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Hemodynamics > Week 3- Hemodynamic Monitoring > Flashcards

Week 3- Hemodynamic Monitoring Flashcards

1
Q

Name Standards for Basic Anesthesia Monitoring

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

Basic Monitoring Techniques

A
  • Inspection
  • Auscultation
  • Palpation
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3
Q

Stethoscope

A
  • Continual assessment of breath sounds and heart tones
  • Precordial placed on chest surface
  • Esophageal placed 28-30 cm into esophagus
  • Very sensitive monitor for bronchospasm, airway obstruction, changes in HR/ rhythm
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4
Q

Purpose of ECG

A
  • Heart rate
  • Electrolyte changes
  • Arrhythmias
  • Pacemaker function
  • Ischemia
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5
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. 5 Lead:
    - Electrodes RA, LA, LL, RL, chest lead
    - Leads I, II, III, aVR ,aVL, aVF, V lead
    - 7 views of heart (adds anterior view)
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6
Q

Gain Setting and Frequency Bandwidth

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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7
Q

Indications of Acute Ischemia

A
  1. ST segment elevation, flat, depression, or downslope , ≥1mm
  2. Peaked T wave, and T wave inversion
  3. Development of Q waves
  4. Arrhythmias
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8
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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9
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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10
Q

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

A

Changes in the V3-V4

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11
Q

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

A

Changes in Lead V1-V2

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12
Q

What lead is best for Ischemia Detection?

A

V5

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13
Q

What lead is best for Arrhythmia Detection?

A

II

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14
Q

How do you calculate a MAP?

A

MAP-time weighted average of arterial pressure during a pulse cycle

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

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15
Q

Systolic BP

A
  • Systolic BP-peak pressure generated during systolic ventricular contraction
  • Changes in SBP correlate with changes in myocardial O2 requirements
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16
Q

Diastolic BP

A
  • Diastolic BP-trough pressure during diastolic ventricular relaxation
  • Changes in DBP reflect coronary perfusion pressure
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17
Q

Pulse Pressure

A

Pulse pressure=SBP-DBP

Normal is 30-40

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18
Q

Non-Invasive BP Measurement

A
  1. Palpation- palpating the return of arterial pulse while on occluded cuff is deflated
    - Underestimates systolic pressure, simple, inexpensive, measures only SBP.
  2. Doppler- based on shift in frequency of sound waves that is reflected by RBCs moving through an artery
    - Measures only SBP reliably.
  3. Auscultation- using a sphygmomanometer, cuff, and stethoscope; Korotkoff sounds due to turbulent flow within an artery created by mechanical deformation from BP cuff (unreliable in HTN pts-usually lower)
    - Permits estimation SBP and DBP
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19
Q

Oscillometry

A

oscillations/fluctuations in cuff pressure by arterial pulsations on cuff deflation

  • 1st oscillation correlates with SBP
  • Maximum/ peak oscillations occurs at MAP
  • Oscillations cease at DBP
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20
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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21
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

-Applied snugly, with bladder centered over the artery and residual air removal

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22
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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23
Q

False Low BP with ….

A
  • Cuff too large
  • Extremity above level of heart
  • Poor tissue perfusion
  • Too quick deflation

Note: Erroneous BP with with dysrhythmias, tremors/shiverying

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24
Q

Invasive BP- IABP (A- lines): how does it work? What does it measure?

A

Percutaneous insertion of catheter –> artery –> transduced -> convert generated pressure –> electrical signal –> waveform

  • Generates real-time beat to beat BP
  • Allows access for arterial blood samples
  • Measurement of CO/ CI/ SVR
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25
Q

Indications for A-line

A

“FEWER RRT”

F- Failure of indirect BP
E- Elective Hypotension
W- Wide shifts in OR BP
E- End organ damage
R- Rapid fluid shifts

R- Rapid change in BP
R- Repeated blood samples
T- Titration of vasoactive meds

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26
Q

A-lines: gauge, sites

A

-Small angiocatheter- 20 gauge

  • Sites of insertion include radial, ulnar, brachial, femoral, dorsalis pedis, axillary
  • Radial artery most common (Allen’s test)
27
Q

A-line Transducer

A

Transducer system- continuous flush device

System dynamics and accuracy improved by minimizing tube length, limit stop cocks, no air bubbles, the mass of fluid is small, using non compliant stiff tubing

-calibration at level of heart (mid-axillary line/right atrium or meatus of ear/circle of Willis if concerned about cerebral perfusion as in sitting pt)

28
Q

Dicrotic Notch signifies what?

A

Closure of Aortic Valve

29
Q

Complications with IABP…

A

“THIN SLAVER”

T- Thrombosis
H- Hematoma
I- Infection
N- Nerve damage

S-Skin necrosis
L- Loss digits
A- Arterial Aneurysm
V- Vasospasm
E- Embolism (Air)
R- Retained Guidewire
30
Q

What is a Pulse Oximeter and how does it work?

A
  • Measuring hemoglobin saturation (Spo2)
  • MUST ALWAYS have variable pitch tone
  • noninvasive

*****BOARD Question:

HOW does it work?
-Pulses red and infrared LEDs on and off several hundred times per second
-Blood absorbs the infrared light (algorithm
to compute a ratio of infrared signal and saturation)

31
Q

Pulse Oximetry: Uses, Sites, Inaccuracies

A
  1. Uses:
    - Detection of hypoxemia, perfusion

2.Sites: fingers, toes, nose, ear, tongue, cheek

3.Inaccuracy
Malposition of probe
Dark nail polish
Different hemoglobin
Dyes
Electrical interference
Shivering
32
Q

Indications of CVC?

A

“BRAVE PFIV”

B- Blood samples
R-Right <3 filling pressure
A- Assess fluid status
V- Vasoactive drugs
E- emboli (Air) removal

P- PAC (pulm art cath)
F- Fluid administration
I- insertion of transvenous pacer leads
V- Vascular access

33
Q

Main Insertion sites for CVC?

A 
****Right internal jugular vein
Left internal jugular vein- higher risk of pneumo
Subclavian veins- risk for pneumo
External jugular veins
Femoral veins-infection
34
Q

Size CVC

A
  • 7 french
  • 20 cm length
  • Multiport catheters most common
35
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
36
Q

Confirming CVC placement in OR

A
  • Placement usually not confirmed by XRAY in OR
  • Aspirate blood from all ports
  • After surgery, XRAY
37
Q

Risks of CVC

A

Poor technique “Please Help! CVC DIE”

Please- Pneumo/Hemothorax
Help- Hematoma

C- Carotid puncture
V- Vascular damage
C- Cardiac tamponade

D- Dysrhythmias
I- Infection
E- Embolism (Air, Thrombo, Guidewire)

38
Q

Contraindications CVC

A

“RIP”

R- Right atrial tumor
I- Infection at site
P- Pneumothorax

39
Q

CVP wave results from

A

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

40
Q

CVP measures…

A

RAP= RV preload

41
Q

CVP in spontaneously breathing pt

A

2-7mmHg

42
Q

How much with CVP rise due to Mechanical Ventilation?

A

3-5mmHg

43
Q

Name 5 Phasic Events for CVP waveform

A

3 Peaks:

  1. A wave- maximal filling of R ventricle = RVEDP
  2. C wave
  3. V wave

2 Descents: X, Y

44
Q

Measuring CVP

A
  • should be done at end-expiration

- Machine= average of measurement

45
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**
46
Q

C Wave (CVP)

A
  • Atrial pressure decreases=atrial relaxation
  • right ventricular contraction: tricuspid valve closed bulges back into the right atrium
  • Inearly systole (after the QRS on EKG)
47
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)

48
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 T-wave on EKG

49
Q

Y Descent

A

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

50
Q

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

A

“CLIP M”

C- CO
L- LV filling pressure/function
I- Intracardiac pressure (PAP, CVP, PCWP)
P- PVR/SVR, pacing options

M- Mixed venous O2 saturation

51
Q

PAP Monitoring looks at what side of the heart?

A

LEFT

52
Q

PAP Catheters

A
  • SIZE 7 french (introducer is 8.5)
  • LENGTH: 110 cm length marked at 10 cm intervals
  • Rarely used anymore*
  • 4 lumens
    1. distal port PAP
    2. second port 30 cm more proximal CVP
    3. third lumen balloon
    4. forth wires for temp thermister
53
Q

Indications for PAP Monitoring/Cath?

A

“PASS CLAV”

P-Pulm HTN
A- ARDS/ Resp Failure
S- Sepsis/Shock
S- Surgery (Cardiac, Aortic, OB)

C- CAD
L- LV dysfunction
A- ARF
V- Valvular dz

54
Q

Complications of PA Catheter

A

“BAKE HEART CIPP”

B-Balloon Rupture
A- Arrythmias (V-Fib, RBBB, LV Heart block)
K- Knotting Catheter
E- Embolism (Air/Thrombo)

Heart- Cardiac Structure damage

C-Contraindication (WPW syndrome, LBBB)
I- Infection (Endocarditis)
P- PA RUPTURE
P- Pneumothorax

55
Q

Distances from RIJ vein to Distal Structures

A 
Vena Cava and RA junction 15cm from skin
RA 15-25cm 
RV 25-35cm
PA 35-45cm
Wedged pulmonary capillary 40-50cm
56
Q

A Wave (PCWP)

A

-contraction of the LA

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

57
Q

C Wave (PCWP)

A
  • rapid rise in the LV pressure in early systole
  • mitral valve to bulge backward (closure) into the left atrium
  • atrial pressure increases momentarily
58
Q

V Wave (PCWP)

A

-blood enters the LA during late systole.

59
Q

Prominent V wave is indicative of…

A

-mitral insufficiency causing blood reflux into the LA during systole.

60
Q

Cardiac Output Monitoring

A

“TUMP”

T- Thermodiluation (Continuous)
U- Ultrasound
M- Mixed Venous Oximetry
P- Pulse Contour

61
Q

TEE: What are the 7 Cardiac Parameters Observed?

A

“VIBE VIC”

V- Ventricular wall motion and characteristics
I- Intracardiac Air
B- Blood flow
E- Est. Diastolic/Systolic End Pressure and volume (EF)

V- Valvular structure and function
I- Intracardiac Masses
C- CO

62
Q

TEE uses in the OR:

A

“WAV at THEM”

W- Wall motion
A- Aortic dissection
V- Valvular function/dysfunction

T- Tamponade (Cardiac)
H- Hypotension (Acute)
E- Embolism (Pulm)
M- Myocardial Ischemia

63
Q

Complications of TEE

A

“Don’t Eat Hot Dogs”

D-Dysrhythmias
E- Esophageal trauma
H- Hoarseness
D-Dysphagia

64
Q

Complication of NIBP

A

“I CUP PIE”

I- IV drug administration (alt timing)

C- Compartment syndrome
U- Ulnar Neuropathy
P- Petechiae/ Bruising

P- Pain
I- IV flow interference
E- Edema

Hemodynamics (4 decks)

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