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GNURS725- Cardio/Thoracic > Monitoring the Cardiovascular Patient > Flashcards

Monitoring the Cardiovascular Patient Flashcards

1
Q

What is one of the primary responsibilities of an anesthesiologist ?

A

Act as a guardian for the anesthetized patient ?

Review slide -4

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2
Q

What is the definition of monitoring ?

A

Continuous or repeated observation + vigilance in order to maintain homeostasis

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3
Q

List the 4 ASA standards of monitoring

A

I. Qualified personnel
II.Oxygenation: SaO2, FiO2
III. Ventilation: ETCO2, stethoscope, disconnect alam
IV. Circulation: BP, pulse, ECG

**Other monitors: Temp Peak airway pressure, Vt, ABG

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4
Q

What are modalities in the OR?

A
  • Arterial Line
  • Systolic Pressure Variation
  • CVP
  • PAC
  • Cardiac Output
  • Mixed Venous O2
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5
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 hypotension
4- Failure of indirect BP: Burns, morbid obesity
5- Pulse Contour Analysis, SPV, SV

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6
Q

What steps do we need order to place a radial artery catheter?

A

Good collateral circulation

*Allen’s test

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7
Q

Uncommon, however what complications can we see with a radial artery line placement that are not?

A
  • Vasospastic disease
  • Prolonged shock
  • High dose vasopressors
  • Prolonged Cannulation
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8
Q

What are alternative arterial line sites ?

A

1-Brachial
—use a longer catheter to traverse elbow joint
–postop keep arm extended
–collateral circulation not as good as hand
2-Femoral
–use guide-wire technique
–puncture femoral artery below inguinal ligament ( easier to compress if required)

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9
Q

How do we calculate systolic pressure variation(SPV)?

A

Difference between maximal + minima values of systolic BP during PPV

-Normal ~ 5 mmHg due to decrease venous return

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10
Q

What SPV value do we use to predict hypovolemia?

A

SPV >15mmHg

or down > 15mmHg

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11
Q

What does PulseCO SPV + SV do for us as providers?

A

1-Predicts SV increase in response to volume are cardiac surgery and in the ICU
2- Similar estimates of preload v. echo during hemorrhage
3-Helpful in dx of hypovolemia after blast injury
4- Limitations: AI, arrythmias,
*Required mechanical ventilation

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12
Q

What are the seven indication of central venous line?

A

1-CVP monitoring
2- Advanced CV disease + major operation
3- Secure vascular access for drugs: TLC
4- Secure access for fluids:introducer sheath
5- Aspiration of entrained air: sitting craniotomies
6- Inadequate peripheral IV access
7- Pacer, Stanz Ganz

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13
Q

What are the steps for a central venous line placement in the right IJ?

A

A. IJ vein lies in grove between sternal and clavicular heads of sternocleidomastoid muscle
B. IJ vein is lateral + slightly anterior to carotid
C.Aseptic technique, head down
D. Insert needle towards ipsilateral nipple
E. Seldinger method: 22G finder, 18G needle, guidewire, scalpel blade, + catheter
F. Observe ECG, maintain control of guidewire
G. US guidance, CXR post insertion

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14
Q

What are the advantages to a RIJ central line placement?

A
  • Consistent, predictable anatomic location
  • Readily identifiable landmarks
  • Short straight course to SVC
  • Easy intro access for anesthesiologist at patients head
  • High success rate , 90-99%
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15
Q

What are the alternate sites to central line placement?

A
  • Subclavian
  • -Easier to insert vs IJ if in C-spine precautions
  • -Better patient comfort vs IJ
  • -Risk pneumo- 2%
  • External Jugular
  • -easy to cannulate if visible, no risk of pneuno
  • -20% cannot access central circulation
  • Double Cannulation of the same RIJ
  • Serious complications: vein avulsion, catheter entanglement, catheter fracture
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16
Q

What does CVP monitoring provide for us?

A 
A-Reflects pressure at junction of vena cava+ RA
B-CVP is driving force for filing RA + RV
C- CVP provides estimate of 
--intravascular blood volume 
--RV preload 
D-Trending CVP is useful 
E. Measure at END- EXPIRATION
F.Zero at mid axillary line
17
Q

What do pulmonary catheters allow ?

A
  • Allows for accurate bedside measurement of important clinical variables: CO, PAP, PCWP, CVP to estimate LV filling volume + guide fluid/ vasoactive drug therapy
  • Discloses pertinent CV data that cannot be accurately predicted from standard signs symptoms
18
Q

PA waveform pressures?

A

Slide 26

19
Q

What are the indications for a PAC by the ASA task force?

A
  • High risk patient with severe cardiopulmonary disease
  • Intended surgery places patient at risk because of magnitude or event of operation
  • Practice setting suitable for PAC monitoring: MD familiarity, ICU, nursing
  • PAC education project
20
Q

What are PAC outcomes?

A
  • Early use of PAC to optimize volume status, and tissue perfusion may be beneficial
  • PAC is ONLY a monitor, it cannot improve outcome if disease has progressed too far, or if intervention based on PAC is unsuccessful or detrimental
  • Many confounding factors: learning’s bias, skill knowledge, usage patterns, medical v surgical illness
21
Q

What are pulmonary artery complications?

A
  • Minor 50% eg: arrhythmias
  • Transient RBBB- 0.9-5%
  • -external pacer if pre-existing LBBB
  • Misinformation
  • Serious 0.1-0.5% : knotting , pulmonary infarction, PA rupture ( e.g. over wedge) ,endocarditis, structural heart damage
  • Death 0.016%
22
Q

Problems Estimating LV Preload ?

A

Review Slide 31

23
Q

Cardiac output is an important feature of PAC, what does it allow calculation of ?

A

-DO2

24
Q

How do you obtain CO on a PAC?

A

Thermodilution: 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

25
Q

T/F: CO is directly proportional to area under the curve?

A

FALSE

Inversely proportional

26
Q

What are the technical problems with CO on a PAC?

A

1- Variations in respiration
–use average of 3 measures
2- Blood clot over thermistor tip inaccurate temp
3- Shunts: LV + RV outputs unequal , CO invalid
4- TR: recirculation of thermal signal, CO invalid
5- Computation constants
–varies for each PAC, check package insert + manually enter

27
Q

Mixed Venous Oximetry - is O2 sat, VO2 + Hgb remain constant, SvO2 is ?

A

An indicator of CO

-Can be measured using oximetric Swan or CVP, or send blood gas from PA/ CVP

28
Q

What is normal SvO2?

A

~ 65%

60-75

29
Q

What does it mean if your SvO2 is >75%?

A
  • Wedged PAC: reflects LAP saturation
  • Low VO2: hypothermia, GA, NMB
  • Unable to extract O2: carbon monoxide
  • High CO: sepsis, burns, L to R shunt, AV fistulas
30
Q

What could a low SvO2 [<60%] mean?

A
  • decreased CO: MI, CHF, hypovolemia
  • low hgb: bleeding, shock
  • decreased SaO2: hypoxia, resp distress
  • increased VO2: fever, agitation, thyrotoxic, shivering
31
Q

The factional area of change of the left ventricular cavity can be used as an index for what?

A

Global systolic function

32
Q

What is the formula for fractional area of change?

A

FAC= (LVAd - LVAs)/ LVAd

Or

FAC = (EDA - ESA)/ EDA * 100

33
Q

What is a normal range for FAC?

A

35-65%

34
Q

Where is the made for FAC and what is it calculating?

A

The measure is made at the mid-papillary level by calculating the cross-sectional area of the LV during systole and diastole

35
Q

What does it mean is you have an elevated SvO2? ( >75)

A
  • Wedged PAC: reflects LAP saturation ( it is too far)
  • Low VO2 state : hypothermia, general anesthesia , NMB
  • Unable to extract O2: Carbon monoxide poisoning
  • High cardiac output “ sepsis, burns, L –> R shunt, AV fistulas
36
Q

What conditions would cause a low SvO2? (< 60%)

A

-decrease of the following
-CO: MI, CHF, hypovolemia
-Hgb : bleeding, shock
-SaO2 : hypoxia, respiratory distress
Increase in :
-VO2: fever, agitation, thyrotoxic shivering

37
Q

Review TEE

A

Slide- 37

GNURS725- Cardio/Thoracic (2 decks)

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