Monitoring Cardiac/noncardiac Flashcards
1
Q
what needs to be documented every 5 mins for all anesthetics
A
BP
HR
RR
2
Q
what reading does methemoglobin give and why
A
85%, absorbs red and infrared light equally
3
Q
what does an increased alfa angle suggest
A
expiratory airway obstruction
-copd, bronchospasm, kinked et tube
4
Q
what can cause increased dead space causing low etco2
A
PE
5
Q
what does an increased beta angle suggest
A
rebreathing due to faulty inspiration valve
soda lime
6
Q
if you intubate too deep, where is tube most likely to go
A
right lung, shorter straighter
7
Q
what needs to be monitored when giving neuromuscular blocking agents
A
neuromuscular function and status
8
Q
how can temperature affect blood loss
A
big temp change can increase blood loss
9
Q
what needs to be monitored continuously on all pediatric (<12) patients receiving general anesthesia and when indicated on other pts
A
body temp
10
Q
what monitors are necessary
A
lung sounds-stethoscope
inspired o2 concentration- gas analysis
expired gas analysis
spo2
pulmonary/chest wall mechanical function
11
Q
what does pulmonary chest wall mechanical function include
A
inspiratory pressures, respiratory volumes
12
Q
what should be monitored continuously on all patients
A
oxyegnation
13
Q
what are the three ways of verify intubation listed on standard 9
A
auscultation,
chest excursion,
confirmation of co2 in expired gas
14
Q
what should be continuously monitored during controlled or assisted ventilation with any artificial airway support
A
ETCO2
15
Q
what is recommended by standard 9 for alarms
A
have threshold and variable pitch audible alarms
16
Q
how many breaths at minimum are needed for etco2 to avoid misinterpretation
A
6 breaths
17
Q
what prevents 93% of anesthetic mishaps
A
pulse oximetry and capnography
18
Q
how is co2 analysis helpful in gas monitoring
A
assesses ventilation and detects equipment/patient problems
19
Q
what are advantages of side stream sampling
A
lightweight,
less chance of disconnect,
accurate <40 breaths/min,
no dead space
20
Q
what are disadvantages of side stream monitoring
A
water/secretions may clog line,
flexible tube easily obstructed,
inaccurate >40 breath so no peds
21
Q
describe side stream sampling
A
pump in monitor aspirates sample of gas through thin/flexible sampling line
22
Q
what monitoring sampling measures gas directly in breathing system
A
mainstream aka non diverting
23
Q
what are advantages of mainstream sampling aka non diverting
A
fast,
good fidelity,
water and secretions not an issue
24
Q
which sampling method can increase etco2
A
mainstream sampling by increasing dead space
25
what are disadvantages of mainstream sampling aka non diverting
heavy in circuit,
increases dead space,
greater opportunity for disconnect,
gas options limited
26
what co2 analysis is ph sensitive, co2 presence changes color, and used most often by ems
colorimetric co2 analysis
27
if you intubate and get color change after 1 breath, what could be a problem
could be co2 from stomach
28
what is the measurement and numerical display of co2 concentrations during respiratory cycle
capnometry
29
what is a graphic record of co2 concentration on screen or paper
capnography
30
what is the actual waveform genered by capnometer
capnogram
31
what may be detected due to abnormalities in capnography
airway obstruction
32
what is produced by cells of body during metabolism into circulatory system and then is diffused into lungs
CO2
33
what is a better indicator of rosc during resuscitation
exhaled CO2
34
what cardiac changes can etco2 aid in detecting
decreased cardiac output,
pulmonary embolism,
reduced blood flow to lungs
35
what guides ventilator changes and can give a trend of anesthesia depth
CO2
36
what could a sudden increase in co2 represent during code
spontaneous cardiac function/output
37
what is difference between etco2 on monitor and blood
blood is usually 5 higher than monitor
38
What are some complications that can happen that etco2 can help alert to
esophageal intubation,
apnea,
extubation,
disconnection,
ventilator malfunction,
ett partial obstruction,
compliance vs resistance changes,
spontaneous resp w/muscle relaxant use,
poor lma fit,
leaking ett cuff
39
what is phase 1 in capnography (A)
inspiratory baseline- 0- low valley
40
what could be a problem if your co2 isn't reading 0 during phase 1
co2 canister needs to be changed out
41
what is phase 2 in capnography and what letters are in it
initiating exhale- b- c
42
what is phase 3 in capnography and what letters are in it
plateau c-d
no plateau= not reading correctly
43
how is slope of phase 3 increased
kink,
ventilation perfusion status,
44
what is phase iv in capnography and what letters are in it
end tidal point down to zero (inhalation)
d-e
45
what is the letter with the highest co2 number on capnography
d- 35-40 torr
46
how wide is alpha angle and when is it increased
100-110 d,
increased with obstructive lung diseases because of increased dead space taking longer to exhale
47
in capnography what does gradual sloping indicating
taking alveoli longer to expel co2 from lungs= copd
48
what is beta angle degrees and when is it increased or decreased
90 d -
increased with rebreathing co2
49
in capnography, what does height depend on
etco2
50
what is the minute ventilation equation
tidal volume x respiratory rate
51
in capnography, what does frequency depend on
respiratory rate
52
what can shape of capnography indicate
lung compliance
53
what are some causes of etco2 and paco2 to be increased
age,
pulmonary disease,
pulmonary emboluse,
low cardiac output,
hypovolemia
54
what does the noninvasive estimate of paco2 assume
2-5 mmHg difference between etco2 and paco2
55
what could cause no co2 in gas line
obstruction,
disconnection,
esophageal intubation,
no blood circulation to lungs
56
what causes etco2 to increase
hypoventilation,
MH,
sepsis,
rebreathing,
bicarb administration,
extremity tourniquet/aortic clamp,
insufflation of co2 during laparoscopy
57
what causes of etco2 to decrease
hyperventilation,
hypothermia,
low cardiac output,
pulmonary embolism,
accidental disconnect,
tracheal extubation,
cardiac arrest
58
what are the kinds of volatile anesthetic measurement
infrared analysis,
refractometry,
piezoelectric analysis
59
what uses each anesthetic gas's ability to absorb specific frequencies of emr in the infrared spectrum
infrared absorption analysis
60
what compares mass to charge ratio of gases and places them into a spectrum- most commonly used
mass spectrometry
61
what anesthesia gas monitoring compares ratios of Fi and et of o2, n2, co2, and n2o
mass spectrometry
62
what anesthesia gas monitoring has advantages of being fast, reliable, low cost, multiagent/multigas
mass spectrometry
63
what anesthesia gas monitoring has disadvantages of warm up time, space, must be scavenged, and measures only preprogrammed gases
mass spectrometry
64
what has a laser that interacts with gas molecule and measures the fraction of energy absorbed at different live wavelengths called scattering
raman spectrometry
65
what anesthesia gas monitoring is less accurate with pediatric cases, since they use high carrier gas flow rates and small tidal volumes
raman spectrometry
66
what are disadvantages of raman spectrometry
costly,
less accurate in pediatrics
67
what are advantages of raman spectrometry
no scavenging,
accurate,
fast multi-gas/agent
68
what do you need to do with o2 flow sensor (galvanic cell)
calibrate to room air,
degrade in 30 days
69
what does vaporizer output assess
detects incorrect agents
detect vaporizer turned off/empty
provides info on uptake and elim of agent in pt
70
what does a galvanic cell play a role in analyzing
o2 analysis
71
what law explains pulse oximetry
lambert beer law
72
what instrument uses a mathematical means of expressing how light is absorbed by matter
pulse ox
73
what are two main types of oximetry
fractional, functional
74
what kind of oximetry measures arterial oxygen saturation (Sao2)
fractional oximetry
75
what kind of oximetry is only measurable by arterial blood sample
fractional ox
76
what absorbs more red light and what is the light wavelength
deoxyhemoglobin- 660
77
what absorbs more infrared light and what is light wavelength
oxyhemoglobin - 940
78
if you are seeing more red light than infrared light what is happening with oxygen
higher oxygen- more infrared light being absorbed means higher oxygen content
79
if you are seeing more infrared light, what is happening to oxygen
decreasing oxygen- more red light being absorbed into deoxyhemoglobin means less oxygen content
80
what is the formula for fractional oximetry
oxyhemoglobin/(oxyhemoglobin+deoxyhemogobin+methemoglobin+carboxyhemoglobin)
81
in 100% pulse ox, which light will you see most of
red light- infrared has been absorbed into oxyhemoglobin
82
what is the formula for functional oximetry
functional oximetry-oxyhemoglobin/(Oxhemoglobin+deoxyhemoglobin)
83
what kinds of light flash hundreds of times per second in pulse ox
red and infrared light
84
what does a pulse ox rapidly sample from each pulse wave
peak and trough
85
what is a trough in pulse ox
vascular bed has arterial,
capillary,
venous blood,
and tissue density
86
what is a peak in pulse ox
all of blood from trough + additional arterial blood
87
when is pulse ox inaccurate
methemoglobin,
methylene blue,
carboxyhgb messes up pulse ox- do abg for real oxygen reading
88
what is it called when neither red or infrared light is emitted from pulse ox
off period
89
what are causes of low etco2
hyperventilation,
decreased co2 production,
alveolar dead space
90
how does a cerebral oximeter work
does not require pulsatile flow, gets readings from vascular beds- also tries to measure arterial through
parabolic arch
91
below what reading is pulse ox not reliable
below 70%
92
what happens during off time in pulse ox
reading of ambient light is read and subtracted from sequences
93
where do you put pulse ox probe to detect changes faster
centrally place
peripheral=slower
94
what are some pulsatile vascular beds you can attach pulse ox to
finger, cheek, ear, toe, nose, penis
95
what are some pulsatile vascular bed you can attach pulse ox to on infant
palm, forefoot, wrist
96
when is pulse oximeter accurate to within 5%
70-100%
97
what happens when pulse ox is below 70%
readings are extrapolated and unreliable
98
what conditions affect accuracy of pulse ox
raynauds,
movement,
vasoconstriction,
poor circulation d/t low co,
improper placement,
hypothermia
99
what are dyes that can cause false high/low readings in pulse ox
methylene blue, indigo carmine
100
exposure to what can cause false high/low pulse ox reading
smoke or fire
101
what causes fire/smoke to give overestimate of pulse ox
carboxyhemoglobin
102
what can fluorescent light cause in pulse ox reading
false high- red light isn't getting absorbed because of same wavelength 660
103
what can drugs cause that makes pulse ox have false high/low reading
methemoglobinemia -doesn't release oxygen
85% reading
104
name some drugs that can induce methemoglobinemia
nitrates,
locals such as prilocaine,
chlorates,
sulfas,
metochlopramide
105
what are two disease that can cause false high/low pulse ox reading
anemia,
sickle cell (vaso-occlusive crisis),
dyes
106
what kind of light can interfere with pulse ox
fluorescent light
107
what happens if esophageal stethoscope enters lungs
makes a leak in cuff, bellows collapse
108
what can inhibit passage of light through finger
nail polish- black henna or dark blue
109
what is placed in nasall/orally and is only used in intubated patients
esophageal stethoscope
110
when is esophageal stethoscope contraindicated
esophageal varices/strictures
111
what should baseline be on capnography
zero
112
what measures depth of hypnosis
bispectral index (BIS)
113
what is the BIS scale and what does its number mean
0-100, correlates to level of sedation
114
what extrapolates via algorithm from EEG channel parameters
bis monitor
115
What does recall correlate well with
level of anesthesia
116
what can bis help prevent
recall under general anesthesia
117
what are some effects of a patient having recall after general anesthesia
ptsd, sleep disturbances, nightmares
118
what was used to predict recall before anesthesia
movement, increased hr/bp, pupillary changes, perspiration, tearing (which can be blocked by opiates/beta blockers)
119
what is the goal bis values for general anesthesia
40-60- low incidence of recall
120
at what bis value is a patient likely to have recall
greater than 70
121
what is the bis range for burst suppression
1-20
122
what is the bis rang for flat line eeg
0
123
what is the bis range for deep hypnotic state
20-40
124
what is the bis range for responding to loud commands or mild shaking
60-80
125
what is the bis range for responding to normal voice
80-100
126
what is the bis range for awake
100
127
what can interfere with bis
shivering, electrocautery, forced air warmer, cardiac pacemaker spikes
128
how does electrocautery interrupt bis
unipolar cautery overloads bis signal transmission
129
when should temperature be carefully monitored according to standard 9
pediatric (<12), or when significant temp change is intended/anticipated/suspected
130
what is a late sign of malignant hyperthermia
increased temperature
131
what does hypothermia triple the incidences of
cardiac complications and surgical wound infections
132
what impact does hypothermia have on blood loss
increase it
133
what is heat production and how is it brought about
thermogenesis- shivering and non shivering
134
what is heat loss
thermolysis
135
what is normal range of temp
36-37.5 c
136
where is thermoregulation controlled
hypothalamus
137
what is total body heat a combination of
zone temperatures- peripheral and core zones
138
what is more important than maintenance of individual temps
maintenance of total body heat
139
what is the peripheral temp zone made up of
skeletal muscle, subcut tissue, skin
140
what is core temp zone made up of
trunk and head- holds more heat and releases more heat
141
how does body respond to cold exposure
increases heat production, reduces heat loss
142
how does body reduce heat loss
vasoconstriction of peripheral vessels, increased metabolic rate, layering w/clothes
143
Why do peds lose heat more quickly than an adult?
bigger core zone than peripheral zone-
144
is hypothermia or hyperthermia more cmmon
hypothermia- body naturally vasoconstricts to increase temp but anesthetics gases cause vasodilation
145
what can you give for shivering
demerol
146
what is shivering indirectly controlled by
catecholamines
147
how does non shivering thermogenesis work with fat
vessels run through brown adipose fat and skeletal muscle and blood gets heated as it moves
148
how much heat can you lose in the first hour aka phase 1
1-1.5 degrees c
149
what is phase 3 of heat loss
equilibrate, plateau, produce same heat you are losing after 4 hours
150
what is phase 2 of heat loss
still declining but plateauing, losing more heat than you can generate for next 2-4 hrs
151
what is most heat lost from most to least
radiation, convection, conduction, evaporation
152
what is it called when body transfers kinetic energy to air molecules on surface of the skin
convection
153
how much air around your body does your body heat and what is this called
1 inch, convection
154
how does convection produce heat loss
molecules with greater kinetic energy rise and are replaced by colder air molecules (w/less kinetic energy)
-air currents removes heat from around body
155
what is the #1 cause of loss of heat in or
radiation
156
what is it called when body heat is transferred to something colder via infrared spectrum
radiation
157
what does conduction require
physical contact- energy transfers from warm object to cold object- warm body on cold table
158
where on body is greatest amount of heat lost from radiation
area of highest blood flow--patient's head
159
what does a blanket stop from happening in heat loss
conduction and convection
160
what does a space blanket/emergency blanket stop in heat loss
radiation-
also force air warmer
161
how can evaporation cause heat loss
sweating, warm air from lungs, liquid prep evaporation, open cavities
162
what are complications of hypothermia
increases risk of post op infection, increases post op recovery, increases cardiac mobidity and myocardial ischemia, increase blood loss
163
how can hypothermia influence ekg
increase pr/qrs/qt
increase or decrease st segment
164
what is the extra wave from hypothermia in ecg
j wave aka osborn wave
165
how does hypothermia affect blood loss
increases it by speeding impeding clotting, decreases platelet function (thromboxane a2 release)
166
how does propofol/barbiturates/opioids/volatile anesthetics affect body temp
changes body's set point- decreases temp when body kicks in to heat up
167
what happens to bodies ability to regulate temp with the more gas you give
decreases with more gas
168
why do patient's lose the most heat in the first hour
more iv fluids because of getting sedation meds in, putting in volatile gases which decreases bodies set point, exposing patient to air=convection
169
why do geriatrics have harder time regulating temp
unable to increase metabolism to increase heat
170
temp monitoring accuracy from least to greatest
pulmonary artery, esophagus, tympanic, nasopharyngeal, bladder
171
how much can a single layer of passive insulation can reduce cutaneous heat loss
30%-
1 cotton blanket- adding more blankets does not equal less heat loss
172
what helps decrease redistribution heat loss
forced air warming 30 minutes preop
-decreases core to periphery gradient by causing peripheral vasodilation
173
what are cvp distances to right atria
subclavian=10cm
right ij= 15
left ij= 20
femoral vein= 40
right median basilic= 40
left median basilic= 50
174
what are parts of cvp waveform
a= atrial contraction
c= tricuspid closure
v= filling of r atrium
175
how does a cerebral oximeter work
skull is translucent to infrared light
travels in arch like (parabolic pattern)
reflects venous return (doesn't need pulse aka artery)
176
what is key in cerebral oximeter
look for a change in 20% below baseline
-big drop could mean stroke
177
how can you increase cerebral oxygenation
-decrease minute ventilation to cause more co2 to cause vasodilation to increase blood flow
