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SRNA4TopicsAnesthesia > M&M: CV Monitoring > Flashcards

M&M: CV Monitoring Flashcards

1
Q

During systole LV

A

ejects blood into vasculature, resulting in BP

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2
Q

As pulse moves through the arterial tree what happens to the wave?

A

Wave reflection distorts the pressure waveform

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3
Q

Systolic BP is the

A

peak pressure generation during systolic contraction

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4
Q

Diastolic BP is the

A

Trough pressure generation during diastolic relaxation

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5
Q

what is pulse pressure?

A

the difference between the systolic pressure and the diastolic pressure.

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6
Q

What is the MAP

A

Average arterial pressure during a pulse cycle.

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7
Q

Any anesthetic delivery is an absolute indication for

A

Arterial BP measurement.

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8
Q

Frequncy of BP measurement should be

A

every 3-5 minutes.

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9
Q

Contraindications to BP measurement with cuff

A

Vascular abnormalities or IV lines (shunts and stuff)

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10
Q

Why is arterial blood pressure used as a measure of organ blood flow?

A

Because intruments that monitor specific organ perfusion and oxygenation are complex, expensive and often unreliable.

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11
Q

Cuff bladder should extend at least

A

halfway around the extremity

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12
Q

Cuff width should be

A

20-50% greater than the diameter of the extremity

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13
Q

Palpation method to measure SBP

A

occluding flow at a palpable peripheral pulse with a BP cuff. The pressure is release 2-3 mmHg per heartbeat, until the pulse is again palpable

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14
Q

What is the doppler effect?

A

shift in sound wave frequency when a source moves relative to an observer.

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15
Q

When should the doppler probe be placed?

A

Positioned directly above an artery so that the beam passes through the vessel wall.

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16
Q

What is the only thing that can be reliably detected by the doppler technique

A

Only systolic pressure.

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17
Q

Maximal oscillation with Oscilllometry occurs at

A

MAP after which oscillations decrease

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18
Q

Automated BP monitors derive

A

SBP, MAP and DBP which is the pressure at which oscillation amplitudes change.

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19
Q

Arterial tonometry

A

pressure transducers are applied to the skin overlying an artery. Beat to beat BP is sensed by the pressure required to partially flatten the artery.

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20
Q

Invasive arterial BP monitoring indications

A

Induced hypotension
Anticipitated wide BP swings
End-organ disease necessitating precise beat to beat BP

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21
Q

Contraindication of Invasive arterial BP monitoring

A

inadequate collateral blood flow or suspicion of vascular insufficiency (Raynaud phenomenon)

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22
Q

Radial artery inadequate collateral flow occurs in______ % of patients

A

5%

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23
Q

Why does some people of inadequate collateral flow ?

A

incomplete palmar arches

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24
Q

How can you access ulnar collateral circulation?

A

Allen’s test, doppler probe, Plethysmography or pulse ox.

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25
Q

Brachial artery and distortion: Advantage

A

Large and easily ID , LESS waveform distortion because it’s proximity to the aorta.

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26
Q

Brachial artery disadvantage:

A

Kinking of the catheter during the flexion of the elbow.

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27
Q

Femoral artery disadvantage:

A

Prone to pseudoaneurysm and atheroma formation.

INCREASE RISK OF INFECTION>

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28
Q

The most distorted waveforms arteries

A

Dorsalis pedis and posterior tibial arteries.

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29
Q

Axillary artery more at risk for

A

Brachial plexus damage

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30
Q

Flushing the left axillary arteyr can easily result in

A

Transmission of air or thrombi to the cerebral circulation.

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31
Q

2 things that Provide optimal exposure of the radial artery

A

Supinate

Wrist extension

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32
Q

How is the radial artery course determined by

A

lightly palpating over the maximal impulse of the radial pulse with the fingertips

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33
Q

Explain the procedure of inserting an aline

A

Skin is prepped
0.5ml of lidocaine is infiltrated directly above the radial artery
20-22 ga cath over a needle is passed through the skin at 45 degree angle directed toward the point of palpation
Blood flashback, guidewire may be advanced through the catheter into the artery
the needle is lowered to 30 degree and advanced 1-2 mm to ensure the catheter tip is in the vessel.
Needle is withdrawn while firm pressure is applied over the artery proximal to the catheter tip to minimize blood loss as the tubing is being connected.

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34
Q

Complications of arterial blood pressure monitoring:

A

Hematoma
Vasospasm
Bleeding
arterial thrombosis

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35
Q

Factors associated with increases rate of complications:

A

Prolonged cannulation, hyperlipidemia, repeated insertion attempts, female gender, extracorporeal circulation, use of vasopressors.

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36
Q

Complications of A line can be minimized by

A

heparinized saline continuous at a rate of 2-3 ml/hr

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37
Q

What is the gold standard of BP monitoring

A

Beat to beat monitoring via arterial cannulation

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38
Q

The transduced waveform depends on the

A

Dynamic characteristics of the catheter-tubing transducer system.

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39
Q

Can lead to OVERDAMPING

A

Tubing, stopcocks and air

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40
Q

Overdamping lead to

A

underestimated systolic pressure.

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41
Q

Underdamping lead to

A

overshoot and a falsely high

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42
Q

What can improve system compliance

A

low compliance tubing
Minimizing tubing and stopcocks
Remove air bubbles.

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43
Q

How does transducers work?

A

Convert mechanical energy of the arterial pressure to an electrical singal and their accuracy depends on the correct calibration and zeroing procedures.

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44
Q

Motion and electrocautery on waveform

A

misleading arterial waveform

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45
Q

Rate of upstroke of the aline indicates

A

Contractility

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46
Q

Rate of downstroke of the aline indicates

A

Peripheral vascular resistance

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47
Q

Exaggerated variations in size for aline during the respiratory cycle suggest

A

Hypovolemia

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48
Q

How is MAP calculated with aline by doing what?

A

Intergrating the area under the pressure curve.

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49
Q

ECG leads are positioned throughout the body to

A

provide different perspectives of the electrical potentials.

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50
Q

What determines the sensitivity of the ECG

A

Lead selection

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51
Q

Lead II results in the

A

Largest P wave voltages of any surface lead.

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52
Q

Lead V liest at the

A

5th ICS at the anterior axillary line.

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53
Q

A true V5 required

A

At least 5 lead wires

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54
Q

What can cause artifacts?

A

Electrocautery

Faulty electrodes

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55
Q

Can be printed to compare with intraoperative settings

A

Preinduction rhythm strip

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56
Q

To interpret ST segment changes properly, ECG must be

A

Standardized so that 1-mV signal results in a deflection of 10mm on a standard strip monitor.

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57
Q

CVC - CVP monitoring good for

A 
fluid administration to treat hypovolemia and shock
infusion of caustic drugs
TPN
Aspiration of air emboli
Insertion of Transcutaneous pacing leads
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58
Q

Contraindications to CVC

A

Tumors, clots or Tricuspid vegetations that can be dislodged during cannulation
Ipsilateral carotid endarterectomy

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59
Q

CVC catheter tip should be placed where?

A

Tip should lie at the junction of the SVC and the RA

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60
Q

Most Central lines placed using what technique?

A

Seldinger techniques.

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61
Q

This is crucial during CVC

A

IJ vein be cannulated because carotid artery cannulation can lead to hematoma, stroke and AIRWAY COMPROMISE

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62
Q

The risk of vein dilator or catheter placment in the carotid artery can be reduced by ?

A

transducing the vessel’s pressure waveform or comparing the blood PaO2 with an arterial sample.

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63
Q

What else can confirm the placment other than transducing the vessel pressure?

A

TEE

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64
Q

Risks of central venous cannulation are

A

infection
air thrombus
arrhythmias
Pneumothorax

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65
Q

WIth central venous cannulation, arrhythmias indicates that

A

Catheter tip is in the RA or RV.

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66
Q

Cannulation of this vein is highly assoiated with significant risk of pneumothorax?

A

Subclavian

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67
Q

Central vein cannulation risk associated with left sided catheterization ?

A

risk of vascular erosion
Pleural effusion
chylothorax.

68
Q

CVP approximates ____pressure

A

RAP

69
Q

Noncompliant ventricles have

A

larger pressure swings with smaller volume changes.

70
Q

Compliant ventricle accomodate

A

High volume with minimal changes in pressure.

71
Q

Better indicator of the patient’s volume responsiveness with

A

Changes associated with volume loading when compulse with other hemodynamic measures (BP, HR, UO)

72
Q

a wave on the CVP waveform associated with

A

Atrial contraction

73
Q

a waves are absent during

A

Afib

74
Q

a waves are EXAGGERATED with

A

Junctional rhythm

75
Q

Cannon a waves seen with

A

JUnctional rhythms

76
Q

c waves caused by

A

Tricuspid valve elevation during early ventricular contraction

77
Q

V waves reflect

A

venous retunr against a closed tricuspid valve.

78
Q

x descent is the

A

downward displacement of the tricuspid vlave during systole

79
Q

y descent is the

A

tricuspid valve opening during diastole.

80
Q

Central venous catheter cannulation landmarks

A

IJ
clavicle
Medial and Lateral head sternocleidomastoid
Mastoid process.

81
Q

Best position for CVC

A

Trendelenburg.

82
Q

What does the PAC provide measurements of

A

CO and PaOP

83
Q

Determination of the PA occlusion or wedge pressure permits estimation of what 2 parameters?

A

LVEDP and ventricular volume.

84
Q

The PAC can only help measure the LVEDP and ventricular volume in the absence of what?

A

Mitral stenosis

85
Q

What is the formula of CO?

A

CO = HR x SV

86
Q

What is the formula for BP?

A

BP = CO x SVR (VIR omh’s law)

87
Q

Numerous studies for PAC indicated that

A

Patients with managed PA did worse than patient w/o PA

88
Q

Relative Contraindications to a PAC why?

A

Left BBB because of the risk of complete HB

89
Q

Relative contraindications to a PAC with arrythmias

A

WPW; ebstein malformation *because of possible tachydysrhythmias , need a catheter with pacing ability

90
Q

Possible complications of PAC

A

PULMONARY ARTERY RUPTURE.
Bacteremia
Endocarditis
Pulmonary infarction

91
Q

How many lumen in a popular PAC? size?

A

5 lumen; 7.5 Fr catheter

92
Q

Length of the PAC

A

110cm

93
Q

Proximal port of the PAC is how far from the tip

A

30 cm from the tip

94
Q

Ventricular port of the PAC is how far from the tip

A

20 cm for infusions.

95
Q

Distal port of the PAC is for what?

A

Aspiration of mixed venous blood samples and measurements of PAP

96
Q

Insertion of PA catheter requires

A

central venous access

97
Q

When inserting a PAC instead of a central venous catheter was is inserted?

A

A dilator and a sheath are threaded over the guidewire.

98
Q

During the PAC advancements the ECG should be monitored for

A

Arrhythmias

99
Q

Transient ectopy during PAC insertion from irritation of the

A

RV by the catheter

100
Q

At what point should the PAC enter the RA?

A

15cm

101
Q

During insertion, when is the balloon inflated

A

after 15-20 cm when the catheter is estimated to be in the RA.

102
Q

Why is the balloon inflated during insertion of a PAC?

A

to allow the RV’s cardiac output to direct the catheter forward

103
Q

What should be done with withdrawal ?

A

balloon should be deflated

104
Q

During PAC insertion , you noticed a sudden increase in the systolic pressure, what is the meaning?

A

Indicates the catheter is in the RV>

105
Q

What indicates entry to the PA with the PAC insertion?

A

Sudden increase in diastolic pressure.

106
Q

Entry to PA normally occur at ______Cm

A

35-45 cm

107
Q

After attaining PA position, to obtain PAOP

A

minimal advancement should be done

108
Q

The PA tracing should reappear after

A

the balloon is deflated.

109
Q

If you notice wedging before maximal inflation of the balloon, what does it mean and what should be done?

A

an overwedged position, and the catheter should be slightly withdrawn with the balloon down.

110
Q

Minimize this with PAC and why?

A

minimize frequency of wedge readings because of the risk of PA rupture.

111
Q

What can confirm the PAC position?

A

Chest Radiograph *Xray

112
Q

Allow continuous measurement of mixed venous blood oxygen saturation?

A

Optional fiberoptic bundles

113
Q

Wedge pressure and PAOP: how does it measure wedge

A

When the distal lumen is properly wedged the PAC is isolated from right-sided pressure by the ballon, therefore, its distal opening is exposed only to PULMONARY CAPILLARY PRESSURE

114
Q

PAOP or pulmonary capillary wedge pressure (PCWP) equals

A

Left atrial pressure

115
Q

PAOP is only accurate at measuring PCWP or PAOP in the absence of

A

High airway pressure

Pulmonary vascular disease.

116
Q

When is the Relationship between PAOP and LVEDP unreliable?

A

Conditions with left atrial or ventricular compliance,
Mitral valve function
Pulmonary vein resistance

117
Q

Conditions in which PAOP > LVEDP (PEML)

A

Pulmonary venous obstruction
Elevated alveolar pressure.
Mitral stenosis
Left atrial myxoma

118
Q

Conditions in which PAOP < LVEDP (DA)

A

–Decreased LV compliance (stiff ventricle or LVEDP >25mmHg)

–Aortic insufficiency

119
Q

CO : thermodilution techniques

A

A known quantity of fluid that is below body temp is injected into RA
Changes in temp of blood in contact with PAC thermistor
The degree of changes is inversely proportional to CO

120
Q

Thermodilution: CO is measured in

A

Area under the curve

121
Q

The degree of change is _______proportional to CO

A

Inversely

122
Q

Factors that determine accurate measurements

Injection, temp, volume, computer, electrocautery

A

rapid and smooth injection
precise injectant temperature and volume
correct computer calibration factors for the type of PAC
avoidance of measurements during electrocautery

123
Q

Factors accurate PA measurements: physiologic

A

absence of tricuspid regurgitation and cardiac shunts.

124
Q

Transpulmonary thermodilution:

A

Uses thermodilution w/o PAC requires central line and a thermistor equipped. USUALLY FEMORAL not radial arterial catheter.

125
Q

Transpulmonary thermodilution determine

A

CO and global end-diastolic volume and extravascular lung water.

126
Q

Cardiac output: dye dilution:

A

Is injected through a central venous catheter.

127
Q

Use only for patients with peripheral access

A

Lithium Chloride (LiDCO)

128
Q

Lithium should not be administered to patients in the

A

1st trimester of pregnancy

129
Q

CO : pulse contour devices

A

Arterial pressure trace is used to estimate CO and parameters such as pulse pressure (PPV) and stroke volume variation (SVV)with mechanical ventilation

130
Q

SVV can only be measured with

A

mechanical ventilation.

131
Q

SVV may suggest whether or not

A

Hypotension is likely to respond to fluid therapy

132
Q

Pulse contour devices rely on algorithms that measure

A

The area of the systolic portion of the arterial pressure trace from end diastole to the end of ventricular ejection.

133
Q

Pulse contour devices must compensate for

A

dynamic vascular compliance.

134
Q

CO: Esophageal doppler relies on the

A

Doppler principle to measure the velocity of blood flow in the descending thoracic aorta.

135
Q

With Esophageal doppler, Blood in the aorta is in relative motion

A

compared with the doppler probe in the esophagus.

136
Q

How does the esophageal doppler work

A

When blood flows toward the transducer, its reflected frequency is higher than that which was transmitted by the probe. When blood cells move away the frequency is lower than that which was initially sent by the probe.

137
Q

What is used to determine the velocity of blood flow in the aorta when an esophageal doppler?

A

Doppler equation

138
Q

With esophageal doppler the monitor approximates the area in the

A

Descending aorta using normograms . The SV in the DESCENDING AORTA is calculated.

139
Q

Knowing the HR with esophageal doppler, allows

A

calculation of that portion of the CO flowing through the descending thoracic aorta, which is approximately 70% of CO. Correcting for this 30% allow the monitor to estimate that patient’s total CO.

140
Q

CO : Thoracic bioimpedance method

A

6 chest electrodes inject microcurrents and sense bioimpedance. Changes in thoracic volume cause chnages in thoracic resistance (bioimpedance) to low amplitue, high frequency currents.

141
Q

Cardiac output : FICK Principle

A

Amount of oxygen consume by an individual (VO2) equals the difference between arterial and venous (a-v) oxygen content (C) (CaO2 and CvO2) multiplied by the CO.

142
Q

Fick’s principle FORMULA: Long

A

CO = Oxygen consumption / a-v O2 content difference (Ca-Cv)

143
Q

Fick’s formula

A

CO = VO2 / Ca-Cv

144
Q

Oxygen consumption can be calculated from the difference between the

A

Oxygen content in inspired and expired gas.

145
Q

Cardiac output : Echocardiography uses

A

ultrasound to generate images of heart structures.

146
Q

TTE invasiveneness and disadvantage?

A

Noninvasive; yet difficult to acquire windows to view the heart.

147
Q

Ideal option to visualize the heart is (TTE vsTEE)

A

TEE

148
Q

Basic hemodynamic information provided by the TEE

A 
Source of hemodynamic instability
Whether the heart is adequately volume loaded
Contraction good or bad (MI, HF)
Not externally compressed
OBVIOUS structural defects
149
Q

What information is provided by advanced TEE?

A

Form the basis therapeutic and surgical recommendations.

150
Q

Echocardiography uses the _____effect to do what?

A

Doppler effect, to evaluate the direction and velocity of blood flow and tissue movement. Using the doppler , it is possible to ascertain the maximal velocity as blood accelerates through a pathologic heart structure such as stenotic aortic valve.

151
Q

Echocardiography uses those 2 things

A

Doppler Effect

Bernoulli equation.

152
Q

Bernouli equation is

A

Pressure change = 4V^2 (V is the area of maximal velocity)

153
Q

What does bernoulli equation allow us to do?

A

Determine the pressure gradient between areas of different velocity .

154
Q

How does color-flow doppler work?

A

Creates a visual picture of the heart’s blood flow by assigning a color code to the velocities in the heart.

155
Q

With color-flow doppler, blood flow directed away from the echocardiographic transducer is colored

A

blue

156
Q

With color-flow doppler, blood flow directed towards the echocardiographic transducer is colored

A

RED

157
Q

Flow pattern changes are used to identify areas of

A

pathology

158
Q

Cardiac output can be measure with TTE or TEE based on what principle?

A

Assuming that the Left ventricular outflow tract is a cylinder, diameter can be measured and then the area through which the blood flow is calculating using the equation AREA= 0.785 x Diameter ^2 . A doppler BEAM is aligned in parallel to the LVOT, AND the velocities passing through it are used by the computer to integrate the velocity /time curve to determine the distance that the blood traveled.

159
Q

CO measurement with TTE or TEE is using the formula

A

Area = 0.785 x Diameter ^2

160
Q

Normal Tissue velocity is

A

8-10cm /s

161
Q

Reduced myocardial velocities associated with

A

impaired diastolic funciton

High LVED pressures

162
Q

Valve replacement surgery necessitates what kind of monitoring? why?

A

Arterial blood pressure monitoring; because of anticipated BP swings and the need for precise beat-to-beat BP regulation to guide the administration of vasoactive medications.

163
Q

Pt has a hx of vascular insufficiency such as RAYNAUD phenomenon, is radial artery a contraindications?

A

No

164
Q

This valve stuck can lead to increased airway pressures

A

Stuck expiratory valve.

165
Q

Beta blocker and bronchospam

A

May exacerbate bronchospasm

166
Q

Mainstem intubation would likely have presented as

A

Increased airway pressure RIGHT AFTER INTUBATION.

SRNA4TopicsAnesthesia (47 decks)

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