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Patient Monitoring > Patient Monitoring > Flashcards

Patient Monitoring Flashcards

1
Q

what is electrocardiogram (EKG or ECG) used for

A

used to monitor electrical activity as it travels through the myocardium of the heart sensed by electrodes on the skin

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2
Q

what can be diagnosed through EKG (4)

A
  1. dysrhythmias such as VFIB, AFIB, VTACH, bradycardia
  2. myocardial ischemia: ST changes, new T-wave changes
  3. conduction defects: AV blocks
  4. electrolyte disturbances: K+, CA++
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3
Q

cardiac conduction (electrical activity) results in

A

mechanical beating of the heart

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4
Q

what is mechanical beating created by

A

created by electrical impulses moving throughout the conduction system

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5
Q

Specific waves that appear on an ECG correspond both to the _____ and the _____ of a particular area of the heart

A

both to the mechanical and the electrical depolarization/repolarization of a particular area of the heart

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6
Q

what is the 5 electrode system

A

all but the posterior wall of the myocardium can be monitored for ischemia
- 1 electrode on each extremity and 1 precordial (chest) lead (v5)

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7
Q

what is v5 electrode best for

A

for monitoring the LV

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8
Q

in patients with coronary artery disease, the ______ is best single lead for diagnosing ______

A

the v5 lead is the best single lead in diagnosing myocardial ischemia

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9
Q

___% of ischemia episodes will be detected by EKG if leads __ and __ are analyzed simultaneously

A 
90% 
leads II (white) and V (brown)
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10
Q

what does the P wave represent

A

depolarization of atria in response to SA node triggering

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11
Q

what does the PR interval represent

A

delay of AV node to allow filling of ventricals

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12
Q

what does the QRS complex represent

A

depolarization of ventricles

triggers main pumping contractions

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13
Q

what does the ST segment represent

A

Beginning of ventricle repolarization

should be flat

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14
Q

what does the T wave represent

A

ventricular repolarization

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15
Q

after the SA node fires, the depolarization wave passes through the right and left atria, stimulating ____ and producing the _____

A

stimulating the atrial contraction and producing the P wave

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16
Q

what does the AV node help with

A
  • only normal conduction pathway between atria and ventricle
  • slows impulse conduction to allow time for the atria to contract and blood to be pumped from atria to ventricles
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17
Q

Conduction time through he AV node accounts for most of the duration of the _____

A

PR interval

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18
Q

what does the Q wave represent

A

-impulse passing through the Purkinje fibers coming from the right and left branches of the Bundle of His

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19
Q

what follows the QRS complex

A

the plateau phase (ST segment)

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20
Q

what produces the T wave

A

ventricle repolarization

takes place slowly, generating a wide wave

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21
Q

what is an important characteristic in determining a normal heart rhythm

A

time

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22
Q

what are the 4 key intervals in particular that aid in the interpretation of ECGs

A
  1. PR interval
  2. QRS interval
  3. QT interval
  4. RR interval
  5. PQRS complex
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23
Q

the normal time for PR interval

A

120-200 ms

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24
Q

if the PR interval is > 200 ms

A

1st degree heart block

delayed conduction through the AV node

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25
Q

if the PR interval is <200 ms

A

suggest pre excitation

-presence of an accessory pathway between the atria and ventricles

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26
Q

normal time for QRS interval

A

60-100 ms

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27
Q

prolonged QRS indicates

A

hyperemia or bundle branch block

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28
Q

increased amplitude of QRS indicates

A

cardiac hypertrophy

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29
Q

when do pathologic Q waves occur

A

when the electrical signal passes through stunned or scarred heart muscle
-markers of previous myocardial infarctions

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30
Q

normal time for QT interval

A

350-430 ms

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31
Q

prolonged QT time

A

> 440 ms

-at risk for ventricular tachyarrhythmias & hypocalcemia

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32
Q

short QT time

A

< 350 ms

genetic disorder, hypercalcemia

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33
Q

RR interval represents

A

1 cardiac cycle

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34
Q

PQRST complex normal time

A

60 ms

(PR + QT) = 0.6 s

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35
Q

how is external measurement of blood pressure normally done

A

normally via the cuff on the brachial artery

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36
Q

too small of a cuff can cause

A

false high readings

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37
Q

too big of a cuff can cause

A

false low readings

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38
Q

non invasive blood pressure is ____ for monitoring hemodynamic parameters during cardiac surgical procedures

A

inadequate

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39
Q

what causes non invasive blood pressure to be inadequate for cardiac surgery

A
  1. inaccurate
  2. intermittent data
  3. requirements for pulsatile flow: this method cannot be used during non-pulsatile flow
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40
Q

what does the strain gauge transducer measure

A

strain on the sensor

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41
Q

what does the strain gauge transducer use to convert measurement

A

Wheatstone bridge

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42
Q

what does the strain gauge transduce convert via the Wheatstone bridge

A

converts measurement of strain to resistance

resistance is then converted to pressure

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43
Q

intravascular pressure monitoring is done via

A

direct cannulation of artery with a small catheter

-also used for arterial blood sampling site

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44
Q

systolic pressure _____ from ___ to _____

A

systolic pressure increases from ascending aorta to peripheral arteries

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45
Q

what is an important difference between intravascular pressure monitoring and non invasive pressure monitoring

A

real time pressure readings

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46
Q

what are some complications of intravascular pressure monitoring

A

infection, ischemia, aneurysm, cerebral embolism

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47
Q

what are the 3 major changes that occur in the arterial pulse contour as the pressure wave travels distally

A
  1. systolic portions of the pressure wave become narrowed and elevated
  2. high-frequency components on the pulse are damped out and soon disappear
  3. hump may appear on the diastolic portion of the pressure wave
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48
Q

what is ABP and what is it used for

A

stands for arterial blood pressure
use to monitor for patient instability, monitor arterial blood gases, direct monitoring even during nonpulsatile flow states

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49
Q

where is the ABP catheter placed

A

in the right or left radial artery prior to induction of anesthesia

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50
Q

what is the test to check and see if the radial artery can be used for the ABP catheter

A

allen test

if the capillary refill is greater than 15 seconds, should not be used

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51
Q

where else can the ABP be placed if radial artery can not be used

A
  1. femoral artery
  2. aorta (not an option at beginning of case, but can be accessed after chest is open to verify ABP)
  3. axillary artery: risk for debris embolus if on right side, safer on left
  4. brachial artery: should be avoided to prevent thromboembolism
  5. ulnar artery: only used if radial can’t be entered
  6. pedal artery: rarely used
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52
Q

HR can be determined from

A

ABP

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53
Q

pulse pressure

A

difference between systolic and diastolic pressure

-provides useful info on volume status and valvular competence

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54
Q

what has a narrowed pulse pressure

A

pericardial tamponade

hypovolemia

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55
Q

a sudden increase in pulse pressure may be a sign of

A

worsening AI

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56
Q

stroke volume can be estimated from

A

area under the aortic pressure wave from onset of systole to diacritic notch

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57
Q

the high position of the diacrotic not on the downslope trace gives an estimate of

A

high vascular resistance

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58
Q

low resistance tends to cause a diacritic notch to be

A

lower on the diastolic portion of the pressure tracing

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59
Q

what is overdamping

A

underestimates SBP, overestimated DBP

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60
Q

causes of overdamping

A
  1. kinking of arterial catheter or tubing
  2. occlusion: air or clot in catheter or tubing
  3. loss of flush pressure
  4. transducer failure
  5. soft compliant tubing
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61
Q

under damping

A

overestimates SBP, underestimates, DBP

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62
Q

causes of underdamping

A
  1. long stiff tubing

2. increased SVR

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63
Q

if a transducer is at the height at the level of the right atrium

A

zero transfer open to air

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64
Q

if the transducer is lower then the level of the right atrium

A

falsely high BP

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65
Q

if the transducer is high than the level of the right atrium

A

falsely low BP

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66
Q

complications of arterial catheters

A
  1. ischemia
  2. thrombosis
  3. infection
  4. bleeding
  5. false lowering of radial pressure immediately after CPB (vasospasm)
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67
Q

central venous pressure is a measure of

A

right atrial pressure

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68
Q

what is CVP used for

A

to monitor preload and to transfuse large volumes of fluids

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69
Q

what is CVP affected by

A
  1. blood volume
  2. venous tone
  3. RV function
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70
Q

CVP wave goes…..

A

a c x v y

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71
Q

a wave

A

atrial contraction

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72
Q

c wave

A

QRS and bulging of tricuspid valve into RA

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73
Q

x deflection

A

tricuspid valve pulled downward during late systole into RV

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74
Q

v wave

A

back pressure wave from right atrial filling

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75
Q

y descent

A

tricuspid valve opens and atrium empties into ventricle: early diastole

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76
Q

pros and cons of central venous pressure

A

pros: reasonable indicator of LV function in the absence of pulmonary hypertension and mitral valve disease, can measure coronary sinus pressure
cons: ventilator PEEP may falsely elevate CVP measurement

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77
Q

complications of CVP

A

dysrhythmias, pneumothorax, infection, carotid artery puncture, air embolism

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78
Q

what kind of catheter is used for a pulmonary artery catheter

A

Swan-ganz catheter

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79
Q

what is pulmonary artery catheter used for

A
  • assessment of cardiac function and volume status
  • access for cardiac pacing
  • access for mixed venous blood sample
80
Q

indications for use of pulmonary artery catheter

A

LV dysfunction, LM lesion, PA HTN, Recent MI, valvular lesion, sepsis, organ failure, major blood loss, aortic crossclamp

81
Q

where is the insertion site for a pulmonary artery catheter

A

right internal jugular vein preferred, otherwise left IJK

82
Q

reasons to not use pulmonary artery catheter

A
  • mechanical right heart valve
  • right ventricle assist device
  • left bundle branch block
83
Q

complications with using pulmonary artery catheter

A
  • dysrhythmias
  • PA rupture
  • right bundle branch block
  • valve damage
  • thrombus
  • balloon rupture
  • infection
84
Q

PA pressure is / of arterial pressure

A

1/3

85
Q

if mean or systolic PAP is greater than 1/3 of the mean or systolic arterial pressure, the patient has

A

pulmonary hypertension

86
Q

what 6 things does the PA catheter measure

A
  1. pulmonary artery pressure (PAP)
  2. pulmonary capillary wedge pressure (PCWP)
  3. central venous pressure (CVP)
  4. mixed venous oxygen saturation: SvO2
  5. cardiac output (CO)
  6. blood temperature
87
Q

main indication for PA catheter

A

to monitor the LV and RV separately

88
Q

what can the PA catheter help detect

A
  1. access volume status
  2. diagnosing LV failure by PAP and PCWP
  3. diagnosing RV failure
  4. diagnosing pulmonary hypertension
  5. assessing valvular disease
89
Q

what are hallmarks of LV failure

A

high PAP and PCWP in the presence of systemic hypotension and low CO

90
Q

what is blood temperature measure by off of the PA catheter

A

thermistor port

thermistor temp reflects core temp

91
Q

what are the ports off of the PA catheter

A
  1. thermistor port
  2. proximal port
  3. distal port
  4. RA infusion port
  5. balloon inflation port
92
Q

prior to CPB, how should the baseline blood gas be measured

A

non-heprainized blood must be in a heparinized syringe

93
Q

on CPB, when should the blood gas be measured

A

within 10 min of initiation

and at least every 30 min after

94
Q

what must you do to maintain anaerobic conditions

A

expel air bubbles and cap syringe

95
Q

gas equilibration between air and blood will lead to

A
  • decreased PaCO2

- increased PaO2

96
Q

normal pH blood gas

A

7.35-7.45

97
Q

normal PaO2 blood gas (partial pressure of O2)

A

80-100 mmHg

98
Q

normal PaCO2 blood gas (partial pressure of CO2)

A

35-45 mmHg

99
Q

normal HCO2 blood gas (bicarbonate level)

A

21-27 mEq/L

100
Q

normal SaO2 blood gas (oxygen sat)

A

95-100%

101
Q

normal FiO2 blood gas (fraction of inspired oxygen)

A

21%

102
Q

what is used routinely to identify instant changes in a patients status

A

trending devices

103
Q

how often should trending devices be calibrated for accuracy

A

each case

104
Q

does trending devices replace the need for routine blood gas>

A

no

105
Q

what does pulse oximetry montor?

A

non invasive way of measuring arterial oxygen saturation (SaO2)

106
Q

how does pulse oximetry work

A

red and infrared light absorbency read by photodetector on opposite end

107
Q

explain Beer’s law

A

amount of light absorbed is proportional to the concentration of the light absorbing substance

108
Q

what does pulse oximetry not differentiate and what will be falsely read

A

does not differentiate between COhB and O2Hb

-falsely elevated readings will be seen in heavy smokers and patients with CO exposure

109
Q

what must you have for an accurate and reliable pulse oximetry reading

A

a pulse

110
Q

what does a low tone in pulse oximetry reading indicate

A

low oxygen saturation

111
Q

beep rate indicates

A

HR

112
Q

problems/ things that pulse oximetry cannot read that well or give false readings on

A
  1. anemia: tissues can suffer hypoxia despite high oxygen saturation in the blood that does arrive
  2. carbon monoxide not differentiated from oxygen bound to hemoglobin therefore high reading may occur despite the pt being hypoexmic
  3. low flow
  4. dark skin pigmentation can overestimate readings
  5. methemoglobinemia cause readings in the mid-80s, cannot bind oxygen
113
Q

large quantities of MetHb greater than 10% may rising in what

A

SpO2 reading of about 85%

114
Q

during cardiac surgery, a pt is at increased risk for adverse neurological effects during surgery due to CPB because of ______ and _____, as well as potential risk of ______.

A

pt is at increased risk for adverse neurological events during surgery due to CPB because of core cooling and changes in blood flow, as well as potential risk of emboli

115
Q

what are 3 main reasons to monitor CNS

A
  1. diagnose cerebral ischemia
  2. assess depth of anesthesia
  3. assess effectiveness of neuroprotective medications
116
Q

what are the monitors used to watch CNS electrical activity

A
  1. electroencephalogram (EEG)
  2. processed EEG
  3. evoked potentials
117
Q

what are monitors of cerebral metabolic functions

A
  1. jugular bulb venous oximetry

2. NIRS

118
Q

what does jugular bulb venous oximetry measure

A

measure mixed venous blood saturation of blood leaving the brain

119
Q

what does NIRS stand for and

A

near-infrared spectroscopy

120
Q

what are monitors for CNS hemodynamics

A
  1. transcranial doppler (TCD)

2. MetaOx

121
Q

what does transcranial doppler (TCD) use

A

uses ultrasonic waves to measure the velocity of blood flow in the brain vessels
-can detect emboli in cerebral circulation

122
Q

what does MetaOx measure

A

measures an index of blood flow using DCS (diffuse correlation spectroscopy)

123
Q

EEG is used to

A
  1. guide seizure measurement
  2. assess level of consciousness
  3. detect cerebral ischemia
  4. monitor effects of medications
124
Q

EEG signs (3)

A

status epilepticus
burst suppression
brain death

125
Q

what is status epileptics on EEG

A

spike in amplitude

126
Q

what is burst suppression on EEG

A

sign of anoxic brain injury to can be induced with medication

127
Q

what does brain death show on EEg

A

cessation of any activity on EEG

128
Q

what are the five frequency bands on EEG

A 
delta
theta
alpha 
beta
gamma
mu
129
Q

what is near infrared spectroscopy

A

trending device used to detect the regional oxygen saturation of brain tissue

130
Q

what does near infrared spectroscopy measure

A

continuous, non invasive measurement of regional cerebral tissue oxygen saturation (SctO2)

131
Q

where is near infrared spectroscopy sensors placed

A

about pt’s brows

132
Q

for near infrared spectroscopy, increased ____ levels will increase values due to an _______

A

increased pCO2 levels will increase values due to an increase on cerebral blood flow

133
Q

for near infrared spectroscopy, decrease in _____ will _____

A

decrease in body temperature will increase the values due to reductions in CMRO2

134
Q

target and threshold values for cerebral oximetry are mostly dependent on what

A

upon patient’s baseline value

135
Q

what is the typical rSO2 range

A

60-80 in adults

40-60 in neonates

136
Q

intervention trigger for cerebral oximetry

A

<50 or 20% decrease for baseline

137
Q

critical threshold for cerebral oximetry

A

<45 or 25% decrease from baseline

138
Q

Bispectral index measures

A

depth of anesthesia and state of hypnosis by analyzing data from the EEG to measure level of sedation

139
Q

why measure BIS

A

prevent patient awareness during surgery

140
Q

what is the goal value for BIS during surgery

A

40-60

90-100 awake patient
0 - electrical silence and absence of brain activity

141
Q

what is the correction dosage to maintain sedation

A

isoflurane on >0.6% on CPB is thought to be sufficient to maintain sedation

142
Q

increase in mean cerebral blood flow indicates what

A

vasospasm

143
Q

decrease in mean cerebral blood flow indicates what

A

impending or completed stroke

144
Q

what are the positions of the 4 transducer position windows

A
  1. transtemporal
  2. transorbital
  3. suboccipital
  4. submandibular
145
Q

why do you monitor renal function during CPB

A

renal failure after CPB occurs 2.5-3.1% of the time

-CPB presents an abnormal physiological state of non pulsatile flow which affects renal autoregulation

146
Q

what is the diuretics used in CPB prim

A

mannitol

147
Q

what are the 2 reasons to use mannitol during CPB

A
  1. hemolysis: urine output should be maintained to avoid damage to renal tubules
  2. deliberate hemodilution: maintenance of good urine output during and after CPB allows removal of excess free water
148
Q

what is an adequate amount of urine output?

A
  1. 5 to 1.0 ml/kg/hr
    - does not mean that no kidney damage has occurred
    - does show that you have blood flow to kidney
149
Q

what are serum electrolytes that should be checked toward the end and after CPB

A

K+
Mg2+
Ca2+

150
Q

what can low ca2+ cause

A

poor myocardial contractility

151
Q

when do you admin calcium

A

15-20 min after the cross clamp is removed and acceptable perfusion to the brain is established or could cause worsen neurologic outcome

152
Q

what can low Ca2+ affect

A

coagulation

153
Q

what can high K+ affect

A

electrical conduction

154
Q

what does core temperature represent

A

temperature of the vital organs

155
Q

where are the temperature monitoring sites

A
  1. esophageal
  2. PA catheter
  3. nasopharyngeal
  4. tympanic
  5. bladder
156
Q

what is the accurate reflection of brain temp on CPB

A

nasopharyngeal

157
Q

what is the best indicator of core temperature when pulmonary blood flow is present (pre and post CPB)

A

PA catheter thermistor

158
Q

what is shell temp

A

majority of body (muscle, fat, bone)

-receives smaller portions of blood flow which can affect temp fluxes

159
Q

when does the shell temp lag behind the core temp

A

during cooling and rewarming

160
Q

what does the shell temp include

A

rectal and skin temp

161
Q

myocardial temperature is the best indicator of what

A

cardioplegia delivery temp

162
Q

recommendations for temperature monitoring on CPM

A

monitor 2 sites: a core and a shell site

monitor arterial and venous line temps

163
Q

normothermic

A

> 34

164
Q

mild hypothermia

A

28-34, <10 min arrest

165
Q

moderate hypothermia

A

20-28

10-19 min arrest

166
Q

deep hypothermia

A

14-20

20-45 min arrest

167
Q

profound hypothermia

A

<14

46-65 min arrest

168
Q

during cooling and rewarming what is the temp gradient and between what

A

8-10 C temperature gradient between patient temp and heat exchanger water source

169
Q

warm normothermic cardioplegia temp causes

A

increase O2 delivery

less time in between doses

170
Q

cold cardioplegia temperature (around 9 C) causes what

A

decreased O2 demand by cooling myocardium, more time in between doses, platelet activation

171
Q

an echocardiogram (echo) uses

A

ultrasound to create pictures of your heart’s movement

172
Q

a trans esophageal echo (TEE) test is…

A

a type of echo that uses a long, thin, tube (endoscope) to guide the ultrasound transducer down the esophagus (“food pipe” that goes from the mouth to the stomach)

173
Q

a combination of a ___,___ and ____ to get information about how blood flows across your heart’s valves

A

TEE, Doppler ultrasound, and color doppler

174
Q

trans thoracic is ___ and utilizes ___

A

noninvasive and utilizes sound waves

175
Q

trans esophageal combines ____ and ____

A

ultrasonography and endoscopy

176
Q

what can you see with TEE

A 
image posterior of the heart
heart structures
clots, valves
PFO
LV function
177
Q

sites of injury from TEE

A

oropharyngeal
esophageal
gastric trauma

178
Q

when can you not use TEE

A 
when pt has: 
esophageal pathology 
recent upper GI surgery 
perforated viscus
full stomach, unprotected airway
179
Q

the output of the roller pump is determined by

A

the rpm of the pump and the volume displaced with each revolution

180
Q

the volume of the roller pump depends on

A

the size of the tubing and the length of the track

181
Q

the flow rate can be seen

A

on the pump control panel

182
Q

2 methods to measure flow on centrifugal pump

A
  • ultrasonic: not in contact with blood but instead wrap around tubing
  • electromagnetic: require blood contacting electrodes and are designed as connectors
183
Q

3/16 tubing has what SV and blood flow

A

7 ml SV

1050 L/min blood flow at 105 PRM

184
Q

1/4 tubing has what SV and blood flow

A

13 mL SV

1950 L/min blood flow at 150 RPM

185
Q

3/8 tubing has what SV and blood flow

A

27 mL SV

4050 L/min blood flow at 150 RPM

186
Q

1/2 tubing has what SV and blood flow

A

54 mL SV

8100 L/min blood flow at 150 RPM

187
Q

systemic flow is most often indexed to

A

the pt’s body surface area (m2) or weight (kg)

188
Q

when normothermic or when cooling, generally accepted indices for systemic flow is

A

2.2 to 2.4 L/min/m2 or 50-65 ml/kg

189
Q

when are higher indices for systemic blood flow used

A

in peds patients or when rewarming

150-200 ml/kg

190
Q

adequacy of perfusion is estimated by

A 
MAP (>50 mmHg)
SVO2 65-75
blood lactate levels (<2)
hematocrit
urine output (0.5-1.0 ml/kg/hr)
central and peripheral temp
blood pH
change in pressure CO2
191
Q

activated clotting time (ACT) should be

A

greater than 400 seconds, to go on bypass: 480

192
Q

how often should ACT be tested

A

every 30 min while cannulated

193
Q

thromboelastography (TEG) is a test of what

A

whole blood coagulation

  • measures the global disco-elastic properties of whole blood clot formation under low shear stress
  • usually performed post CPB due long amount of time to perform the test
194
Q

thromboelastography may be used to

A

guide blood product administration in bleeding patients

195
Q

glucose levels should be

A

greater than 200 ml/dL

196
Q

what are glucose levels treated with

A

insulin

Patient Monitoring (1 decks)

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