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ANAESTHESIA > 5b. Patient Monitoring > Flashcards

5b. Patient Monitoring Flashcards

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1
Q

How long does sedation take with SQ, IM and IV>

A

SQ 20-30, unreliable for sedation
IM 15m
Iv 3-5m

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2
Q

What degree of sedation do we want?

A

depends on drugs used and environment - in a dark, quiet, familiar, owner present, other animals

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3
Q

How long could sedation last?

A

8 hours - may still be sedated during recovery, at time of discharge and maybe after arriving home and could be painful when it ears off

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4
Q

What are the signs of sedation?

A
  1. T: usually constant; may be slightly decreased
    P: slight dec; severe dec if a A2 agonist
    R: slight dec, may pant if hydro (dog)
  2. Prolapsed 3rd eyelid
  3. pupil size - same or relative miosis
  4. Ataxia - mild to severe, to recumbent
  5. check for muscle rigidity, twitches
  6. GI - V/D possible, in saliva
    record lvl/effects in record
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5
Q

What changes are NOT acceptable during sedation and might indicate an adverse reaction to premeds or patent pathology

A
  1. TPR: inc temp, sudden onset murmurs or arrhythmia’s, severe bradycardia (need to check BP)
  2. MM - cyanosis or very pale
  3. Abnormal nystagmus
  4. blood or foreign object in V/D
  5. Tremors, seizures
  6. Weakness, stupor, unconsciousness; inability to arouse
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6
Q

How might we monitor at induction?

A

Induction begins w/ induction agent
Goal is stage 3, plane 1
watch for changes consistent w/ stage 1 > 3 > 3 plane 1
Stage 1: open mouth breathing, irregular depth of resp, saliva, redness of eyes (conjunctivitis), inc TPR (from fighting
Stage 2: vocalizing, tremors, twitching, paddling
Stage 3: relaxed, recumbent

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7
Q

Which one is faster, injectable or mask?

A

injectable

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8
Q

Once we monitor during induction, do we stop? What do we keep monitoring

A

continuous monitoring of heart and resp, MM color
Wasy to forget when setting up monitoring equipment and intubation
Check MM color
watch chest rise/fall
Check with auscultation

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9
Q

WHY do we monitor?

A

for safety and monitor anesthetic depth
Monitoring is manual (by person), machines are back up only
Monitor: patient stability and anesthetic depth

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10
Q

Why is monitoring useful, what can it help with?

A

Anesthetics ALWAYS have S/E
ITs purpose is to warn early about changes in anes depth and patient condition
Healthy patients are at risk; risk inc w/ inc PS score
Drug selection, dose and duration of GA will affect stability and depth
Risks include cardiac arrest, pulmon arrest, brain stem depression, coma, vasogenic/cardiogenic/hypovolemic shock, drug reactions

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11
Q

What are the minimal monitoring parameters?

A

HR and rhythm
Rate and depth of resp
MM color, CRT
pulse strength
BP (minimum is systolic),
Temp

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12
Q

What are some additional values to monitor?

A

diastolic, MAP, arterial BP
Oxygen saturation (SpO2)
End-tidal CO2
ECG

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13
Q

What do we monitor to know anesthetic depth?

A

Values should remain stable, a dec in HR, RR, P, BP indicates problems
Monitoring muscle tone and reflexes - includes eye position, pupil size, jaw tone, limb flaccidity
Goal is to find balance btw sufficient anesthesia to block sensation of pain while allowing for procedure

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14
Q

What are the standards of monitoring GA?

A

Starts from time of induction
Monitor a min of q5m if P1 and P2
Monitor continuously if P3 or above, if a horse on inhalants or 45+ min of GA
Once patient has recovered, continue monitoring q15m until patient can sit or lay in sternal and TPR has returned to pre-anes values

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15
Q

We often use machines during GA, should we trust the machines? What about them do we care about when monitoring?

A

MUST look and require manual verification and HANDS ON check of patient
Look at anes machine: o2 flow, vaporizer, bag, pop-off valve, pressure gauges - record O2 flow and % gas

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16
Q

How do we know a patient is in Stage 1, what is stage 1 called?

A

Occurs after GA drug (proper pre-med/sedation should NEVER result in stage 1)
Goal: move through it as fast as possible
Still conscious (but losing consciousness towards end)
Fear, excitement, disorientation, struggling
Inc HR and RR
Panting, urination, defecation
Pupil dilation
Patient is difficult to handle
End of stage 1 - can’t stand, recumbent (make sure body properly supported

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17
Q

How do we know a patient is in stage 2, what is it called

A

involuntary excitement
unconscious “fight or flight”
Unconscious
Invol movement (twitching, paddling, rigid muscles)< vocalization, pee/poo
Pupils dilated, muscle tone and reflexes present or slightly exaggerated
Inc HR and RR, irregular breathing, may be open mouth but never cyanotic
End: muscles relax, slowing HR/RR, decreasing reflexes

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18
Q

How do we know a patient is in stage 3, plane 1. What is it called?

A

Unconsciousness, light sx plane
Goal when inducing, time to intubate, fine for prep and moving patient, not good for most sx
Unconscious, muscles relaxed but still have tone; limbs relaxed
Dec jaw tone (Some tone, can open + close)
Dec reflexes - slow PLR, palpebral, pedal (AKA withdrawal)
Dec gag/swallow > can pass ETT; start on inhalant
Dec cardiopulmonary fxn - Mild dec HR, RR, temp, BP; breathing is regular
Pupils: constricted, centrally located
Loss of tear prod - need to apply lube

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19
Q

How do we know a patient is in stage 3 plane 2, what is it called?

A

Good for sx - surgical plane
Same as above except pupils less constricted, eyes ventromedial (D,C; but NOT H)
NO swallow/gag/palpebral/pedal
Dec muscle tone - limbs extended but not flaccid
HR, RR, BP, slight dec from plan 1 but steady and stable
MM still pink, CRT <2
Will continue to drop temp
certain sx stim SHOULD cause mild inc HR, RR, BP
Patient remains unconscious and immobile

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20
Q

How do we know a patient is in stage 3, plane 3? What is it called?

A

deep anes
EXCESSIVE CNS depression, significant CV and pulmon depression
NO response to surgical stimulation
dec HR/RR/BP, approaching minimal cut-offs
Dec tidal volume (Dec O, inc CO2)
Low pulse strength, prolonged CRT, pale MM
pupils moderately dilated, centrally located
Muscles are flaccid (NO jaw tone, limp)
WARNING patient not stable
1. dec anes
2. likely requires manual ventilation - start bagging

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21
Q

How do we know a patient is in stage 5, what is it?

A

OVERDOSE - BAD
pupils completely dilated, eyes centrally located
ALL reflexes absent
All muscles paralyzed or flaccid
CV and resp collapse = shock
VERY brief, transiet symp response; followed by rapid dropping vital signs like HR, RR, P
Prolonged CRT, MM - pale or cyanotic
Death in 1-5m

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22
Q

How frequent do we monitor C/D?

A

m q5min for P1 and P2, continuous if P3+

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23
Q

How frequent do we monitor equine and exotics?

A

continuous if on inhalants or more than 45m

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24
Q

How frequent do we monitor temperature?

A

q15m in all species

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25
What signs do we monitor for vital signs groupings?
1. circulation: HR/P*, rhythm, CRT, MM color, BP*, pulse strength/quality 2. Oxygenation: MM color, O saturation (SpO2), inspired O, arterial blood O (PaO2: blood gas) 3. Ventilation: RR and depth, breath sounds, end-tidal CO lvls (ETCO2), arterial CO2, blood pH 4. Temp: related to circulation, but other factors also contribute greatly to change in temp * absolute minimum
26
What is a pulse oximeter probes
You can place them on the tongue, lip, inguinal, popliteal, toe, base of tail, edge of ear
27
What is the PR interval?
time for ventricles to fill
28
What is the QRS complex
ventricular depolar/contract, 2nd heart sound
29
What is the T wave
ventricular repolar
30
What is a 1st degree AV-block
normal in athletes, longer interval btw P and QRS
31
What is a 2nd degree AV block: normal in athletes
Occasionally missed QRS after a P
32
What happens if your ECG doe snot read?
check your patient (MM, pupil positioning, auscultate heart) b4 assuming problem w/ leads
33
What is CRT?
capillary refill time Should not change under GA Subjective indicator of peripheral tissue blood perfusion >2s is reason to report Causes: vasoconstriction due to epinephrine or excessively cold Low BP - dec cardiac output, dehydration, hypothermia, cardiac failure, excessive anesthetic depth, blood loss, shock Correlation btw dec perfusion and cooling of that part of body
34
WHat is blood pressure?
force exerted by flowing blood on arterial walls best measure of tissue perfusion during anes Gives info on heart function: HR, stroke volume Vascular resistance - size of blood vessels; too much vasodilation? Blood volume Must know minimum acceptable values and how to respond if there is a drop below accepted value all machines measure systolic pressure
35
What is systolic, diastolic and mean arterial pressure?
Systolic: prod by contraction of L ventricle - indicates force of heart contraction; force of blood out of heart, all BP intrumets give this Diastolic: pressure that remains in arteries when heart is in resting phase btw contractions, not all BP monitoring instruments can measure diastolic pressure MAP: need to know ^^, best indicator of tissue perfusion, most instruments provide MAP Systolic = MAP diastolic
36
What is the best indicator of tissue perfusion?
MAP
37
What are some indirect BP monitors?
oscillometric - systolic, diastolic, MAP Sphygomanometer and cuff - can be used with dopplers
38
What are direct BP monitors
cath placed in an artery and blood flow into cath is run thru transducer that measure the force of flow. Most accurate
39
WHat is pulse strength?
very rough indicator of BP Diff btw systolic and diastolic blood BP - if syst + dia both dec, pulse will remain the same Can't palpate if <60mmHG also affected by vessel diameter, temp, SQ fat Can palpate a peripheral artery like lingual, dorsal pedal, femoral, carotic, facial, aural Diff arteries are appropriate for diff species Compare w/ pre-anes pulse: should be SAME BOUNDING/weak/thread/absent are bad
40
At what value can you no longer palpate a pulse strength?
<60mmHg
41
42
What is a transmission lingual probe?
clothes pin-shaped, light emitted from one side; sensor on other REflective rectal probe - light reflects off tissue, goes back to probe, place against rectal wall
43
What value must ETCO be to drive the breathing refelx?
>40mmHg Acceptable is 35-45mmhG
44
What is a capnograph?
measures RR, tidal volume, ETCO Measures start of expire, dead space gase replaced by alveolar gas, pure alveolar gas, start of inspire and dilution of alveolar gas by inspired fresh gas
45
What is end tidal CO2?
measure of ventilation Specifically measures how much CO2 is breathed out Also takes into account: tissue metabolism, cardiac output (blood must carry Co2 from tissues back to lungs)< pulmonary funct (tidal volume, respi) normal ETCO approx 35-45mmHG inc indicates dec RR and dec tidal volume If remains high, will lead to resp acidosis
46
What happens when ETCO2 >45mmHg?
hypercapnea Indication of hypoventilation; not enough CO2 is being exchanged for O2 Build up of CO2 causes resp acidosis Patient is also receiving less gas anes and less O2 Signal is sent to resp center in brain that stims patient to take more/deeper breaths (CO2 drive) if patient continues to hypoventilate or is apneic, start manual ventilation (no more than 4 deep breaths/min) until ETCO is around 40mmHg Patient is not well ventilation, too deep, acidosis and body is getting rid of excess CO2
47
What happens when ETCO is <35mmHg?
hypocapnea indication of hyperventilation (sucking in O2) Dec Co2, causes resp alkalosis Causes incl. stress, anxiety, pain (too light?), CNS depression (too deep), drug reaction If <40mmHg, will turn off resp drive so patient may stop breathing on own until Co2, builds up to approve 40mmHg
48
What is core body temp?
Temp doesn't tell O or ventilation: its tells us brainstem and hypothalamic func, maybe circulation Monitor pre-anes, q15-30m during anes and during recovery. Monitor more often if low, small, thin, neonates, abdominal sx - hypothermia prolongs recovery and inc drug risks Stop active warming after 37, continue to monitor until back to normal expected drop in temp w/ GA and sx inc temp not common. due to drug reaction (hydro), fentanyl in cats; iso), or vascular dz (cant vasodilate)
49
What are 7 things to monitor for anesthetic depth?
1. eye position 2. pupil size 3. reflexes 4. Muscle tone 5. lacrimation and salivation 6. Hr, RR, BP, other vitals 7. Spontaneous movement/response to surgical stimulus
50
What are the pupile size and eyeball position from sedation > stage 4?
Sedation: pos - voluntary, tthird eyelid may be up Stage 1-2: dilated, central - may be moving Stage 3.1 - constricted, central Stage 3.2 - Constricted, ventromedial (C, D only, not H) pupil stay central Stage 3.3 - more dilated central Stage 4 - dilated, central
51
About the eyes, are are some important things to remember when monitoring depth?
both eye/pupils should be symmetrical Animals that are given atropine as part of premed may have more dilation than anims that have not been administered atropine 3rd eyelid remains prolapsed throughout
52
How do we monitor muscle tone under GA?
check jaw and limb tone Stage 1+2: inc tone, limbs may be rigid or plastic Stage 3.1: slight dec, relaxed, slight pressure will open jaw Stage 3.2: further dec tone, but still require pressure to open jaw Stage 3.3: limp to flaccid Stage 4: flaccid Jaw tone dec in Stage 3.1 enough that most animals can have their jaw opened to intubate
53
When might palpebral, PLR, pedal/withdrawal, Swallow (gag), laryngeal (cough), nystagmus reflexes disappear or decrease?
Palpebral: disappeares Stage 3.2 in D/C, 3.3 in Eq PLR: dec and gone during 3.2 Pedal/withdrawal: disappears in 3.1 Swallow: dec in 3.1 to intube, disappears 3.2 Laryngeal: same as above, note: must be gone in cats b4 intub to prevent laryngospams nystagmus: faster when light, slow to gone in 3.3 in eq May be affected by drugs, dz, or patient variation Mark as present, dec or absent; abnormalzaQ
54
What is the palpebral reflex?
blink reflex in response to light tap on medial or lateral canthus Absent in D/C in 3.2 present, but dec in eq in 3.2
55
What is the swallowing (gag) reflex
watch ventral neck region Dec 3.1 - dec enough to allow intubation, if patient gags, swallow is still intact (patient needs to be deeper b4 incubating) Returns just before patient regains consciousness extube when dog swallow, and cats BEFORE swallow
55
What is the pedal (withdrawal reflex)
flexion or withdrawal of limb in response to hard pinch of digit, web btw digits or pad also used to judge deep pain response SA only Absent in 3.1
55
What is the PLR reflex?
Constriction of both pupils in response to bright light shined on one retina direct (pupil constricts in same eye that light is shone into) Consensual (Other eye constricts) may be present 3.2; is definitely absent in 3.3
55
What is the laryngeal cough reflex
epiglottis and vocal cords close immediately when larynx is touched by an object prevents tracheal aspiration present, but dec in 3.1 this is what makes intubation difficult bc if too much tone in larynx, can cause laryngospasm or trauma. Especially in cats. In these patients, intube stage 3.2 OR can use topical lidocaine spray Warning: nee to calculate lidocaine dose as max dose; some sprays can contain up to 12mg of lidocaine per dose
55
What reflexes are different in an equine?
eyes remain central, pupils dilated Ocular reflexes most reliable - palpebral slows as horse depends. Should still be present but sluggish at a sx plane if completely absent = too deep Corneal reflex disappears at deeper planes - careful with this one horse too light if there is a brisk palpebral, nystagmus and tearing ocular signs less reliable if horse develops significant periorbital edema from being in dorsal a long time or from head trauma
56
Why do we record keep during GA?
Legal documents !! Record preanes patient parameters - gives values; normal/healthy NOT acceptable record dose and route of ALL drugs admin; AND time of each, WHO admined record all fluid orders and changes in orders monitor q5m if PS1-2; continuously if P3 or more Pay close attention to CHANGE - allow rapid intervention Record all adverse events Contine monitoring and recording until animal is out of recovery (in sternal, responsive, vitals are back to pre-anes values record: start/end of sx, when gas off, when O2 off, time of extube

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