance

A

35-45

89
Q

Wedged PA distance

A

40-50

90
Q

How do PA wedge waveform compare to CVP?

A

More damping through pulmonary system so less distinct waveforms., Events come much later. (Line up with t wave more or less)

91
Q

PCWP waveform a wave

A

Contraction of left atrium. Small deflection unless resistance to blood moving as with mitral stenosis

92
Q

PCWP C waveform

A

Due to rapid ris in LV pressure in early systole. Mitral valve bulges into LA

93
Q

PCWP v waveform

A

Blood enters LA during late systolie

94
Q

Prominent v wave on PCWP

A

Shows mitral insufficiency d/t large blood going back into LA DURING SYSOTLE

95
Q

SV normal

A

60-90

96
Q

SVR normal

A

800-1200 dynes, 10-20 wood units

97
Q

PVR normal

A

0.5-3

98
Q

MVO2

A

70-80

99
Q

Co NORMAL

A

4-6.5

100
Q

SBP NORMAL

A

90-140

101
Q

DBP normal

A

60-90

102
Q

MAP normal

A

70-105

103
Q

Systolic pressure variation

A

5

104
Q

PPV

A

10-13%

105
Q

RV PRESSURE

A

15-30/8

106
Q

PA pressure

A

15-30/5-15

107
Q

Mean PA pressure

A

9-20

108
Q

PCWP normal

A

6-12

109
Q

LA Pressure

A

4-12

110
Q

SPO2

A

95-100

111
Q

Co

A

4-8 L/MIN

112
Q

CI

A

2.4-4 L/MIN/M2

113
Q

Peak inspiratory pressure normal

A

15-20

114
Q

TV normal

A

6-8 mL/kg of IBW

115
Q

ETCO2 normal

A

35-40 mmHg

116
Q

ICP normal

A

5-15 mmhg

117
Q

BIS normal (awake)

A

80-100

118
Q

What is standardized gain on EKG?

A

1mV= 10 mm calibration

Therefore 1 mm ST segment change is accurately assessed

119
Q

How does oscillometry BP work?

A

Senses oscillations/fluctuations in cuff pressure

1st oscillation correlates with SBP
MAXIMAL degree of detectable pulse is the mAP
Oscillations cease at DBP

With oscillometry methods underestimate systolic and overestimate diastolic

Underestimate mean values during HTN
Overestimate mean during hypotension

120
Q

How long do you want to see color return in the Allen test?

A

6-10 seconds

121
Q

4 ways of NIBP (General)

A

Palpation
Doppler
Auscultation
Oscillometry

122
Q

How can you improve system dynamics and accuracy with arterial line?

A 
Minimize tube length
Limit stop cocks
No air bubbles
Mass of fluid small
Use non compliant, stiff tubing
123
Q

When does the systolic upstroke of the arterial line start?

A

180 seconds after R wave.

124
Q

What happens during interval b/w r wave and upstroke of arterial line?

A

Depolarization of ventricular myocardium
Isovolumetric left ventricular contraction
Opening of aortic valve
Left ventricular ejection
Propagation of aortic pressure wave
Transmission of the signal to pressure transducer.

125
Q

What are the actions for damped waveforms on Aline?

A 
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable
126
Q

Talk about pulse pressure variation

A

PPV is calculated as diff between maximal PPmax and PPmin pulse pressure during single respiratory cycle, divided by average of these two values

PPmax 150-70= 80
PPmin 120-60= 60
PPV= PPmax-PPmin/((PPmax+PPmin)/2)
(80-60)/((80+60)/2)= 29%

Normal 9-13% >13% needs fluids <9% should not receive intravascular expansion if 9-13, uncertain if volume would be helpful or not

In order to measure PPV accurately: TV 8-10mL/kg, PEEP >5, regular cardiac rhythm, normal intraabdominal presure, closed chest

127
Q

What happens with blood flow in heart during positive pressure ventilation?

A

Increase in lung volume compresses lung tissues, displaces blood within pulmonary venous reservoir into left heart chambers, this increases LV PRELOAD. Increase in intrathoracic pressure also decreases after load.

This increase in LV preload and LV afterload, produces an increase in LV SV, increase in CO, and arterial pressure.

128
Q

What does ASA/AANA standards for basic monitoring require for pulse ox?

A

Variable Pitch tone must be audible when in use

129
Q

What is the relationship between Sao2 AND pao2?

A

SaO2 is function of PaO2. The relationship b/w the two is described by O2Hb dissociation curve.

Curve is not linear, which means Sao2 CANNOT discriminate between normoxic and hyperoxic conditions.

SPO2 accuracy is reduced at values Lower than 70-75%

130
Q

What is the gold standard for SaO2 measurements when pulse ox inaccurate/unobtainable?

A

Co-oximetry

131
Q

Explain why the LIJ site is not preferred for CVC

A
  • Cupola of pleura is high on left, increasing risk fo pneumothorax
  • Thoracic duct might be injured during procedure as it enters venous system at junction of LIG and SCL vein
  • LIJ is often smaller than right
  • Injury might incur on right lateral walll of suprerior vena cava as the catheter transverse the left brachiocephalic vein and enter the SVC perpendicularly
132
Q

How much blood remains in ventricle after ventricular systole?

A

50-60mL of blood or ESV (end systolic volume)

133
Q

Size of pa Cather? Lumens?

A 
7 French (introducer is 8.5 for)
110 cm length marked at 10 cm
4 lumens
-distal port PAP
Second port 30 cm more proximal to CVP
3rd lumen balloon
4th wires for temp thermistor
134
Q

Size of CVC catheter?

A

7 French, 20 cm length

135
Q

Uses of TEE in OR

A 
Unusual causes of acute hypotension
Pericardial tamponade
Pulmonary embolism
Aortic dissection
Myocardial ischemia
Valvular dysfunction
Valvular function
Wall motion
136
Q

7 cardiac parameters observed

A

1) Ventricular wall characteristics and motion
2) Valve structure and function
3) Estimation of end-diastolic and end-systolic pressure and volumes
4) CO
5) Blood flow characteristics
6) Intracardiac air
7) Intracardiac masses

137
Q

Complications TEE

A

Esophageal trauma
Dysrhythmia
Hoarseness
Dysphagia

137
Q

Types of cardiac output monitoring

A 
Thermodilution
Continuous thermodilution
Mixed venous oximetry
Ultrasound
Pulse contour
138
Q

Arterial oxygen content

A

16-20. Normal 18

139
Q

Tell me about pulse ox

A

Method of measuring hemoglobin oxygen saturation (SPO2)

  • Non invasive
  • Measures transmission of light through a solution to the concentration of the solut in the solution (application of beer lambert law)

-Uses wavelengths of 660 (unoxygenated) and 940 (oxygenated)
Pulse oximeter is composed of light emitters and a photodectector

Use- hypoxemia and detection of perfusion

140
Q

Effect of methylene blue on SPO2 relative to Sao2?

A

Decrease

141
Q

Carboxyhemoglobinemia will do what to SPO2?

A

Increase

142
Q

Methemoglobinemia will do what to SPO2

A

Constantly reads 85%

Intro Nurse Anesthesia (5 decks)

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