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Cardiovascular Study Guide, Constable > Monitoring the Cardiac Surgical Patient - Chapter 4 > Flashcards

Monitoring the Cardiac Surgical Patient - Chapter 4 Flashcards

1
Q

What information does the pulse pressure provide?

A

fluid status and valvular competence

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2
Q

What is the disadvantage of the three-electrode system?

A

It cannot monitor the anterior wall and only one pair of electrodes can be selected for monitoring at one time.

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3
Q

What is the recommendation for ECG monitoring for cardiac surgical anesthesia?

A

A five-electrode surface ECG monitor be used in the diagnostic mode, with a frequency response of 0.05 to 100Hz. Ideally, this monitor should be able to display at least two leads simultaneously. Typically leads V5 and II are monitored.

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4
Q

What systolic pressure variation (SPV) is highly predictive of hypovolemia?

A

SPV > 15 mmHg

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5
Q

What precaution should be taken with the placement of the five-electrode system?

A

All leads should be protected with waterproof tape

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6
Q

What is a “pop” test?

A

It is a square wave method to estimate both the natrual frequency and the damping coefficient of a system

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7
Q

What does the PCWP catheter measure?

A

A direct estimate of LA filling pressure.

An indirect estimate of LV filling pressure.

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8
Q

How does an optimally or critically damped system appear after a flush during the “pop” test?

A

A critically damped system will settle to baseline after only one or two oscillations and will reproduce systolic pressures accurately.

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9
Q

What is the disadvantage of the five-electrode system?

A

The V5 electrode will interfere with a left thoracotomy incision

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10
Q

What is the correlation between CO and area under the curve (AUC)?

A

Inversely proportional

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11
Q

What is the recommendation for temperature monitoring during cardiac surgery?

A

Monitor temperature at two sites: a cord site and shell site

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12
Q

How does increasing the temperature of thermodilution injectate affect CO measurement?

A

1 degree of increase in the temperature overestimates CO by 3%.

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13
Q

Name the two most preferred routes to the CVP insertion.

A

The right IJV is the most preferred, followed by left subclavian vein

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14
Q

What are some of the limitations in measuring CO by thermodilution?

A

Inaccurate temp: Blood clot over thermistor tip

Invalid CO: Shunts (LV + RV outputs unequal)

invalid CO: Tricuspid Regurg (recirculation of thermal signal)

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15
Q

What are the three positive deflections and two negative deflections in CVP tracings?

A
  1. Positive deflections: a, c, and v waves
  2. Negative deflections x and y descents
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16
Q

How is thermodilution done?

A

inject fixed volume, 10 ml, (of room temp or iced D5W) into CVP port at end-expiration + measure resulting change in blood temp at distal thermistor (average of 3 measures)

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17
Q

What diuretic is used in CPB prime to ensure adequate urine output?

A

Mannitol

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18
Q

Can a PAC be placed in a patient with LBBB?

A

LBBB is a relative contraindication. Should PAC be warranted, an external pacing should be immediately available d/t the risk of RBBB.

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19
Q

What are bipolar leads and unipolar leads in the augmented three-electrode system?

A

Bipolar leads: I, II, III

Unipolar leads: AVR, AVF, AVL

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20
Q

What are some of the contraindications for PAC placement?

A
  1. significant tricuspid/pulmonary stenosis, endocarditis or mechanical prosthetic valve replacement
  2. Presence of a right-sided mass (tumor/thrombosis)
  3. LBBB (relative contraindication) - PAC placement may can cause RBBB. (Have temporary pacemaker ready.)
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21
Q

How does an underdamped system appear after a flush during the “pop” test and how does it affect blood pressure monitoring?

A

An underdamped system will continue to oscillate for a prolonged time. In terms of pressure monitoring, this translates to an overestimation of systolic BP and an underestimation of diastolic BP.

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22
Q

Will NIBP work during CPB?

A

No. Pulsatile blood flow is absent

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23
Q

What is a concern for brachial artery catheterization?

A

Compromised flow distal to catheter placement. It is a secondary option or is not utilized in non-heparinized surgical procedures.

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24
Q

What are the leads in the three-electrode system and their augmented leads and what do each lead help detect?

A

I, aVL: lateral ischemia

II: inferior ischemia; dysrhythmias (maximal P wave and QRS height)

III, aVF: inferior ischemia

aVR: Not monitored

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25
Q

If a subclavian cannulation is unsuccessful, what action must be taken prior to an attempt on the contralateral side?

A

CXR must be taken to confirm there is no pneumothorax on the unsuccessful side.

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26
Q

What is a shell compartment?

A

It represents the majority of the body (muscle, fat, bone), which receives a smaller proportion of the blood flow.

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27
Q

When is endotracheal leads used and what does it help to monitor?

A

For pediatric population to detect atrial dysrhythmias

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28
Q

What is the contraindication for femoral artery catheterization?

A

Prior vascular surgery involving the femoral arteries or a skin infection of the groin

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29
Q

What is the formula and normal value for systemic vascular resistance (SVR)?

A

Formula: 80 x (MAP - CVP) / CO

Normal value: 700 - 1600 dyne/s/cm5

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30
Q

What voltage does the ECG generate?

A

0.5mV - 2mV at the skin surface. (Very weak)

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31
Q

What do a, c, v waves reflect?

A

a wave - atrial contraction

c wave - the bulging of blood against the tricuspid valve during systole

v wave - atrial filling

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32
Q

What does SvO2 indirectly indicate?

A

SvO2 is an indirect indicator of CO if O2 sat, VO2, and Hgb remain constant

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33
Q

Describe the a, c, v waves in correlation with ECG.

A

a wave - P wave

c wave - QRS

v wave - after the T-wave

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34
Q

What is the main source of ECG artifact?

A

The loss of integrity of the insulation on leads and connecting cables

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35
Q

What does PulseCO SPV + SV predict?

A
  1. Predicts SV­ in response to volume after cardiac surgery + in ICU
  2. Similar estimates of preload v. echo during hemorrhage
  3. Helpful in dx of hypovolemia after blast injury
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36
Q

What does the PA catheter measure?

A

RV function, pulmonary vascular resistance (PVR), and left atrial filling pressure (CO, PAP, PCWP, CVP to estimate LV filling volume)

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37
Q

What method is used to measure CO by PAC?

A

Thermodilution with cold injectate by inject fixed volume, 10 ml, (of room temp or iced D5W) into CVP port at end-expiration + measure resulting change in blood temp at distal thermistor.

CO is inversely proportional to the area under the curve.

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38
Q

Where should the tip of the PAC be placed in order to accurately measure CO?

A

The tip of the catheter must be in the PA and not “wedged.”

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39
Q

How does myocardia ischemia affect PA pressure or PCWP?

A

MI increases PCWP and PA pressure d/t decreased ventricular compliance

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40
Q

What is the normal value for mixed venous oxygen saturation (SVO2)?

A

75%

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41
Q

What is the formula and normal value for pulmonary vascular resistance (PVR)?

A

Formula: 80 x (PAM - PCWP) / CO

Normal value: 20 - 130 dyne/s/cm5

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42
Q

What are some of the causes for a large v wave?

A

mitral regurgitation, myocardial ischemia, ventricular pacing, PVCs

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43
Q

What is the unipolar lead in the five-electrode system?

A

Precordial unipolar lead (Left precordial V5 or right precordial V4R)

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44
Q

What are the four mandatory ASA standards of monitoring and what means are available for the monitoring of those four standards?

A

I. Qualified personnel

II. Oxygenation: SaO2, FiO2

III. Ventilation: ETCO2, stethoscope, disconnect alarm

IV. Circulation: BP, pulse, ECG

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45
Q

What is macro shock?

A

Current >1 mA, which is the perception threshold

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46
Q

What is a modified three-electrode system?

A

It is a three-electrode system with different locations of the lead placement

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47
Q

What can a narrow pulse pressure on the arterial waveform indicate?

A

pericardial tamponade and hypovolemia

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48
Q

What are the differences among aortic, femoral and dorsalis pedis arterial pressure waveform?

A
  1. Aortic: round waveform, prominent dicrotic notch at the upper part of the descending wave
  2. Femoral: delay in pulse transmission (higher systolic pressure) and slurring
  3. Dorsalis pedis: loss of dicrotic notch, second wave
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49
Q

Name four complications of a radial artery line placement?

A
  1. vasospastic disease
  2. prolonged shock
  3. high-dose vasopressors
  4. prolonged cannulation
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50
Q

What are the indications for an ECG?

A

Diagnosis of dysrhythmias, ischemia, conduction defects, electrolyte disturbances, and monitor effect of cardioplegia during aortic cross-clamp

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51
Q

Which type of central line cannulation carries the highest risk for pneumothorax?

A

Subclavian

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52
Q

What is Seldinger method used for?

A

To place a central venous line

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53
Q

What type of cardiac surgical patients is CVP monitoring indicated?

A

All cardiac surgical patients

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54
Q

Which type of the electrode cardiogram is preferred for cardiac surgical patients?

A

The five-electrode system

55
Q

Which alternate site for a central line is the least preferred?

A

External jugular vein

56
Q

How many leads can be monitored with the five-electrode system and what are those leads?

A

Seven: (I, II, III, aVL, aVF, aVR, plus one precordial unipolar leads, V5 or V4R)

57
Q

Name six complications of IJ central line placement.

A
  1. Pnemothorax/hemothorax
  2. Air embolism
  3. Arrhythmias
  4. Carotid artery puncture/cannulation
  5. Chylothorax
  6. Infection
58
Q

How can mixed venous oxygen saturation (SVO2) be measured?

A

With PAC or by venous blood gas

59
Q

Which side does the central line cannulation risks the laceration of the thoracic duct?

A

left side

60
Q

What are some of the relative contraindications for IJ central line placement?

A
  1. Presence of carotid disease
  2. Recent cannulation of the IJV
  3. Contralateral diaphragmatic dysfunction
  4. Thyromegaly or prior neck surgery
61
Q

Describe the damping coefficent of an underdamped, optimal and overdamped system.

A

underdamped: 0.2 - 0.4
optimal: 0.4 - 0.6
overdamped: 0.6 - 0.8

62
Q

What are the advantages of the five-electrode system?

A
  1. Seven different leads can be monitored simultaneously.
  2. Anterior, lateral, and inferior (except for the posterior) wall can be monitored for ischemia.
63
Q

What is a common non-cardiac complication of CPB?

A

Acute renal failure (2.5% to 31%)

64
Q

What are the five indications for an arterial line?

A
  1. Rapid moment to moment BP changes
  2. Frequent blood sampling
  3. Circulatory therapies: bypass, IABP, vasoactive drugs, deliberate hypotensionn
  4. Failure of indirect BP: burns, morbid obesity
  5. Pulse contour analysis: SPV, SV
65
Q

What is the goal of glucose level during CPB and how often should blood glucose be measured

A

Under 200 mg/dL and every 30-60mins

66
Q

When is noninvasive methods for measuring blood pressure (BP) indicated for monitoring hemodynamic parameters during a cardiac surgical procedure?

A

NIBP monitoring should only be used until an arterial catheter is placed and as a back-up monitor after arterial catheter placement.

67
Q

Where is the reference point of CVP transducer?

A

Right atrium

68
Q

How is damping coefficient calculated?

A

The damping coefficient is calculated by measuring the amplitude ratio of two successive peaks after a flush

69
Q

What are epicardial electrodes also know as?

A

Atrio-Ventricular (AV) pacing wires

70
Q

What factors affect CVP?

A

Circulating blood volume (fluid status), venous tone, and RV function

71
Q

What is a “underdamped” waveform and how is it manifested?

A

The rate of dissipation of the energy of a pressure wave is slower than expected and will display a sharper and higher waveform.

72
Q

How can stroke volume be monitored from the arterial waveform?

A

SV can be estimated from the area under the aortic pressure wave from the onset of systole to the dicrotic notch

73
Q

What is the advantage of the modified three-electrode system?

A

Modified three-electrode system can be used to maximize P wave height for the diagnosis of atrial dysrhythmias or to increase the sensitivity of the three-lead ECG for the detection of anterior myocardial ischemia. It can monitor anterior, lateral and inferior wall but not simultaneously.

74
Q

What is the advantage of brachial arterial line over the radial arterial line? Disadvantage?

A

Advantage: Minimzes arterial occlusion (bent wrist will not affect the pressure monitoring)

Disadvantage: Collateral circulation not as good as the hand. Greater risk for thrombosis

75
Q

What is used to monitor adequate heparin effect in CPB?

A

Activated clotting time

76
Q

What are some of the reasons for the placement of epicardial electrodes?

A
  1. Before weaning the patient from CPB or before sternal closure.
  2. Allow AV pacing in the post bypass period.
  3. Record atrial and/or ventricular epicardial ECGs.
  4. Most useful in the postoperative diagnosis of complex conduction problems and dysrhythmias.
77
Q

What is the risk involved in axillary artery catheterization?

A

Cerebral embolus of air or debris

78
Q

Name three factors that invalidate cardiac output measurement by thermodilution.

A
  1. blood clot over the thermister tip
  2. Shunts: LV + RV outputs unequal
  3. Tricuspid regurgitation: recirculation of thermal signal
79
Q

What is the normal systolic pressure variation?

A

Down ~ 5 mm Hg due to decreased venous return

80
Q

What can a widened pulse pressure on the arterial waveform indicate?

A

worsening aortic valvular insufficiency or hypovolemia

81
Q

Distinguish the four different waveforms of PAC

A

RA pressure waveform: small with a, c, v waves

RV pressure waveform: Increased systolic wave

PA pressure waveform: diastolic pressure increases

PCWP waveform: smaller waveform, similar to RA

82
Q

What is the most common complication associated with PAC insertion?

A

Dysrhythmias

83
Q

What part of the arterial waveform correlates with the systemic resistance?

A

the position of the dicrotic notch

84
Q

What is “overdamped” waveform and how is it manifested?

A

The rate of dissipation of the energy of a pressure wave is faster than expected and will display a rounder and lower waveform.

85
Q

What is the contraindication for radial artery catheterization?

A

Inadequate collateral flow to the hand

86
Q

What happens to the body when the temperature falls below 32C?

A

The myocardium is irritable and subject to complex arrhythmias, esp ventricular tachycardia and fibrillation. Coagulation is inhibited.

87
Q

What does CVP provide an estimate of?

A

Intravascular blood volume

RV preload

88
Q

What is a pulse pressure?

A

The difference between systolic and diastolic pressures

89
Q

What are the hallmarks of LV failure in a central line monitoring?

A

Simultaneous readings of high PA pressure and wedge pressure in the presence of systemic hypotension and low CO

90
Q

What is an adequate activated clotting time?

A

> 400s

91
Q

What does Somatosensory evoked potentials (SSEPs) help monitor?

A

The integrity of the spinal cord

92
Q

How does an overdamped system appear after a flush during the “pop” test and how does it affect blood pressure monitoring?

A

An overdamped system will not oscillate at all but will settle to baseline slowly, thus underestimating systolic and overestimating diastolic pressures.

93
Q

What does the esophageal leads monitor?

A

atrial dysrhythmia and posterior wall ischemia

94
Q

What is systolic pressure variation (SPV)?

A

Difference between maximal + minimal values of systolic BP during PPV

95
Q

Simultaneous analysis of what two leads in the five-electrode system can identify 90% of ischmeic episodes?

A

If leads II and V5 are analyzed simultaneously

96
Q

Name four factors that can increase SVO2.

A
  1. Wedged PAC
  2. Low VO2: hypothermia, general anesthesia, NMB
  3. Unable to extract O2: Carbon monoxide poisoning
  4. High CO: burns, sepsis, L to R shunt, AV fistulas
97
Q

What does the core temperature represent?

A

The temperature of the vital organs.

98
Q

What can a high or low dicrotic notch position indicate?

A

high dicrotic notch - high vascular resistance;

low dicrotic notch - low vascular resistance

99
Q

Name three complications of double cannulation of RIJ.

A

vein avulsion, catheter entanglement, catheter fracture

100
Q

What is micro shock?

A

Crrent <1 mA, which requires a means to bypass skin resistance in order to cause hazard

101
Q

Where is IJV located in relation to the carotid artery?

A

Anterolateral to carotid

102
Q

Name four factors that can decrease SVO2.

A
  1. decreased CO: MI, CHF, hypovolemia
  2. decreased Hgb: bleeding, shock
  3. decreased SaO2: hypoxia, respiratory distress
  4. increased VO2: fever, agitation, thyrotoxic, shivering
103
Q

What are the limitations of TEE?

A
  1. Diseases near the descending aorta
  2. airway interferes with TEE signal
104
Q

How should IJV catheter be introduced into the vessel?

A

From medial to lateral, caudad.

105
Q

What is a catheter “whip?”

A

A phenonmenon in which the motion of the catheter tip itself produces a noticeable pressure swing. More common with PAC or LV catheters.

106
Q

What is the practical gold standard for evaluating CO?

A

PAC

107
Q

What are the leads of the modified three-electrode system and what do each lead help to monitor?

A

CS5, CM5: anterior ischemia

CB5: Anterior ischemia; dysrhythmia (maximal P wave)

MCL1: Dysrhythmias (maximal P wave and QRS height)

CC5: global ischemia

108
Q

What does the central venous pressure measure?

A

Direct measurement of the RA pressure and indirect estimate of the LV filling pressures

109
Q

Name the five complications of arterial catheterization.

A

Ischemia, throbosis, infection, bleeding, false lowering of radial artery pressure imemdiately after CPB

110
Q

What is the formula and normal value for Cardiac Index (CI)?

A

Formula: CO/BSA

Normal Value: 2-5 - 4.2 L/min/m2

111
Q

Does the rectal temperature reflect core temperature?

A

No. It reflects the muscle mass temperature.

112
Q

What can distort PCWP’s estimation of LV filling pressure?

A

mitral valvular pathology

MI

LV dysfunction

113
Q

Define monitoring.

A

Continuous or repeated observation + vigilance in order to maintain homeostasis.

114
Q

How does the arterial systolic pressure measurement change between aortic pressure and radial pressure?

A

The systolic pressure measured in a radial arterial catheter may be up to 20 to 50 mm Hg higher due to decreased peripheral arterial elastance and wave summation

115
Q

What is the landmark for a central IJ line placement?

A

Apex of triangle formed by lateral (clavicular) and medial (sternal) head of SCM. Aim needle caudally and laterally toward ipsilateral nipple

116
Q

Describe the patient position during IJ central placement.

A

Place the patient in a supine position, at least 15 degrees head-down to distend the neck veins and to reduce the risk of air embolism. Turn the head away from the venipuncture site.

117
Q

What can cause a distortion of CVP?

A

LV dysfunction, decreased LV compliance (MI), PHTN, valvular disease of the mitral valve

118
Q

When is the risk for chylothorax increased with the IJ central line placement?

A

when the line is placed on the left side

119
Q

How does RV failure affect CVP?

A

CVP is increased

120
Q

When should CVP be measured during the respiration cycle?

A

At end-expiration

121
Q

What are some of the reasons for arterial catheterization?

A
  1. small or rapid changes in arterial perfusion pressure may increase patient risk requiring beat-to-beat assessment.
  2. wide variation in BP or intravascular volume is anticipated.
  3. frequent blood smpling is required.
  4. assessment of BP cannot be performed by other methods.
122
Q

What is the ultimate purpose of monitoring?

A

To evaluate oxygen supply and demand

123
Q

What is the damping coefficient of a pressure waveform?

A

The rate of dissipation of the energy of a pressure wave

124
Q

What two locations in the five-electrode system can the precordial unipolar lead be placed on and what do each position help to monitor?

A
  1. V5 position, along the anterior axillary line in the 5th intercostal space, to best monitor the LV.
  2. Right precordium to monitor the right ventricle (RV; V4R lead)
125
Q

How do high and low SVO2 correlate with DO2 (oxygen delivery) and VO2 (oxygen consumption).

A

high SVO2: increased delivery or decreased consumption

low SVO2: decreased delivery or increased consumption

126
Q

What is the most common access route for a central line placement?

A

Right internal jugular

127
Q

What is the disadvantage of the three-electrode system?

A

It cannot monitor the anterior wall

128
Q

How can contractility influence the arterial waveform?

A

Contractility can be judged by the rate of pressure rise during systole

129
Q

Name some core temperature sites / methods.

A

nasopharyngal, tympanic membrane, bladder, esophageal, CPB arterial / venous line temperature, PAC thermistor

130
Q

What is natural frequency or resonant frequency in an intravascular pressure monitoring system?

A

Refers to the frequency at which a monitoring system itself resonates and amplifies the signal

131
Q

What information can be obtained from arterial tracing?

A

heart rate and rhythm, pulse pressure, respiratory variation and volume status, and hemodynamic indices (stroke volume, contractility, and vascular resistance)

132
Q

How does the catheter lumen diameter, tubing connection length, system compliance, and the density of fluid contained in the system affect the natrual frequency?

A

Directly proportional to the catheter lumen; inversely proportional to the square root of the tubing connection length, system compliance and the density of fluid contained in the system

133
Q

What happens to the body when the temperature rises above or equal to 41C?

A

Significant enzyme desaturation and cell damage can occure

134
Q

What can cause a cannon a wave?

A

heart block (particularly third degree), PHTN, tricuspid valve stenosis, AV dissociation, RA contraction against a closed tricuspid valve

Cardiovascular Study Guide, Constable (2 decks)

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