Week 3- Hemodynamic Monitoring Flashcards
Name Standards for Basic Anesthesia Monitoring
- Oxygenation- skin color, Fio2, ABG
- Ventilation-Breath sounds, chest rise,
- Circulation- BP, invasive cath (Aline, PA), Pulse ox
- Temperature
- *All Continually Evaluated**
Basic Monitoring Techniques
- Inspection
- Auscultation
- Palpation
Stethoscope
- 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
Purpose of ECG
- Heart rate
- Electrolyte changes
- Arrhythmias
- Pacemaker function
- Ischemia
Explain the difference between 3Lead and 5Lead ECG?
- 3 Lead:
- Electrodes RA, LA, LL
- Leads I, II, III
- 3 views of heart (no anterior view) - 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)
Gain Setting and Frequency Bandwidth
*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
Indications of Acute Ischemia
- ST segment elevation, flat, depression, or downslope , ≥1mm
- Peaked T wave, and T wave inversion
- Development of Q waves
- Arrhythmias
In what leads will you see Ischemia to the Posterior/ Inferior Wall (RCA)?
Changes in LEAD II, III, AVF
In what leads will you see Ischemia to Lateral Wall (Circumflex branch of LCA)?
Changes in Lead I, AVL, V5-V6
In what leads will you see Ischemia to the Anterior Wall (LCA)?
Changes in the V3-V4
In what leads will you see Ischemia to the Anterio-septal wall (LDA)?
Changes in Lead V1-V2
What lead is best for Ischemia Detection?
V5
What lead is best for Arrhythmia Detection?
II
How do you calculate a MAP?
MAP-time weighted average of arterial pressure during a pulse cycle
MAP= SBP + 2 (DBP) ( OR) DBP + 1/3 (SBP-DBP)
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Systolic BP
- Systolic BP-peak pressure generated during systolic ventricular contraction
- Changes in SBP correlate with changes in myocardial O2 requirements
Diastolic BP
- Diastolic BP-trough pressure during diastolic ventricular relaxation
- Changes in DBP reflect coronary perfusion pressure
Pulse Pressure
Pulse pressure=SBP-DBP
Normal is 30-40
Non-Invasive BP Measurement
- Palpation- palpating the return of arterial pulse while on occluded cuff is deflated
- Underestimates systolic pressure, simple, inexpensive, measures only SBP. - Doppler- based on shift in frequency of sound waves that is reflected by RBCs moving through an artery
- Measures only SBP reliably. - 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
Oscillometry
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
Automated BP Cuffs work by what mechanism?
Oscillometry: measure changes in oscillatory amplitude electronically, derives MAP, SBP, DBP by using algorithms.
What should the size of your NIBP cuff be?
-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
False High BP with….
- Cuff too small
- Cuff too loose
- Extremity below level of heart
- Arterial stiffness- HTN, PVD
False Low BP with ….
- Cuff too large
- Extremity above level of heart
- Poor tissue perfusion
- Too quick deflation
Note: Erroneous BP with with dysrhythmias, tremors/shiverying
Invasive BP- IABP (A- lines): how does it work? What does it measure?
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
Indications for A-line
“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
A-lines: gauge, sites
-Small angiocatheter- 20 gauge
- Sites of insertion include radial, ulnar, brachial, femoral, dorsalis pedis, axillary
- Radial artery most common (Allen’s test)
A-line Transducer
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)
Dicrotic Notch signifies what?
Closure of Aortic Valve
Complications with IABP…
“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
What is a Pulse Oximeter and how does it work?
- 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)
Pulse Oximetry: Uses, Sites, Inaccuracies
- 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
Indications of CVC?
“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
Main Insertion sites for CVC?
****Right internal jugular vein Left internal jugular vein- higher risk of pneumo Subclavian veins- risk for pneumo External jugular veins Femoral veins-infection
Size CVC
- 7 french
- 20 cm length
- Multiport catheters most common
Where is CVC tip located?
- 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
Confirming CVC placement in OR
- Placement usually not confirmed by XRAY in OR
- Aspirate blood from all ports
- After surgery, XRAY
Risks of CVC
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)
Contraindications CVC
“RIP”
R- Right atrial tumor
I- Infection at site
P- Pneumothorax
CVP wave results from
results from ebbs and flows of blood in the right atrium.
CVP measures…
RAP= RV preload
CVP in spontaneously breathing pt
2-7mmHg
How much with CVP rise due to Mechanical Ventilation?
3-5mmHg
Name 5 Phasic Events for CVP waveform
3 Peaks:
- A wave- maximal filling of R ventricle = RVEDP
- C wave
- V wave
2 Descents: X, Y
Measuring CVP
- should be done at end-expiration
- Machine= average of measurement
A Wave (CVP)
- 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**
C Wave (CVP)
- Atrial pressure decreases=atrial relaxation
- right ventricular contraction: tricuspid valve closed bulges back into the right atrium
- Inearly systole (after the QRS on EKG)
X Descent (CVP)
-Atrial pressure continues
to decline during ventricular contraction due
to atrial relaxation
- “Systolic collapse in atrial pressure”
- Mid-systolic event (Tricuspid valve now closed)
V Wave (CVP)
-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
Y Descent
-Decrease in atrial pressure as the
tricuspid opens and blood flows from
atrium to ventricle
- “Diastolic collapse in atrial pressure”
Right-sided heart catheter (PAWP monitoring) used for direct bedside assessment of :
“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
PAP Monitoring looks at what side of the heart?
LEFT
PAP Catheters
- 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
Indications for PAP Monitoring/Cath?
“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
Complications of PA Catheter
“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
Distances from RIJ vein to Distal Structures
Vena Cava and RA junction 15cm from skin RA 15-25cm RV 25-35cm PA 35-45cm Wedged pulmonary capillary 40-50cm
A Wave (PCWP)
-contraction of the LA
Normally a small deflection unless there is resistance in moving blood into the left ventricle (mitral stenosis)
C Wave (PCWP)
- rapid rise in the LV pressure in early systole
- mitral valve to bulge backward (closure) into the left atrium
- atrial pressure increases momentarily
V Wave (PCWP)
-blood enters the LA during late systole.
Prominent V wave is indicative of…
-mitral insufficiency causing blood reflux into the LA during systole.
Cardiac Output Monitoring
“TUMP”
T- Thermodiluation (Continuous)
U- Ultrasound
M- Mixed Venous Oximetry
P- Pulse Contour
TEE: What are the 7 Cardiac Parameters Observed?
“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
TEE uses in the OR:
“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
Complications of TEE
“Don’t Eat Hot Dogs”
D-Dysrhythmias
E- Esophageal trauma
H- Hoarseness
D-Dysphagia
Complication of NIBP
“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
