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Intro To Anesthesia > Week 3- Hemodynamic Monitoring > Flashcards

Week 3- Hemodynamic Monitoring Flashcards

1
Q

Name Standards for Basic Anesthesia Monitoring

A
  • Qualified Provider
  • Oxygenation- skin color, Fio2, ABG
  • Ventilation-Breath sounds, chest rise,
  • Circulation- BP, invasive cath (Aline, PA), Pulse ox
  • Temp
  • *All Continually Evaluated**
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2
Q

Who is a qualified Provider

A

Must be able to give CONTINUOUS care once anesthetic started (even in prep)

  • PREOP: License nurse can stay w/ pt
  • OR: SRNA, CRNA, MDA, and (AAs only under supervision)
  • ONLY EXCEPTION: Laboring epidurals, and pain mgt
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3
Q

Minimal Standard: What monitoring needs to be USED?

A

1 .Electrocardiogram (HR and rhythm)

  1. Blood pressure
  2. Pulse oximetry
  3. Oxygen analyzer
  4. End tidal carbon dioxide
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4
Q

Minimal Standard: What needs to be MONITORED?

A
  1. Electrocardiogram
  2. Blood pressure
  3. Heart rate
  4. Ventilation status
  5. Oxygen saturation
    * * All alarms must be audible
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5
Q

What does Esophageal (or Precordial stethoscope) do?

A

-Continual assessment of breath sounds and heart
tones
-Used in intubated patients only placed 28-30 cm into
esophagus
—- Very sensitive monitor for bronchospasm and
changes in pediatric patients

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6
Q

Purpose of ECG

A 
-— detect arrhythmias
—- monitor heart rate
—- detect ischemia
-— detect electrolyte changes
-— monitor pacemaker function
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7
Q

Explain the difference between 3Lead and 5Lead ECG?

A
  1. 3 Lead:
    -Electrodes RA, LA, LL
    —- Leads I, II, III
    —- 3 views of heart (no anterior view)
  2. 5Lead:—
    - Electrodes RA, LA, LL, RL, chest lead
    —- Leads I, II, III, aVR ,aVL, aVF, V lead
    —- 7 views of heart
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8
Q

Gain Setting and Frequency Bandwidth (LOOK UP) (Explain settings)

A

*Gain should be set at standardization
— - 1 mV signal produces 10-mm calibration
pulse
— - A 1-mm ST segment change is accurately
assessed
—
* Filtering capacity should be set to diagnostic
mode
— - Filtering out the low end of frequency
bandwidth can distort ST segment

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9
Q

If you increase the Gain, what may happen? (Check card for accuracy)

A

(1box-1mm)

-May distort image

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10
Q

Diagnostic Mode

A
  • Wide and Best analysis= Whole picture

- Can be problem in OR–> Equipment may interfere causing artifact

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11
Q

Monitoring Mode

A

Filters out some of the picture in the analysis but gets rid of artifact

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12
Q

Indications of Acute Ischemia

A 
1. — ST segment elevation , ≥1mm
—2.  T wave inversion
3. — Development of Q waves
—4. ST segment depression, flat or downslope of
≥1mm
—5. Peaked T waves
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13
Q

In what leads will you see Ischemia to the Posterior/ Inferior Wall (RCA)?

A

Changes in LEAD II, III, AVF

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14
Q

In what leads will you see Ischemia to Lateral Wall (Circumflex branch of LCA)?

A

Changes in Lead I, AVL, V5-V6

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15
Q

In what leads will you see Ischemia to the Anterior Wall (LCA)?

A

Changes in the Lead I, AVL, V1-V4

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16
Q

In what leads will you see Ischemia to the Anterio-septal wall (LDA)?

A

Changes in Lead V1-V4

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17
Q

What lead is best for Ischemia Detection?

A

V5

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18
Q

What lead is best for Arrhythmia Detection?

A

II

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19
Q

How do you calculate a MAP?

A

MAP= SBP + 2 (DBP) ( OR) DBP + 1/3 (SBP- DBP)
———————
3

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20
Q

What is a normal Pulse Pressure?

A

40

-Also know it widens as you go down )

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21
Q

Widened pulse pressure seen in…?

A

sepsis, tamponade, HB, Increased ICP, HTN

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22
Q

Narrow pulse pressure seen in…?

A

CHF, Aortic Stenosis

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23
Q

Korotkoff sounds occur because of what?

A

due to turbulent flow within an artery created by mechanical deformation from BP cuff (unreliable in HTN pts-usually lower)

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24
Q

Oscillometry

A

-NIBP method: Senses oscillations/fluctuations in cuff
pressure produced by arterial pulsations while deflating
a BP cuff
— - 1st oscillation correlates with SBP
-— Maximum/ peak oscillations occurs at MAP
— - Oscillations cease at DBP

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25
Q

Automated BP Cuffs work by what mechanism?

A

Oscillometry: measure changes in oscillatory amplitude electronically, derives MAP, SBP, DBP by using algorithms.

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26
Q

What should the size of your NIBP cuff be?

A

-Bladder width is approximately 40% of the
circumference of the extremity

—- Bladder length should be sufficient to encircle at least
80% of the extremity

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27
Q

False High BP with….

A

—- Cuff too small
—- Cuff too loose
-— Extremity below level of heart
-— Arterial stiffness- HTN, PVD

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28
Q

False Low BP with ….

A

—- Cuff too large
—- Extremity above level of heart
—- Poor tissue perfusion
—- Too quick deflation

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29
Q

Invasive BP- IABP

A

Involves percutaneous insertion of catheter into an artery, which is then transduced to convert the generated pressure into an electrical signal to provide a waveform
— - Generates real-time beat to beat BP
-— Allows access for arterial blood samples
— - Measurement of CO/ CI/ SVR

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30
Q

Describe Allen Test and when it would be used?

A
  • Ensures collateral blood flow to hand prior to Aline placement** RADIAL MOST COMMON
  • Place pressure to occlude both radial, and ulnar arteries
  • While holding=make a fist (exsanguination)
  • Let go of the ulnar artery and ensure the t blood flow returns in case you trash radial blood flow
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31
Q

Aline Transducer system

A

–>continuous flush device
–>— 1-3 mL/hour NS, prevents thrombus formation
—–> Allows rapid flushing

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32
Q

Accuracy of IABP line depends on what?

A

correct calibration and zeroing

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33
Q

Leveling Transducer (Aline) to what?

A

—- Mid axillary line in supine pts (right atrium)
-— Level of the ear (circle of Willis) in sitting
pts.

34
Q

Dicrotic Notch signifies what?

A

Closure of Aortic Valve

35
Q

ADD PIC SLIDE 26

A 
1, Systolic upstroke
2, systolic peak pressure
3, systolic decline
4, dicrotic notch aortic valve closure
5, diastolic runoff
6, end-diastolic pressure
36
Q

What is Distal Pulse Amplification?

A

When Arterial BP waveforms travel through the arterial tree to periphery

  • ——>SBP peak increases
  • ——>DBP wave decreases
  • ——>MAP not altered
  • ——>Dicrotic notch becomes less and appearslater
37
Q

Complications with IABP…

A 
— Nerve Damage
— Hemorrhage/ Hematoma
— Infection
— Thrombosis
— Air embolus
— Skin necrosis
— Loss of digits
— Vasospasm
— Arterial aneursym
— Retained guidewire
38
Q

What is a Pulse Oximeter and how does it work?

A
  • Method of measuring hemoglobin saturation (Spo2)
  • MUST ALWAYS have variable pitch tone when in use

*****BOARD Question=HOW does it work?—->Pulses red and intrared LEDs on and off several hundred times per second
—  Absorption of intrared light in blood (uses an algorithm
to compute a ratio of infrared signal and saturation)

39
Q

What is the difference btwn SpO2 and SaO2?

A

SpO2: Measuring Hemoglobin saturation of oxygen in blood via Oximeter

SaO2: Functional oxygen saturation (SaO2) is the ratio of
oxyhemoglobin to all functional hemoglobin via Blood test

40
Q

Indications of CVC?

A 
—- Measure right heart filling pressures
—- Assess fluid status/blood volume
—- Rapid administration of fluids
—- Administration of vasoactive drugs
—- Removal of air emboli
-— Insertion of transvenous pacing leads
—- Vascular access
-— Sample central venous blood
—- Pulmonary artery catheters
41
Q

Main Insertion sites for CVC?

A 
—****Right internal jugular vein
— Left internal jugular vein
— Subclavian veins
— External jugular veins
— Femoral veins
42
Q

Size CVC

A

—SI 7 french
— 20 cm length
— Multiport catheters most common
—

43
Q

Where is CVC tip located?

A

— Ideally, tip within the SVC, just above junction of venae cavae and the RA

  • parallel to vessel walls
  • positioned below the inferior border of clavicle and above the level of 3rd rib, the T4/T5 interspace, the carina, or takeoff right main bronchus
44
Q

CVC in the OR…

A

-Placement usually not confirmed by XRAY in OR
—- Aspirate blood from all ports
—- After surgery, XRAY

45
Q

Risks of CVC

A 
Usually due to poor technique
-— Air or thromboembolism
-— Dysrhythmia (during placement= tickle SA node)
-— Hematoma- RIJ
-— Carotid puncture
—- Pneumo/hemothorax
—- Vascular damage
-— Cardiac tamponade
-— Infection
—- Guidewire embolism
46
Q

Contraindications CVC

A

— R atrial tumor

— Infection at site

47
Q

CVP wave results from

A

results from ebbs and flows of blood in the right atrium.

48
Q

CVP

A

RAP= RV preload

49
Q

Mean RA pressure in spontaneously breathing pt

A

1-7mmHg

50
Q

How much with CVP rise due to Mechanical Ventilation?

A

3-5mmHg

51
Q

Name 5 Phasic Events for CVP waveform

A 
3 Peaks:
1. A wave- MOST IMPT- coincides with point of maximal filling of R ventricle = RVEDP
2. C wave
3. V wave
               2 Descents:
1. X
2. Y
52
Q

Measuring CVP

A
  • should be done at end-expiration

- Machine= average of measurement

53
Q

Causes of an increased CVP?

A
  • Volume Overload
  • Right Heart failure (pump failure= P increases)
  • Tension Pneumo
  • Tamponade
54
Q

Causes of a deacreased CVP?

A
  • Hypovolemia

- Shock

55
Q

A Wave (CVP)

A

—- Caused by atrial contraction (follows
the P-wave on EKG)
-— End diastole
—- Corresponds with “atrial kick” which
causes filling of the right ventricle
Peak is where you get the CVP measurement from

56
Q

C Wave (CVP)

A

-Atrial pressure decreases after the “a” wave as a result of atrial relaxation
—-due to right ventricular contraction
- tricuspid valve closed bulges back into
the right atrium
—- Occurs in early systole after the QRS on EKG)

57
Q

X Descent (CVP)

A

-— Atrial pressure continues
to decline during ventricular contraction due
to atrial relaxation
-— “Systolic collapse in atrial pressure”
—- Mid-systolic event (Tricuspid valve now closed)

58
Q

V Wave (CVP)

A

—-Last atrial pressure increase is caused by filling of the atrium with blood from the vena cava
—- Occurs in late systole with the tricuspid still
closed
—- Occurs just after the Twave on EKG

59
Q

Y Descent

A 
-— Decrease in atrial pressure as the
tricuspid opens and blood flows from
atrium to ventricle
—- “Diastolic collapse in
atrial pressure”
60
Q

Large A waves can seen with…

A

Tricuspid Stenosis
Pulm HTN
Decreased RV compliance (Stiff)

61
Q

Decreased A waves (or none observed) seen with …

A

Afib (no pressure, No Kick)

62
Q

Large V Waves seen with…

A

Volume Overload
Tricuspid Regurgitation
-Anything causing more pressure/ squeezing pf the heart (ex. Tamponade, Pericarditis)

63
Q

— Right-sided heart catheter (PAWP monitoring) used for direct bedside assessment of :

A 
—- Intracardiac pressures (CVP, PAP, PCWP/ PAWP)
—- Estimate LV filling pressures
—- Assess LV function
—- CO
—- Mixed venous oxygen saturation
—- PVR and SVR
—- Pacing options
64
Q

PAP Monitoring looks at what side of the heart?

A

LEFT

65
Q

PAP Catheters

A 
-SIZE— 7 or 9 french
—-LENGTH: 110 cm length marked at 10 cm intervals
***Rarely used anymore***
-— 4 lumens
—      1. distal port PAP
—      2. port 30 cm more proximal CVP
—      3.  lumen balloon
—      4. wires for temp thermister
66
Q

Indications for PAP Monitoring/Cath?

A

-— LV dysfunction
-— Valvular disease
-— Pulmonary HTN
-— CAD
-— ARDS/ resp failure
-— Shock/sepsis
—- ARF
—- Surgical procedure: cardiac, aortic, OB

67
Q

Complications of PA Catheter

A

Arrhythmias (including V-fib, RBBB, complete heart block)
—- Catheter knotting
—- Balloon rupture
-— Thromboembolism; air embolism
—- Pneumonthorax
—- Pulmonary infarction
— PA rupture
—** Infection (endocarditis)- MOST COMMON
—- Damage to cardiac structures (valves, etc.)
—- Relative Contraindications– WPW syndrome, Complete LBBB

68
Q

Distances from RIJ vein to Distal Structures

A

Slide 53

69
Q

PAWP Wave Form

A

Slide 57 pic

  • A wave
  • C wave
  • V wave
70
Q

A Wave (PAWP)

A

-represents contraction of the left atrium

(Normally it is a small deflection unless there is resistance in moving blood into the left ventricle as in mitral stenosis)

71
Q

C Wave (PAWP)

A

-due to a rapid rise in the left ventricular
pressure in early systole
-causing the mitral valve to bulge backward (closure) into the left atrium
-so that the atrial pressure increases momentarily

72
Q

V Wave (PAWP)

A

-produced when blood enters the left
atrium during late systole.
—

73
Q

Prominent V wave is indicative of…

A
  • reflects mitral insufficiency causing large amounts of blood to reflux into the left atrium
    during systole.
74
Q

Cardiac Output Monitoring

A 
-Thermodilution
—- Continuous thermodilution
—- Mixed venous oximetry
—- Ultrasound
—- Pulse Contour
75
Q

Factors that Can distort CVP/ PAOP waveforms- LOSS OF ‘A’ WAVES

A

— A fib

— Ventricular pacing

76
Q

Factors that Can distort CVP/ PAOP waveforms- GIANT ‘A’ WAVES (“cannon”)

A 
—- Junctional rhythms
—- Complete HB
—- Mitral stenosis
—- Diastolic dysfunction
—- Myocardial ischemia
—- Ventricular hypertrophy
77
Q

Factors that Can distort CVP/ PAOP waveforms- Large ‘V’ WAVES

A
  • — Mitral regurgitation

- — Acute increase in intravascular volume

78
Q

TEE: What are the 7 Cardiac Parameters Observed?

A

—1.  Ventricular wall characteristics and motion
—2. Valve structure and function
3. — Estimation of end-diastolic and end-systolic pressures and volumes (EF)
4.— CO
—5. Blood flow characteristics
—6. Intracardiac air
7. — Intracardiac masses

79
Q

TEE also Used to look for:

A 
—- Unusual causes of acute hypotension
-— Pericardial tamponade
—- Pulmonary embolism
-— Aortic dissection
-— Myocardial ischemia
-— Valvular dysfunction
-Volume status
-Ischemia (wall motion and valvular function)
80
Q

Complications of TEE

A
  • — Esophageal trauma
  • — Dysrhythmias
  • — Hoarseness
  • — Dysphagia
  • *Most complications in awake pt**

Intro To Anesthesia (5 decks)

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