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SRNA4TopicsAnesthesia > APEX: Monitoring II: HEMO > Flashcards

APEX: Monitoring II: HEMO Flashcards

1
Q

A blood pressure cuff that is too large requires

A

less pressure to occlude the artery

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2
Q

An improperly sized NIBP cuff leads to

A

inaccurate results

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3
Q

The Ideal bladder length equals

A

80 % of the EXTREMITY CIRCUMFERENCE

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4
Q

The Ideal bladder Width equals

A

40% of the EXTREMITY circumference

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5
Q

A cuff that is too small

A

Overestimates SBP

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6
Q

A cuff that is too large

A

Underestimates SBP

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7
Q

Although rare, nerve injury due to NIBP measurements tends to affect the

A

ulnar or median nerve.

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8
Q

The auscultation method relies on the

A

Korotfoff sounds

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9
Q

There are how many sounds with BP cuff

A

five

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10
Q

Where is the SBP measured with BP measurement

A

First sound

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11
Q

Where is the DBP measured with BP measurement

A

Last sound

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12
Q

Uses the Oscillatory Method of BP

A

Automated NIBP machines

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13
Q

How does the oscillatory method of SBP work

A

Inflatable cuff occlude arterial blood flow and as the cuff pressure is released, the monitor measure the pressure fluctuations that occur in response to arterial pulsations

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14
Q

With oscillatory method, SBP is measured when

A

Oscillations first appears (The appearance of flow after occlusion by the cuff)

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15
Q

With oscillatory method, MAP is measured when

A

When the amplitude of the oscillation is greatest

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16
Q

With oscillatory method, DBP is measured when

A

at the minimum pressure where oscillation can still be registered.

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17
Q

With oscillatory method, which measurement is most susceptible to error

A

DBP

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18
Q

The oscillatory method requires

A

Pulsative flow,

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19
Q

Because The oscillatory method requires so a NIBP wont function in those patients

A

pt on CBP or with a LVAD. Those patients require an A-line

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20
Q

Cuff Location : as the pulse move from the aortic root towards the periphery the systolic pressure_____and the diastolic pressure _______and the pulse pressure _____

A

Increases ; decreases; widents.

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21
Q

What remains constant through the arterial tree

A

MAP

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22
Q

At the aortic root, the SBP is the _____And DBP is the ________and PP is the

A

Lowest, highest, narrowest

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23
Q

At the dorsalis pedis, the SBP is the _____And DBP is the ________and PP is the

A

highest, lowest, widest

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24
Q

Blood in the circulation behaves like a column of fluid and follows the rules of

A

Hydrostatic pressure.

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25
Q

If the BP cuff location is above the heart , the BP reading will be

A

falsely decrease (there is less hydrostatic pressure)

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26
Q

If the BP cuff location is below the heart , the BP reading will be

A

Falsely increase (there is more hydrostatic pressure)

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27
Q

For every 10cm change, the BP changes by

A

7.4 mmHg

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28
Q

For every inch change, the BP changes by

A

2 mmHg

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29
Q

For examples the BP cuff is 10 inches below the level of the heart, what is the true BP at the level of the heart?

A

10 inch x 2 mmHg = 20 mmHg

The BP on the monitor falsely increases, therefore the BP at the heart is 20mmHg less than what you see on the monitor.

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30
Q

Never measure BP in the Calf when patient is in these 2 positions? why?

A

Revere Tredelenburg or SITTING. Because cerebral ischemia may occur with a normal BP on the monitor.

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31
Q

Complications of BP on the limb

A

Neuropathy (radial, ulnar and median)
Limb ischemia
Compartment syndrome

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32
Q

Complications of BP other

A

Pain
Bruising
Petechiae
Interference with IV medications

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33
Q

Where to not put BP cuff

A

over a PICC line
Bone fracture
Limb with an AV fistula.

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34
Q

Avoid BP in arm with Severe axillary node dissection why?

A

May impair lymphatic drainage and cause limb edema, .

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35
Q

Arterial BP waverform: Dicrotic notch indicates______followed by

A

AV closure; Diastolic runoff

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36
Q

A-line where is systolic BP read

A

Peak of the waveform

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37
Q

A-line where is DBP read

A

Trough of the waveform

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38
Q

A-line where is PP read

A

Peak - trough

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39
Q

A-line where is contractility

A

Upstroke

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40
Q

A-line where is SV read

A

Area under the curve

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41
Q

A-line what does the dicrotic notch indicates

A

Closure of aortic valve

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42
Q

Is the height of the dicrotic notch a reliable estimate of SVR

A

NO

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43
Q

Optimally damped system:

A

Baseline is re-established after 1 oscillation

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44
Q

Under- damped system: baseline, SBP, DBP and MAP

A

Baseline is re-established after several oscillations (SBP is overestimated, DBP is underestmiated, and MAP is accurate.

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45
Q

Over- damped system: baseline, SBP, DBP and MAP

A

Baseline is re-established after no oscillations (SBP is underestimated, DBP is overestimated, and MAP is accurate.

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46
Q

Causes of OVERDAMPED SYSTEM

A

AIr bubble
Clot in the pressure tubling
Low flush bag pressure.

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47
Q

Invasive blood pressure monitors measure BP at the

A

Level of the transducer

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48
Q

As long as the transducer is at the ___________ changes in body or extremity position will not affect the accuracy of the arterial BP measurement.

A

Level of the right atrium

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49
Q

When inserting a central line in the Right IJ vein, how far should the catheter be advanced to achieve correct placement?

A

15 cm

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50
Q

The tip of the CVC should reside where?

A

the junction of the vena cava and the Right atrium. It SHOULD NOT ENTER THE Right atrium

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51
Q

The distance from SKIN to the junction of the VC and RA is

A

15 cm.

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52
Q

Why should the tip of the CVC be placed in the RA?

A

It will increase the risk of dysrhythmias, thrombus formation and cardiac perforation

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53
Q

The tip of the PAC should reside where?

A

in the pulmonary catheter, distal to the pulmonic valve.

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54
Q

Tip of PAC in relation to the VC junction

A

2535cm

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55
Q

Insertion site to VC and RA junction: Right IJ insertion site.

A

15cm

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56
Q

Insertion site to VC and RA junction: Left IJ insertion site.

A

20 cm

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57
Q

Insertion site to VC and RA junction:Femoral insertion site.

A

40cm

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58
Q

Insertion site to VC and RA junction: Subclavian insertion site.

A

10cm

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59
Q

Vena Cava and R atrial Junction –> catheter tip: RA

A

0-10cm

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60
Q

Vena Cava and R atrial Junction –> catheter tip: RV

A

10-15cm

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61
Q

Vena Cava and R atrial Junction –> catheter tip: PA

A

15-30cm

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62
Q

Vena Cava and R atrial Junction –> catheter tip: PAOP position

A

25-35 cm

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63
Q

While obtaining venous access possible complications are

A 
Arterial puncture
Pneumothorax
AIr embolism
Neuropathy
Catheter knot
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64
Q

During catheter residence complications are

A 
Bacterial colonization of catehter, heart or PA
Myocardial or valvular injury
Sepsis
Thrombus formation
Thrombophlebitis
Misinterpretation of data
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65
Q

What are the risk of obtaining access via left IJ?

A

Puncturing the thoracic duct. This can cause CHYLOTHORAX (lymph in the chest)

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66
Q

What is the most common complication while obtaining access?

A

Dysrhythmias

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67
Q

What is thest best way to treat PACs and PVCs during PAC insertion?

A

Withdraw the catheter and start over

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68
Q

The incidence of catheter related infection increases after how many days?

A

3

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69
Q

Who shouldn’t you float a PAC in ? why?

A

Patient with LBBB. Because advancing the catheter into the RV can cause a RBBB and this can put the patient in a complete HB.

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70
Q

What is the classic presentation of PULMONARY ARTERY RUPTURE?

A

Hemoptysis

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71
Q

Major complication of PAC

A

Pulmonary artery rupture.

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72
Q

Pulmonary artery rupture chances increases if

A

Balloon is inflated with more than 1.5 ml

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73
Q

The risk of pulmonary artery rupture is increased by patient factors such as

A

Anticoagulation
Hypothermia
Advanced age.

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74
Q

The risk of pulmonary artery rupture is increased by Providers factors such as

A 
Inserting catheter too far
prolonged balloon inflation
chronic irritation of vessel wall
unrecognized wedging
filling the balloon with liquid instead of air
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75
Q

CVP passive filling is the ___Wave

A

V wave

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76
Q

The CVP waveform is a reflection of the pressure inside the

A

RA

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77
Q

CVP waveform has ____Peaks and ______troughs

A

3; 2

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78
Q

Tricuspid valve elevation into RA is the ____wave

A

C

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79
Q

Downward movement of contracting RV is _____descent

A

x descent

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80
Q

RA empties through open tricuspid

A

y descent

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81
Q

A wave Mechanical event vs electrical events

A

Right atrial contraction (mechanical)

Just after the P wave (Atrial depolarization)

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82
Q

C wave Mechanical event vs electrical events

A

Right ventricular contraction (bulding of Tricuspid in RA)’->mechanical
Just after the QRS complex (ventricular depolarization)

83
Q

X Descent Mechanical event vs electrical events

A 
RA relaxation (mechanical)
ST se
84
Q

X Descent Mechanical event vs electrical events

A 
RA relaxation (mechanical)
ST segment (Electrical event)
85
Q

V wave Mechanical event vs electrical events

A

Passive filling of RA (mechanical)

Just after T wave begins (ventricular repolarization)

86
Q

Y descent Mechanical event vs electrical events

A

RA empties through open tricuspid valve (mechanical)

After T wave ends

87
Q

CVP and PEEP

A

Increase PEEP

88
Q

PEEP and PVR

A

Increases PVR which creates additional resistance against RV ejection, which can increase RVEDP and CVP.

89
Q

A transducer above the zero point and CVP

A

Underestimated CVP

90
Q

Pericardial tamponade produces a

A

Compressive force around the hearts. This reduces RA compliance and increases (Not decreases) CVP

91
Q

VSD typically ________RVEDV and CVP

A

Increases

92
Q

Where should CVP be zeroed?

A

AT the phlebostatic axis

93
Q

Where is the Phlebostatic axis?

A

4th intercostal space MID anteroposterior level

94
Q

A transducer placed below the zero point

A

overestimated CVP

95
Q

When should CVP be measured?

A

End Expiration

96
Q

During this phase of the ventilatory cycle , end expiration , what happens to pressure?

A

Extravascular pressure equals atmospheric pressure, and this allows us to measure CVP relative to Atmospheric pressure.

97
Q

CVP measurement is not affected by _____Pressure if the reading is recorded at end-expiration

A

Intrathoracic pressure

98
Q

The normal CVP in the adults

A

1 - 10 mmHg

99
Q

CVP is a funciton of

A

Intravascular volume
venous tone
RV compliance.

100
Q

Right atrial pressure reflects

A

LV End Diastolic pressure

101
Q

In a perfect world, Right ventircular output equals

A

LV output

102
Q

Low CVP usually means

A

low intravascular volume

103
Q

High CVP indicates

A

Hypervolemia
Reduce ventricular compliance
Increase Intrathoracic pressure.

104
Q

2 factors that decrease CVP

A

Transducer above the phlebostaxis axis

Hypovolemia

105
Q

Constrictive pericarditis on CVP

A

increase

106
Q

VSD on CVP

A

increase

107
Q

PEEP on CVP

A

INCREASE

108
Q

Pulmonic stenosis or tricuspid stenosis

A

INCREASE

109
Q

RV failure and CVP

A

increase

110
Q

Conditions that increase the amplitude of the a wave on the CVP waveform?

A

Tricupid stenosis

Diastolic dysfunction

111
Q

Loss of a wave of CVP corresponds to

A

Atrial fibrillation

V-pacing if the underlying rhythm is ASYSTOLE

112
Q

Large a wave occurs when

A

Atria contracts and EMPTIES AGAINST A HIGH RESISTANCE such as resistance at the valve or NONcompliant ventricle.

113
Q

Valve condition associated with large a wave

A

Tricuspid stenosis

Diastolic dysfunction

114
Q

Heart condition associated with large a wave

A

Myocardiac ischemia
AV disssociation
V pacing asynchronous
PVCs

115
Q

Lung condition with large a wave

A

Chronic lung disease leading the RV hypertrophy

116
Q

Large V wave occurs when

A

Tricuspid regurgitation allows a portion of the RV colume to pass through the closed by incompetent tricuspid valve during RV systole. This increases the volume and presure in the RA and manifests as LARGE V WAVES>

117
Q

3 conditions associated with LARGE V waves

A

Tricuspid regurgitation
Acute increase in intravascular volume
RV papillary muscle ischemia

118
Q

Cannon a waves seen with

A

atrium contracting against a closed tricuspid valve, as seen during AV dissociation.

119
Q

FIndings once PA catheter enter PA

A

Dicrotic notch

Increased DIASTOLIC BLOOD PRESSURE

120
Q

Normal RAP is

A

1 - 10 mmHg

121
Q

Normal RVP Systolic/Diastolic

A

15-30 / 0-8 mmHg

122
Q

Normal PAP Systolic/Diastolic

A

15-30 / 5-15 mmHg

123
Q

Normal PAOP

A

5 - 15 mmHg

124
Q

RVP what happens to SBP and DBP

A

SBP increase

DBP is equal to CVP

125
Q

PAP what happens to SBP and DBP

A

SBP remains same
DBP increases
Dicrotic notch formed during pulmonic valve closure during diastole

126
Q

In which lung zone should the tip of the PAC be placed?

A

Three (zone III)

127
Q

Why zone III for the placement of the PAC?

A

because it provides the most accurate estimation of LVEDP.

128
Q

Each lung zone is defined by the what 3 factors

A

Relative pressure in the alveolus
Arterial pulmonary capillary
Venous pulmonary capillary

129
Q

Zone III is defined as

A

P arterial > P venous > P Alveolus

130
Q

In what region is zone III?

A

Dependent

131
Q

Zone III in a sitting position is

A

At the lung base

132
Q

Zone III in a supine position

A

Towards the back

133
Q

Zone III in a prone position

A

Towards the chest

134
Q

Zone III in a lateral position

A

Towards the dependent

135
Q

How can you tell the tip of PAC is in Zone III

A

PaOP > pulmonary artery EDP

Inability to aspirate blood from the distal port when the balloon is in the wedged position.

136
Q

When does pulmonary artery occlusion pressure overestimated LVEDP?

A

PEEP

Diastolic dysfunction

137
Q

Anything that impairs the normal pressure gradient between the PAC tip and the

A

LV can impact PAOP

138
Q

PAOP underestimates LVEDV in

A

Aoritc insufficiency.

139
Q

When PAOP DOES NOT accurately predict LVEDV? and overestimates it: Pulmonary

A

COPD
PEEP
Pulmonary HTN
Non west zone III placement for PAC

140
Q

When PAOP DOES NOT accurately predict LVEDV? and overestimates it: Heart

A 
Impaired LV compliance (ischemia)
MV disease (stenosis or regurgitation)
L to R cardiac shunt
Tachycardia
PPV
141
Q

Which situation underestimates CO obtained by the thermodilution method?

A

High Injectate volume

142
Q

CO is_________ to the area under the curve with the thermodilution

A

Inversely proportional

143
Q

A high injectate volume _______CO

A

Underestimates

144
Q

A low injectate volume _______CO

A

Overestimates

145
Q

Injectate that is too warm will_______CO

A

Overestimates CO

146
Q

A right to left intracardiac shunt has an

A

Unpredictable on CO measurement.

147
Q

What is the most common way to measure CO with the PAC?

A

Thermodilution method

148
Q

Explain the thermodilution method?

A

An injection of dextrose or 0.9% NaCL of known quantity and temperature is bolused through the PROXIMAL port on the PAC. each injection should occur during the same phase of the respiratory cycle and be completed < 4 seconds. Average 3 separate injections to get final CO.

149
Q

If CO is high, the injectate ______and the AUC is

A

Travels toward the distal tip of the PAC. AUC is smaller

150
Q

If CO is low, it takes ______And the AUC is ______

A

longer for the injectate to travel past the distal tip of the PAC, the AUC is larger

151
Q

Factors that influence themodilution CO measurement: Underestimate CO

A

Injectate volume too high

Injectate solution too cold

152
Q

Factors that influence themodilution CO measurement: Overestimate CO

A

Injectate volume too low
Injectate solution too hot
Partially wedged PAC
Thrombus on tip of PAC

153
Q

Factors that influence themodilution CO measurement: Unable to predict

A

Intracardiac shunt

TR

154
Q

There is a _______Delay between the time CO is measured and when it appears on the monitor

A

30 seconds

155
Q

Factors that increased Mixed venous oxygen saturation?

A

Sodium nitroprusside toxicity

Sepsis

156
Q

SvO2 (mixed venous O2 sat) is a function of what variables:

A

CO
Arterial oxygen saturation
Amount of Hgb
Oxygen consumption

157
Q

Thyroid storm on SvO2

A

oxygen demand and decreases SvO2

158
Q

Cyanide toxicity on SvO2

A

Impaired O2 utilization , and sepsi

159
Q

Sepsis on SvO2

A

High cardiac output state increase SvO2

160
Q

Anemia on SvO2

A

Anemia reduces oxygen delivery , and decreases SvO2

161
Q

Four variables for calculations of SvO2

A 
Q = Cardiac output (L/min)
VO2 = Oxygen consumption (mL O2/min)
Hgb = Amount of hemoglobin (g /dL)
SaO2 = Loading of Hgb in arterial Blood (%)
162
Q

SvO2 formula:

A

SaO2 - VO2/ (Q x 1.34 x Hgb x10)

163
Q

Normal SvO2

A

65-75%

164
Q

Mixed venous oxygen saturation an indirect monitor of CO when

A

hgb, SaO2 and VO2 are held constant.

165
Q

Factors that change SvO2

A

When oxygen consumption increases or oxygen delivery decreases, the oxygen content returning to the heart decreases, as manifested as a decreased SvO2

166
Q

Mixed Venous O2 sat is decreased by either

A

Increased O2 consumption OR Decreased O2 delivery

167
Q

Mixed Venous O2 sat is increased by either

A

Decreased O2 consumption OR increased O2 delivery

168
Q

Increased O2 delivery by _____PaO2, Increased _______ and ______

A

Increased; hgb and CO

169
Q

Decreased O2 consumption occur with

A

Hypothermia

Cyanide toxicity

170
Q

Increased O2 consumption occur with

A 
Thyroid storm
Stress
Fever
Shivering
Pain
171
Q

Decreased O2 delivery by _____PaO2, Increased _______ and ______

A

Decreased, decreased Hgb, and CO

172
Q

Sepsis creates a

A

High CO state

173
Q

Why is there an increase SvO2 with sepsis

A

Even though sepsis causes end organ hypoxia, O2 bypasses the tissues and SvO2 remains elevated

174
Q

Increased SvO2 and tissues

A

Impaired oxygen uptake by tissues.

175
Q

Classic example of impaired oxygen uptake by tissues

A

Cyanide poisoning from sodium nitroprusside

176
Q

Mixed oxygen venous

A

Left to RIght shunt. Oxygenated blood travels from the left heart to the right heart and is added to pulmonary venous blood.

177
Q

What do you need to measure SvO2 and why?

A

PAC is needed because different organs extract different amounts of O2, a true mixed venous sample must contain blood returning from the SVC, IVC, and the coronary sinus.

178
Q

Preload responsiveness is expected to be present if a 200-250ml fluid bolus increases the SV in excess of

A

10 %

179
Q

Most of the pulse contour monitors use the ______to complete their calculations

A

Arterial waveform or the SPO2 waverorm to complete their calculations.

180
Q

Pulse contour analysis provides a measure of

A

Preload responsiveness as a function of how SV changes during the respiratory cycle (assumes PPV).

181
Q

What can influence SV

A

Changes in intra-thoracic pressure duing PPV

182
Q

Inspiration on LV filling

A

A positive pressure breath augments LV filling (compression of the pulmonary veins and pleural restriction impedes RV filling)

183
Q

Increases LV filling on SV

A

Increases SV

184
Q

Expiration on LV filling

A

LV filling decreases (decreases RV preload on previous beats reduces LV preloads, the time delay is called pulmonary transit time.

185
Q

Decreases LV filling on SV

A

Reduces stroke volume

186
Q

A hypovolemic patient will have a ________stroke volume variation throughout the respiratory cycle as a function of intrathoracic pressure’s effect on RV filling and function

A

GREATER DEGREE of SVV

187
Q

Dynamic measures of the pulse contours are

A

SVV, SPV, PPV, PVI

188
Q

Dynamic measures of the pulse contours tend to predict volume responsiveness when the calculated measurement is greater than

A

13-15 %

189
Q

Limitations of pulse contous

A 
NOt used with spontaneous ventilation
Open chest
dysrhythmias
PEEP
Small tidal volume
190
Q

Gold standard for assessing myocardial function

A

TEE

2nd is ESOPHAGEAL DOPPLER

191
Q

The tip of the esophageal probe should be positioned

A

~ 35 cm from the incisors. or at the 3rd sternocostal junction

192
Q

Do not use the ESOPHAGEAL DOPPLER IF THE PATIENT HAS

A

Esophageal disease

193
Q

Definition of SV

A

Volume of blood pumped by LV per beat/min

194
Q

Definition of SI

A

SV indexed to BSA

195
Q

SVV (stroke volume variation)

A

Change in strove volume per beat

196
Q

Peak velocity

A

Index of contractility

197
Q

Peak velocity Definition

A

Index of contractility

198
Q

Flow time Definition

A

Time between aortic opening and closure

199
Q

Stroke distance Definition

A

How far SV is pumped per beat

200
Q

T wave corresponds with _____wave

A

V wave

201
Q

ST segment corresponds with _______

A

X descent

202
Q

QRS complex corresponds with

A

C wave

203
Q

V wave is the

A

passive filling

204
Q

X descent is

A

Right atrial relaxation

SRNA4TopicsAnesthesia (47 decks)

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