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6902-cardiac > Monitoring > Flashcards

Monitoring Flashcards

1
Q

standard monitors

A

VOTC:

ventilation, oxygenation, temperature, circulation

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2
Q

cardiac surgery monitors in addition to standard

A

invasive BP, CVP, TEE, UOP, ABGs, neuromonitoring

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3
Q

Preload

A
  • tension on LV wall after diastole
  • LVEDP indirectly
  • increased preload=increased SV
  • determined by intravascular volume (determined by total body sodium-controlled by aldosterone), venous tone, and ventricular compliance
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4
Q

Contractility

A
  • -hearts ability to generate force

- chemical event from intracellular calcium

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5
Q

afterload

A
  • Tension on LV when aortic valve opens
  • indirectly measured by SVR
  • increased SVR=increased afterload and decreased SV
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6
Q

Arterial pressure monitoring
-ideal location
which artery?
US?

A

ideal location is acending aorta
-most common: radial (ulnar nerve supplies 90% of flow)

*US as rescue tecnique

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7
Q

reasons for arterial line

A
  • major surgery with blood loss or fluid shifts
  • CP bypass
  • Aortic surgery
  • need ABGs
  • shock
  • recent MI
  • permissive hypotension
  • hypotehtermic procedures
  • trauma
  • inotropic support
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8
Q

arterial line contraindications

A
  • local infections
  • coagulopathy
  • vasooclusive disease (raynauds)
  • harvesting sites
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9
Q

arterial line complications

A
  • infection (most common with femoral)
  • hematoma
  • spasm
  • thrombosis (long catheters for a long time)
  • ischemia
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10
Q

Arterial line waveform

A
  • systolic bp=peak
  • diastolic=trough
  • pulse pressure= peak-trough
  • contractility= upstroke
  • stroke volume= area under curve
  • closure of aortic valve=dicrotic notch
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11
Q

CVP why to do it

A
  • major surgery with fluid shifts and blood loss
  • massive trauma
  • ionotropic support
  • electrolyte or metabolic conditions requiring frequent sampling
  • TPN
  • high risk air embolism
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12
Q

CVP contraindications

A
  • SVC syndrome
  • coagulopathy (relative)
  • new pacer/aicd
  • surgical site access
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13
Q

CVP waveforms

A

a wave=contraction of RA
c wave= closure of tricuspid (RV contraction)
v wave= passive filling of RA, ventricular systole
x decent-atrial diastole
y decent= opening of tricuspid

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14
Q

CVP waveforms and cardiac cycle

A

A wave= RA contraction (just after P wave)
C wave= RV contraction (bulging of tricuspid into RA) (Just after QRS)
x decent= RA relaxation (ST segment)
V wave= passive filling of RA (just after T wave-ventricular repolarization)
Y descent= RA empties through open tricuspid (after t wave)

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15
Q

Normal CVP

elevations due to?

A 
1-10
mean=5
elevations due to:
RV disease
pulm HTn
pulmonic stenosis
TV disease (TR= tall v waves)
tamponade
restrictive cardiomyopathies
hypervolemia
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16
Q

CVP insertion sites

A
  1. IJ- short, straight course
    just under medial border of SCM (carotid is deeper and more medial)
    *use ultrasound
  2. EJ- valves, more difficult
    3.SC- increased risk of pneumothorax, tamponade, aortic injury
  3. basilic/cephalic- migrates with arm movement
  4. femoral- easiest (no US) higher infection rates
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17
Q

CVP complications

A
  • infection
  • hemorrhage (lungs deflated when inserting)
  • VAE
  • thrombosis
  • nerve injury
  • thoracic duct puncture
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18
Q

PA catheter indications,

measures directly and indirectly

A

*obtain hemodynamic parameters and check O2 delivery and demand
DIRECTLY:
CVP/RAP, RVP, PAP, PAOP, CO, mixed SvO2
INDIRECTLY:
SVR, PVR, CI, SVI, LVSWI, RVSWI, DO2, VO2

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19
Q

PA catheter contraindications

A
  • severe tricuspid or pulmonic disease
  • RA or RV mass
  • tetralogy of fallot
  • arrythmias
  • LBBB
  • new pacer wires (6 weeks)
  • severe coagulopathy
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20
Q

PA catheter complications

A
  • complete heart block
  • endobronical hemorrhage
  • pulm infarct
  • catheter knotting
  • valve damage
  • thrombocytopenia
  • thrombus
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21
Q

PA catheter indications

A
  • pulmonary HTN
  • cardiogenic shock
  • mixed shock
  • tamponade
  • transplant
  • mechanical complication of stemi (RV infarct, papillary muscle rupture, septal rupture)

*innapropriate (use non invasive): high risk surgery, septic shcok, heart failure, ARDS

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22
Q

PVR and SVR

A

-PVR= estimate of RV afterload. elevated in pulm htn
normal= 150-250
SVR= estimate of LV afterload. increased in LV wall stress
determinant of O2 consumption
normal=900-1400

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23
Q 
distance to the junction of vena cava and ra from:
subclavian
RIJ
LIJ
femoral
right median basilic
left median basilic
A 
subclavian: 10cm
RIJ: 15cm
LIJ: 20cm
femoral: 40cm
right median basilic: 40cm
Left median basilic: 50cm
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24
Q 
distance from RIJ to distal structures:
Cavoatrial junction
RA
RV
PA
wedge
A 
cavoatrial junction: 15
RA: 25-35
RV: 35-45
PA: 45-55
wedge: 50-60
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25
Q

Goal placement of PAC and details about zone

A

west lung zone III. bulk of pulmonary blood flow is in this region. provides most accurate estimate of LVEDP

zone III: arterial pressure >venous pressure>alveolus pressure

  • *it is the DEPENDENT region of lungs
  • base when sitting
  • towards back when supine
  • towards chest when prone
  • towards dependent lung in lateral

*tip in zone I or II –> variations in PAOP, lost a and v waves, PAOP>PADP

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26
Q 
Normal pressures:
RA
RV
PA
Wedge
LA
LVEDP
A 
RA: 5
RV: 25/5
PA: 25/10 (quarter over dime)
Wedge: 10
LA: 8
LVEDP: 8
27
Q

PAOP waveforms

A
  • a wave: LA systole
  • c wave: LV systole- upward displacement of mitral valve into LA
  • V wave: passive LA filling
28
Q

distortion of CVP and PAOP waveforms

  • no a waves
  • giant a waves
  • large v waves
A
  • no a waves: a fib, ventricular pacing
  • large a waves: junctional rhythms, complete heart block, diastolic dysfunction, tricuspid or mitral stenosis (atrium tries to contract against closed valve- tricuspid or mitral)
  • large v waves- tricuspid or mitral regurg, acute increase in volume
29
Q

increased CVP causes

A
  • RV failure (back pooling)
  • TS or TR
  • cardiac tamponade (restricted ventricular emptying)
  • constrictive pericarditis (restricted ventricular emptying)
  • volume overload
  • pulm HTN (backing up)
  • LV failure
30
Q

Elevated RV pressures

systolic and diastolic

A 
-systolic: pulmonary issue causing RV to pump into stenotic vessel
pulmonary HTN (high RA- >25 and high PA)
Pulmonary stenosis (high RA, normal PA)
PE
-diastolic: RV issues causing limited filling
cardiomyopathy
RV ischemia
cardiac constriction
tamponade
RV failure
31
Q

monitoring limitations

A
  • CVP does not approximate PADP with change in RV compliance or tricuspid disease
  • PADP does not approximate PAOP with pulm HTN, MR or AR, lung zone II or III, tachycardia, ARDS, RBBB
  • PAOP does not approximate LAP with PEEP, lung zone II or III, mediastinal fibrosis, RBBB
  • LAP does not approximate LVEDP with PEEP, mitral valve disease, change in LV compliance, pulm disease
  • LVEDP does not approximate LVEDV with PEEP, change in LV compliance (ischemia)
32
Q

pressures in LV failure

A

high CVP, high PADP, high PAOP

blood backing up through pulmonary circuit

33
Q

pressures in RV failure

TS or TR

A

high CVP, normal or low PADP, normal or low PAOP

blood backing up systemically. unable to eject into pulmonary circuit

34
Q

pressures in PE

A

high CVP, high PADP, normal or low PAOP

35
Q

pressures in pulmonary HTN

A

high CVP, high PADP, normal PAOP

36
Q

pressures in tamponade

A

high CVP, high PADP, high PAOP

37
Q

pressures in LV ischemia or MR

A

normal CVP, high PADP, high PAOP

blood backing up into pulmonary circuit

38
Q

pressures in ARDS

A

low CVP, high PADP, normal PAOP

39
Q

pulse ox

A
  • based on beer lambert law. 2 waves of light
  • red light- preferentially absorbed by deoxyhemoglobin (higher in venous)
  • near infrared light-preferentially absorbed by oxyhemoglobin (higher in arterial)
  • need pulsatile flow
  • at <60mmhg pao2 steep decline in SpO2
40
Q

SVO2

A

normal= 65-75%

decreases when decreased O2 delivery or increased O2 consumption

41
Q

ECGs

  • 3rd degree block
  • AV dissociation
  • bundle branch blocks
  • digitalis
  • electrolytes (Ca, K)
  • hypothermia
  • pericarditits
  • tamponade
  • pneumo
  • PE
  • subarachnoid hemorrhage
  • WPW
A
  • 3rd degree: atria/ventricles beat independent, NO p wave conducted through
  • AV dissociation: atria and ventricles beat independent, p wave IS conducted through
  • bundle branch blocks: complete=QRS>.12, incomplete = QRS .10-.12
  • digitalis: ST segment sloping
  • hypercalcemia: increased PR, decreased QT
  • hypocalcemia: increased QT
  • hyperkalemia: increased QT, peak t wave
  • hypokalemia: u wave
  • hypothermia: bradycardia, prolonged PR and QT
  • pericarditis: diffuse ST and T wave changes
  • tamponade: low voltage p wave
  • pneumo: right axis deviation, decreased QRS amplitude, inverted T waves in V1-V6
  • PE: Q waves in III and AVl
  • subarachnoid: t wave inversion, prominant U waves, bradycardia
  • WPW: short PR interval, wide QRS * avoid digoxin (increases conduction through bundle of kent)
42
Q

ischemia on ECG

  • earliest sign
  • depolarization order
A
  • earliest deterction intraop is from TEE (see diastolic dysfunction first)
  • earliest sign on ECG is iso-symmetrical t-waves in 2 leads
  • J point elevation 0.1 or hihger in any lead (except V2, V3) required for STEMI in 2 or more contiguous
  • ventricular depolarization goes endocardium to epicardium (in to out)
  • ST elevation correlates with offending vessel. can have depression in recipricol leads
  • typically see ST elevation, t wave increase, presence of Q waves
43
Q

inferior MI (second most sensitive)

A

II, III, aVF

RCA

44
Q

Posterior

A

recipricol changes in V1-V4 (dont monitor posterior)
R waves, ST and T depression
Left cirfumflex

45
Q

Lateral (most sensitive)

A

I, aVL, V5, V6

left circumflex

46
Q

anterior

A

V3, V4

LAD

47
Q

septal

A

V1-V4

LAD

48
Q

EEG

laws

A

postsynaptic APs of cortical neurons

  1. EEG amplitude and frequency are inversely related
  2. simultaneous decrase indicates hypothermia, ischemia, anoxia, or excessive hypnosis
  3. simultaneous increase indicates seizure or artifact
49
Q

eeg waves

A

beta- awake
alpha-moderate sedation
-theta-general anesthesia
-delta-deep anesthesia

50
Q

BIS

A

40-60=general anesthesia

51
Q

transcranial doppler

A

US waves transmitted through temporal bone

52
Q

jugular bulb oximetry

A

measures cerebral venous sat through catheter
55-70%=normal
global measurement (cant detect focal ischemia)

53
Q

cerebral oximetry

A
  • noninvasive. uses infrared light
  • non pulsatile (use for CPB)
  • normal = <20% of baseline
54
Q

coagulation in bypass

A

CPB produces massive inflammatory response-activates clotting cascade use heparin

55
Q

heparin

A

binds to antithrombin III and increases efficacy. (non functional if low endogenous antithrombin III). inhibits factor x –> inhibits prothrombin–> thrombin

56
Q

protamine reversal

A

1mg protamine reverses 100 units of heparin

protamine can cause anaphylaxis- hypotension, right HF, pulm edema, platelet inhibition

57
Q

ACT

A

normal=80-120

CPB= 300-400

58
Q

aPTT

A

intrinsic and final

normal 28-32

59
Q

PT

A

extrinsic and final
normal 12-14
guide coumadin

60
Q

heparin resistance

A

due to competitive antagonism, need to increase dose

61
Q

HIT

A

autoimmune reaction. platelet consumption forming clots but still bleeding. usually 5-14 days after heparin

62
Q

TEG

A

looks at integrity of platelets and clotting cascade to evaluate clot strength and ability to maintain hemostasis through breakdown

63
Q 
TEG parts
R time
K time
alpha angle
MA
lysis at 30 min
A
  • R time (5-10 minutes) time to start forming clot. problem with coagulation factors. tx with FFP
  • K time (1-3 minutes) time until clot reaches a fixed strength. problem with fibrinogen. tx with cryo
  • alpha angle (53-72 degrees) speed of fibrin accumulation. problem with fibrinogen. tx with cryo
  • MA (50-70mm) highest verticle amplitude of TEG. platelets
  • lysis at 30 min (0-8%) if higher-problem with fibrinolysis. tx with TXA

6902-cardiac (2 decks)

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