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Perf Monitoring > test 9 continued > Flashcards

test 9 continued Flashcards

1
Q

Morbid Neurological Outcomes type 1

A

 Cerebral Death
 Non-fatal strokes
 New Transient ischemic attack (not causing permanent damage but is an indicator for bad things down the road)

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2
Q

Morbid Neurological Outcomes type 2

A

 New intellectual deterioration

 New seizures upon discharge (more seizures after surgery)

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3
Q

Type I Predictors

A

 Advanced age is the single greatest
 < 60 : 1% risk
 > 70 ; 4 to 9% risk
 Aortic atherosclerosis (calcified aorta)
 History of prior neurologic events – 15%
 Carotid stenosis
 # of GMEs

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4
Q

Type II Predictors

A

 Low cardiac output states/hypotensive states
 GMEs (size)
 Atrial arrhythmias
 Systolic Hypertension
 Diabetes mellitus (lack of control of glucose)
 Pulmonary Disease
 Excessive Alcoholism

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5
Q

Prevalence of CVS Complications

A

 Neuro Impairment: 6.1% (stroke, coma, seizures)
 Post-Op Delirium: 10-60%
-neurologic dysfunction after bypass results in a longer length of stay
-post-op psychometric testing scores 100%

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6
Q

when does the Incidence of Neurologic Dysfunction happen most in surgery (single greatest neurological stress)

A

-filling of the heart because there are many pocket inside the heart that have chances of bubbles

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7
Q

Surgical Technique to decrease Atheroembolism

A

 Epiaortic ultrasound
 Single Cross Clamp
 No touch techniques
 Paying attention

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8
Q

How do Perfusionists

Contribute

A

 Focal (embolism)
 Hypoperfusion
 Inflammation
 Global

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9
Q

How do Perfusionists

Contribute globally

A 
 Complete
    Cardiac Arrest
    Deep Hypothermic Circulatory Arrest
 Incomplete
    Hypotension
    Inadequate CPB flow
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10
Q

Factors Affecting Blood Oxygenation

A
  • Tailoring Oxygen Delivery

- Tailoring Oxygen Consumption

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11
Q

Tailoring Oxygen Delivery

A
  • Mean Arterial Pressure
  • CO2
  • Cardiac Index and Pump Flow
  • Hematocrit
  • Mechanical Issues
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12
Q

Tailoring Oxygen Consumption

A
  • Anesthetic Agent and Depth

* Temperature

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13
Q

Brain Monitoring

A

 Neurological exam
 Blood Pressure monitoring (doesn’t tell what is actually happening)
 EEG – Electroencephalogram
 BIS – Bispectral Index
 TCD – Transcranial Doppler
 ICP – Intra-cranial pressure monitoring
 SjVO2 – Saturation of Jugular Venous Oxygen
 SvO2 – Saturation of Venous O2 (global)
 rSO2 – REGIONAL SATURATION OF OXYGEN

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14
Q

Ways to help prevent brain injury

A

 EEG: Electroencephalogram
 BIS Monitoring: Bispectral Index
 Cerebral Oximetry

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15
Q

What is an Electroencephalogram (EEG)?

A
  • large footprint so rarely used
  • a lot of leads and need someone to read it
  • reads electrical activity on the surface of the brain but does not measure what is going on deeper in the brain
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16
Q

Alpha and Beta waves of EEG

A

-patient is awake

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17
Q

Theta and Delta waves of EEG

A
  • patient descends into sleep or a coma

- are not normally seen in awake patients unless pt has past cerebral injury

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18
Q

common abnormalities of EEG waves

A

15% of population show abnormalities due to old injuries

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19
Q

Clinical Usage

A 
 Main Reason
    EPILEPSY (number 1 usage)
    Brain Tumors
    Stroke
    Focal brain disorders
 Secondary reason
    Diagnosis of coma
    Encephalopathies
    Brain death
20
Q

Disadvantages in the OR

A

 Analysis is complex
 Distracting anesthesiologist from patient care
 any other electrical activity will affect this (machinery, skeletal and cardiac myofibrils)

21
Q

Bispectral Index (BIS)

A

 Processed EEG information as a measure of sedative effects of anesthesia medications
 Information displayed every 10-15 seconds
 Graphical trend and numerical value
-cheap and easy to interpret

22
Q

BIS Monitoring

A

 Allows anesthesia the ability to access the complicated EEG information during the case
 Uses easy numbering system to identify depth of anesthesia

23
Q

How does bispectral index work (4 things correlated)

A
  1. degree of high frequency activation
  2. degree of low frequency synchronization
  3. degree of periods near suppression
  4. degree of periods completely suppressed
24
Q

BIS index

A

 The index is a number

between 1 and 100 (100= wide awake)

25
Q

Association between clinical states and BIS values

A 
 100 Awake
 80 Light/Moderate Sedation
 60 General Anesthesia
 40 Deep Hypnotic State
 20 Burst Suppression
 10 Flat Line EEG
-a BIS below 70 the pt will not remember things
26
Q

Target BIS values

A

 Need to be tailored for each individual
 Using opioid anesthesia (40-60)
 Using opioid anesthesia on pump (Normally 25 to 35, TARGET to titrate to 45 - 55)

27
Q

If the BP starts to increase, what is another thing you could do other than turn down your flow

A

-turn up the gas anesthetic

28
Q

Why is the BIS important to us

A

 BIS helps us maintain our hemodynamics (doesn’t tell a lot about the brain)
 Reduction in primary anesthetic use
 Reduction in emergence and recovery time
 Improved patient satisfaction

29
Q

Disadvantages of BIS

A

 It is a trending device
 We can’t be responsible to treat the level of sedation
 Often monitor only faces anesthesia

30
Q

Transcranial Cerebral

Oximetry

A

 measures not only surface, but down into the brain. Non-invasive and measures the oxygen metabolism in terms of how much oxygen the brain is pulling off of each hemoglobin.

31
Q

The INVOS System clinical benefits

A

 Noninvasive, continuous, direct, real time measurements of the oxygen hemoglobin extraction done by the brain
 Site-specific (regional) measure vs systemic; often signals earlier warning of reversible ischemia
 Need to set a BASELINE otherwise you don’t know if you are high or low
 Not a trending device, it tell you if have a problem
 Major improvement on Major Organ Morbidity or Mortality percent

32
Q

Adult Applications of INVOS to Date

A 
 Cardiac surgery
 Vascular surgery
 Cardiac cath lab
 Neurology / Neurosurgery
 ER / traumatic brain injury
 General surgery
 Spinal injury
33
Q

Pediatric Applications of INVOS to

Date

A

 Cardiac surgery
 ECMO (Extracoporeal Membrane Oxygenation)
 Cardiac Cath lab (at times)
 Neurology / Neurosurgery
 Still being studied – must convince the caregivers that
the data is useful
 Sensors are improving (much work to do)

34
Q

Placement of the Sensors

A
  • Clean area with alcohol - let it dry
  • Attach sensors above the eye brows
  • Connect to machine
  • SET BASELINE (very important to set baseline before anesthesia induction and nasal oxygen)
35
Q

How optical technology works

A
  • Infrared shoots through the head and the different levels of oxygenated hemoglobin absorb the infrared light
  • it tracks out the surface absorption and the deeper absorption
36
Q

INVOS measures adequacy of cerebral perfusion giving you

A
  • supply of blood to the brain
  • supply of O2 to the brain
  • any inflow or outflow obstructions
37
Q

Cerebral Inflow Issues

A
  • Head Position
  • Heart Position
  • Arterial Obstruction (Carotid Disease, Clamp, Hand, Sponge)
  • Cannula Malposition
38
Q
  1. Cerebral rSO2 detects O2 supply issues associated with inflow obstructions
A
  1. rule out mechanical cause (head position or cannula position)
39
Q
  1. Cerebral rSO2 detects O2 supply issues associated with oxygen delivery
A
  • Increase blood pressure
  • Increase FiO2
  • Increase cardiac output (pump flow)
  • Increase hematocrit
40
Q
  1. Cerebral rSO2 detects
    O2 supply issues
    associated with
    oxygen delivery: decrease demand (cerebral metabolism)
A
  • Increase anesthetic

- Decrease temperature

41
Q

cerebral supply issues

A
  • Low FiO2
  • Low Hgb
  • Low MAP
  • Pump Flow
  • Spasm
42
Q

rSO2 Target & Thresholds

Intervention threshold

A

-rSO2 < 50 or 20% drop
from baseline
-need to start making people aware
-look at the 3 step algorithm

43
Q

rSO2 Target & Thresholds

Critical threshold

A

-rSO2 < 40 or 25% drop
from baseline
-longer your values below critical thresholds, are related to your cerebral outcomes

44
Q

Regional Oximetry

A
  • not invasive

- not just trending values, actually gives real time things that are happening

45
Q

What you can do to protect your patient’s brain?

A

 Medical History
 Monitor for cerebral ischemia
 Use filters on heart lung machine for embolic phenomena
 Use glucose free fluids to avoid significant hyperglycemia
 Maintain controlled temperature
 Maintain appropriate perfusion pressure and flow during CPB
 Consider pharmacologic brain protection
 Utilize brain hypothermia during periods of reduced flow or perfusion pressure
 Perform left ventricular de-airing methods
 Ensure high normal postoperative blood pressures

Perf Monitoring (6 decks)

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