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Physiological Monitoring of the Surgical Patient Flashcards

1
Q

Hemodynamic Monitoring purposes

4

A
  1. Provides information as to the CP status of the patient
  2. Traditional clinical assessments are usually unreliable
  3. Major changes in the cardiovascular status may not be clinically obvious
  4. Invasive techniques must be utilized
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2
Q

Hemodynamic Monitoring

A. Arterial Catheterization (“ART Line”) indications? 2

A
  1. Need for continuous blood pressure monitoring

2. Need for frequent arterial blood sampling

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3
Q

Hemodynamic Monitoring
Arterial Catheterization
Conditions that need continuous and accurate BP monitoring? 6

A
  1. Shock states
  2. Hypertensive crisis
  3. Surgery in high risk patients
  4. Use of potent vasoactive or inotropic drugs
  5. Controlled hypotensive anesthesia
  6. Situations that may lead to rapid changes in cardiac function
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4
Q 
Hemodynamic Monitoring
Arterial Catheterization
Contraindications
1. Absolute? 1
2. Relative? 4
A

Contraindications
1. No ABSOLUTE contraindication to arterial catheterization

  1. RELATIVE contraindications are:
    a. Bleeding problems (hemophilia)
    b. Anticoagulant therapy
    c. Presence of a vascular prosthesis
    d. Local infection
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5
Q

Hemodynamic Monitoring
Arterial Catheterization
Sites for catheterization? 6

A
  1. radial artery
  2. axillary artery
  3. femoral artery
  4. dorsalis pedis artery
  5. superficial femoral artery
  6. brachial artery
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6
Q

Hemodynamic Monitoring
Sites for Catheterization
whats the most commonly used site?

A

Radial artery

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7
Q

Radial artery: Why do we used this site commonly for arterial cath? 3

Monitoring before insertion and during? 4

A
  1. Duel blood supply
  2. simple canulation
  3. low complication rate
  4. modified “Allen’s” test – assess ulnar artery
  5. Doppler technique,
  6. plethysmography, 4. pulse oximetry
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8
Q 
Sites for Catheterization
Axillary artery:
1. Used for what?
2. Size?
3. Location? 2
4. Technical difficulty with this?
5. Located near what?
A
  1. for long term monitoring
  2. large size
    • close proximity to the aorta
    • deep location
  4. technical difficulty in insertion
  5. located near neurovascular structures
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9
Q 
Sites for Catheterization
Femoral artery:
1. Size and location?
2. Prone to what?
3. Difficulty?
A
  1. large size and superficial location
  2. prone to atherosclerosis
  3. difficult to keep clean
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10
Q

Sites for Catheterization
Superficial temporal artery:
1. Whats required for this? 1
2. Complication observed? 1

A
  1. surgical exposure is required

2. neurologic complications observed

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11
Q
  1. Which cath site is used for short term only?

2. Greatest risk with this?

A
  1. brachial artery

2. risk of median nerve contracture (Volkman’s contracture)

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12
Q

Arterial Catheterization

Complications of arterial catheterization? 7

A
  1. failure to cannulate
  2. hematoma
  3. disconnection from monitoring system
  4. Infection
  5. retrograde cerebral embolization
  6. A-V fistula / pseudoaneurysm
  7. severe pain, distal necrosis
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13
Q

What things make infection more likely for arterial cath? 3

A
  1. catheters in place for more than 4 days
  2. surgical insertion
  3. local inflammation
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14
Q
  1. Central venous pressure… a direct measurement of what?
  2. It is acquired by threading a central venous catheter where?
  3. Threaded so that the tip of the catheter rests where? The pressure monitoring assembly is attached to the distal port of a multilumen central vein catheter.
A
  1. the blood pressure in the right atrium and vena cava.
  2. (subclavian double lumen central line) into any of several large veins.
  3. in the lower thirdof the superior vena cava
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15
Q
  1. In seriously ill patients the vital problem is determination of the proper amount of fluids
    and blood requirements necessary to MAINTAIN an optimal blood volume in the what? 3
A
  1. Preoperative
  2. Operative
  3. Postoperative
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16
Q

Hemodynamic Monitoring
1. Central Venous Pressure Monitoring is a reliable procedure to evaluate what?

  1. The procedure removes much of the guess work in rapid restoration and maintenance of adequate circulation w/o fear of what?
A
  1. properly and promptly optimal fluid and blood requirement in these patients.
  2. overloading the heart
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17
Q 
Central Venous Pressure Monitoring
Sites of catheterization
1. What is the easiest to cannulate?
2. Most common complication?
3. Difficulty?
A
  1. Subclavian vein
  2. pneumothorax most common complication
  3. difficult to control bleeding
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18
Q

Central Venous Pressure Monitoring
Sites of catheterization
1. Which has the lowest risk of pneumothorax?
2. Most common complication?

A
  1. internal jugular vein

2. arterial puncture most common complication

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19
Q

Central Venous Pressure Monitoring
1. CVP measured anywhere in the what or their immediate tributaries»>Innominate, and the Common Iliac Veins? 2

  1. It is determined by a complex interaction of? 3
  2. Serves as index of what relative to the Cardiac Pump Action?
A
  1. Superior VC or Inferior VC
    • Blood Volume
    • Cardiac Pump Action
    • Vascular Tone
  3. circulating blood volume
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20
Q

Central Venous Pressure Monitoring
1. CVP or the pressure in the Right Atrium & adjacent Caval system will reflect ability of the Cardiac Pump Action to handle the what?

  1. Indications? 5
A
  1. returning blood volume at that particular time.
    • When Massive blood replacement is instituted rapidly in rapid exsanguinating type of bleeding.
  • In Acute blood volume deficit in cases operated for strangulating type of Intestinal
    Obstruction where rapid fluid replacement is indicated
  • In obscure cases of Shock immediately post-op whether hypovolemic due to internal
    bleeding or nonhypovolemic from Myocardial Infarction.
  • In elderly patients with limited cardiac reserve undergoing difficult, time consuming operations.
  • In surgical patients with anuria due to possible renal shutdown.
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21
Q

Central Venous Pressure Monitoring
Basic Facts about CVP.
1. Normal CVP is about ______?

  1. Low CVP is what levels and indicates what?
  2. High CVP is what?
A
  1. 4 to 7 cm
  2. 0-3 indicates circulating blood volume is below the normal blood volume the
    heart can handle.
  3. 8-20 (more than the heart can handle)
22
Q

Central Venous Catheterization
Indications:

7

A
  1. access for fluid therapy
  2. access for drug infusion
  3. parenteral nutrition
  4. CVP monitoring
  5. aspirate air embolism
  6. placement of cardiac pacemaker / vena cava filters
  7. hemodialysis access
23
Q

Central Venous Catheterization

  1. Useful in what pts?
  2. Tracings for?
  3. Gives information about the relationship between what?
  4. Use what for pressure measurements?
  5. Normal CVP measurement?
A
  1. Useful in hypotensive patients
  2. Tracings for arrhythmias
  3. Gives information about the relationship between intravascular volume and right
    ventricular function
  4. Use of a water manometer for pressure measurements
  5. Normal CVP measurement 4-7 mmH2O
24
Q

Central Venous Pressure Monitoring

  • Technique
    1. Cannulation of the Superior Vena Cava through what? 2
  1. A polyethelene tube size what inches long is inserted at the Basilic Vein
  2. just above the where and pushed up to where?
  3. Connect an Intravenous administration set to the venous catheter in order to?
  4. A _________ is connected to IV set w/ a three way stopcock.
  5. Zero point should be at
    level of the what? 2
A
  1. Basilic or Cephalic Veins.
  2. French 8 and 42
  3. elbow and pushed up to 20 inches.
  4. through which IV fluid may be administered.
  5. Manometer
  6. atrium or approximately at Mid-axillary line
25
Q

Swan-Ganz Pulmonary Artery Catheter

  1. Pulmonary artery catheterization (PAC) is the insertion of a catheter into the what?
  2. Whats its purpose?
  3. Used to detect? 4
  4. Allows direct, simultaneous measurement of pressures in what? 4
A
  1. pulmonary artery.
  2. Its purpose is diagnostic
  3. Used to detect
    - heart failure,
    - sepsis,
    - monitor therapy, and
    - evaluate the effects of drugs.
  4. Allows direct, simultaneous measurement of pressures in:
    - the right atrium
    - right ventricle
    - pulmonary artery
    - filling pressure (“wedge” pressure) of the left atrium.
26
Q

General indications for PAC?

8

A
  1. Management of complicated myocardial infarction
  2. Assessment of respiratory distress
  3. Assessment of type of shock
  4. Assessment of therapy
  5. Assessment of fluid requirement in critically ill patients
  6. Management of postoperative open heart surgical patients
  7. Assessment of valvular heart disease
  8. Assessment of cardiac tamponade/constriction
27
Q

PAC
1. Management of complicated myocardial infarction such as? 6

  1. Assessment of respiratory distress: specifically? 2
  2. Assessment of therapy: such as? 4
  3. Assessment of fluid requirement in critically ill patients: What are we assessing for? 4
A
    • Hypovolemia vs cardiogenic shock
    • Ventricular septal rupture (VSR) vs acute mitral regurgitation
    • Severe left ventricular failure
    • Right ventricular infarction
    • Unstable angina
    • Refractory ventricular tachycardia
    • Cardiogenic vs non-cardiogenic pulmonary edema
    • Primary vs secondary pulmonary hypertension
    • Afterload reduction
    • Vasopressors
    • Beta blockers
    • Intra-aortic balloon counter-pulsation
    • Hemorrhage
    • Sepsis
    • Acute renal failure aka Acute Kidney Injury
    • Burns
28
Q

The PAC is inserted percutaneously into a what via an introducer sheath? 1

Preference considerations for cannulation of the great veins are as follows? 3

A
  1. major vein (jugular, subclavian, femoral)
  2. Right internal jugular vein (RIJ)
  3. Left subclavian
  4. Femoral veins
29
Q

Describe the advantages of the following:

  1. Right internal jugular vein (RIJ)? 1
  2. Left subclavian? 1
  3. Femoral veins? 1
  4. Disadvantages for femoral? 2
A
  1. Shortest and straightest path to the heart
    • Does not require the PAC to pass and course at an acute angle to enter the SVC (compared to the right subclavian or left internal jugular [LIJ])
  3. Nevertheless, these sites are compressible and may be preferable if the risk of hemorrhage is high.
    • These access points are distant sites, from which passing a PAC into the heart can be difficult, especially if the right-sided cardiac chambers are enlarged.
    • Often, fluoroscopic assistance is necessary.
30
Q

CVP Monitoring
Complications
5

A
  1. catheter malposition
  2. dysrythmmias
  3. embolization
  4. vascular injury
  5. cardiac, pleural, mediastinal, neurologic injury
31
Q

Respiratory Monitoring
Monitoring ventilation and gas exchange

  • Indications? 4
A
  1. Decision making for the need of mechanical ventilation.
  2. Assessment of response to therapy.
  3. Optimize ventilatory management.
  4. Decision to wean from ventilator.
32
Q

Monitoring ventilation and gas exchange

Ventilation monitoring: What does it measure and describe what it is? 4

A
  1. Tidal volume – volume of air moved in or out
    of the lung in a single breath
  2. Vital capacity – maximal volume at expiration
    after a maximal inspiration
  3. Minute volume – total volume of air leaving
    the lung each minute
  4. Physiologic dead space – the portion of tidal volume that does not participate in in gas exchange
    a. anatomic dead space
33
Q

Monitoring ventilation and gas exchange
Ventilation monitoring
Physiologic dead space – the portion of tidal volume that does not participate in in gas exchange

What are the two kinds of dead space?

A

a. anatomic dead space

b. physiologic dead space

34
Q 
Monitoring ventilation and gas exchange
Gas Monitoring
1. Reported as directly measured what?
2. Use of what for continuous 
measurements?
  1. Blood gas analysis – information about what? 3
A
  1. partial pressures (PO2 and PCO2)
  2. pulse oximeters
  3. a. efficacy of gas exchange
    b. adequacy of alveolar ventilation
    c. acid–base status
35
Q

Monitoring ventilation and gas exchange
Gas Monitoring
1. What is Capnography?

  1. What are the different forms we can measure this in? 5
A
  1. graphic display of CO2 concentration in wave form
  2. a. infrared analysis
    b. mass spectrometry
    c. Raman scattering
    d. disposable colorimetric devices
    e. semi-quantitive measurement on the end- tidal CO2 concentration
36
Q

Gas Monitoring
Pulse oximetry
1. reliable, real time estimation of the what?

A
  1. arterial Hgb saturation

- wide clinical acceptance

37
Q

Monitoring ventilation and gas exchange
Gas Monitoring
1. Gastric Tonometry is what?

A

relatvely non-invasive monitoring of adequacy of aerobic metabolism in organs whose superficial mucosal lining is extremely vulnerable to low flow changes and hypoxemia

38
Q

Renal monitoring:
1. The kidney is an excellent monitor of what?

  1. Prevention of what?
  2. Predict what?
A
  1. adequacy of perfusion
  2. renal failure
  3. drug clearance and proper dose adjustment
39
Q 
Renal monitoring: 
Urine Output
1. Commonly monitored but?
2. Normal urine output?
3. Correlates with what?
4. High output may not accuraltely refelct what?
A
  1. Commonly monitored but may be misleading
  2. Normal urine output → 0.5 ml/kg/hour
  3. Correlates with glomerular filtration rate (GFR)
  4. High output may not accurately reflect GFR
    ex. Diabetes Insipidus
40
Q
  1. What is the most common type of indwelling urinary catheter?
A
  1. A Foley catheter is a flexible tube passed through the urethra and into the bladder to drain urine.
41
Q
  1. The tube of a Foley catheter has two separated lumens, running down its length. One lumen is open at both ends, and drains where?
  2. The other lumen has a valve on the outside end and connects to a what?

The balloon is inflated with sterile water when it lies inside the bladder to stop it from slipping out.
Commonly made from silicone rubber or natural rubber.
Should be used only when indicated, as use increases the risk of catheter-associated urinary tract infections

A
  1. urine into a collection bag

2. a balloon at the tip.

42
Q

Glomerular Function Tests?

A
  1. Blood Urea Nitrogen (BUN)
  2. Plasma Creatinine
  3. Creatinine Clearance
43
Q 
GFR tests:
Blood Urea Nitrogen (BUN)
1. Affected by what? 2
2. When is it increased? 5
3. Lowered in what? 2

Plasma Creatinine
1. Describe its accuracy compared to BUN?
2. Directly proportional to what?
3. Inversely related to?
4. Not affected by what? 3
5 Related to?

Creatinine Clearance

  1. Used when?
  2. Describe its reliability?
A
  1. Affected by GFR and urea production
  2. Increased in
    - TPN,
    - GI bleeding,
    - trauma,
    - sepsis,
    - steroid use
  3. Lowered in
    - starvation,
    - liver disease
  4. More accurate than BUN
  5. Directly proportional to creatinine production
  6. Inversely related to GFR
  7. Not affected by
    - protein or
    - nitrogen production or
    - rate of fluid flow through tubules
  8. Related to muscle mass
  9. used if values of plasma creatinine are affected by muscle disease
  10. serial determination of urine is done and is currently the most reliable method
    of assessing GFR
44
Q

Renal Monitoring:
1. What is The most reliable test to distinguish pre-renal azotemia from tubular necrosis?

  1. Requires what?
A
  1. Tubular funciton tests

2. Requires simultaneous collected urine and blood samples

45
Q

Neurologic Monitoring…key points

2

A

-Early recognition of cerebral
dysfunction
-Facilitate prompt intervention
and treatment

46
Q

A. Intracranial Pressure Monitoring

2

A
  1. Cerebral Perfusion Pressure >70mmHg

2. Glasgow Coma Scale

47
Q

Electrophysiologic Monitoring

1. Reflects what?

A

spontaneous and on-going electrical activity in the brain

48
Q

Trans-cranial Ultrasound used for what? 2

A
  • Monitors cerebral blood flow

- Detects vasospasm

49
Q

Jugular Venous Oximetry

Measures what?

A

Measures relationship of blood flow to O2 consumption

50
Q

Metabolic Monitoring…key points

2

A
  1. Caloric Demands

2. Respiratory Quotient of Food

51
Q

Temperature Monitoring…key points

3

A

A. Rectal

B. Middle Ear

C. Esophageal

Surgery (20 decks)

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