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ONCOLOGY & CC > CCU: Monitoring > Flashcards

CCU: Monitoring Flashcards

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1
Q

Dehydration is a deficit in

A

extracellular fluid

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2
Q

What are the 6 perfusion parameters that are important to monitor for shock

A

1) Heart Rate
2) Pulse quality
3) Mucous membrane color
4) Capillary refill time
5) Extremities temperature
6) Mentation

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3
Q

T/F: compensated shock has normal blood pressure

A

true- blood pressure is highly preserved by the compensatory response

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4
Q

What are the indications for measuring arterial blood pressure

A

1) Routine monitoring
2) Anesthetized patients
3) Classification of compensated / decompensated shock
4) Monitoring resuscitation

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5
Q

What is normal blood pressure

A

Systolic: 120-140mmHg
Diastolic: 70-90mmHg
Mean: 90-110mmHg

140/80 with a mean of 100 *

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6
Q

What are the limitations of arterial blood pressure measurements

A

-Dont indicated if patient is in shock or not
-Not a measure of perfusion
-Insensitive- highly preserved by compensatory response. Arterial BP is the last thing to go
-Variability in measurement, especially indirect BP: obtain repeated 3-5 measurements and average
-Can be affected by other factors (pain, stress, etc)

*Must correlate findings to physical exam/clinical picture

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7
Q

How should you obtain a reliable blood pressure when indirect BP often has variability

A

obtain repeated 3-5 measurements and average

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8
Q

What is the gold standard for arterial blood pressure measurement

A

direct

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9
Q

What are the pros of arterial blood pressure

A

Systolic, diastolic and mean pressure
arterial waveform for further analysis
continuous monitoring allows close monitoring of changes

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10
Q

What are the cons of direct arterial blood pressure measurement

A

-Requires placement of arterial catheter
-Invasive, technically challenging
-Requires monitor and pressure transducer for measurements
-Pressure tracings can be distorted: clots, kinks, inappropriate tubing

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11
Q

What are the two main devices of indirect blood pressure measurement

A

1) Doppler with Sphygmomanometer
2) Oscillometry

noninvasive
readily invasive

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12
Q

In most studies does Osc vs Doppler vs Direct perform better in dogs and is more accurate

A

Oscillometry

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13
Q

Pros and Cons of Doppler

A

Pros:
-Inexpensive
-Readily available
-Auditory signal generated
-Better in cats

Cons:
-Less accurate in dogs
-Measures systolic BP only
-May not actually measure SBP
-Requires patient manipulation
-People/time consuming
-Operator dependency
-Auditory signal generated

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14
Q

Pros and Cons of Oscillometric

A

Pros
-Accurate
-Readily available
-Systolic, diastolic and mean BP
-Measures HR
-Not operator dependent
-Hands off measurement
-Automatically cycle for repeated measurements

Cons:
-More expensive
-May be affected by motion, variable heart rate, and pulse deficits
-Black box effect

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15
Q

Dopper measures ___________
Oscillometric measures_______

A

Doppler: Systolic BP only

Oscillometric: Systolic, diastolic, and mean BP

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16
Q

What values define hypotension

A

MBP <60-65mmHg
SBP <90mmHg

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17
Q

Hypotension is more commonly seen in

A

ER/Urgent care due to decompensated shock secondary to severe dehydration, acute hemorrhage, trauma, sepsis

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18
Q

T/F: blood pressure is necessary to diagnose shock

A

False- it is not necessary but it does help to classify it between compensated and decompensated

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19
Q

What aspect of blood pressure do mot ECC clinicians worry about most

A

CPP = MBP - ICP

depends on the MBP

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20
Q

What values define hypertension

A

MAP> 160mmHg or SBP >200mmHg

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21
Q

Hypertension might be secondary to

A

1) Pain, stress = physiological response
2) cardiac disease
3) renal disease
4) Cushing’s disease
5) Pheochromocytoma
6) Toxin injection (ie chocolate)

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22
Q

How do you treat hypertension

A

target the cause and/or vasodilators, ACE-inhibitors

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23
Q

What are the indications for measuring ECG

A

-Unstable patients- heart rate is an early indicator of CV instability
-Presence of brady or tachyarrhthmias
-pulse deficits
-guide shock resuscitation
-guide anti-arrhthmic therapy

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24
Q

How do you do apply ECG

A

3 leads (LF,RF, LH)
most commonly interpreted in lead II (RF, LH)

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25
represents the summed electrical activity in the heart
Electrocardiogram (ECG)
26
produced with anaerobic metabolism marker for perfusion, O2 delivery or utilization
lactate
27
How is lactate measured
blood gas analyzer or hand-held lactometer
28
What are the indicators for measuring lactate
-Patients with evident or suspected hypoperfusion (objective assessment, guide therapy) -Can be served as a guide for fluid therapy/resuscitation -Help decide need for RBC transfusion
29
Does lactate has a prognostic marker or severity of disease
failure to improve may have prognostic value lactate clearance is a better prognosis marker
30
What are the limitations of lactate
1) May be high with altered cellular utilization of oxygen 2) Cellular energy demand exceeds a normal supply (seizures, physical exertion, etc) 3) Can reflect abnormalities with clearance or overproduction (Type B hyperlactemia, liver disease, drugs, sepsis, etc)
31
What can abdominal POCUS tell you
1) Caudal Vena Cava Collapsibility (Subxyphoid or hepatic or intercostal view) 2) CVC:Ao ratio (Paralumbar view)
32
What can cardiac POCUS tell you
1) Detection of pericardial effusion 2) Subjective assessment of systolic function = contractility 3) Subjective assessment of cardiac underfilling or overloading
33
What does a flat Caudal Vena Cava on POCUS mean
Hypovolemic
34
What does a fat Caudal Vena Cava on POCUS mean
Fluid overloaded or well fluid
35
CVC diameter is larger in inspiration or expiration
expiration
36
What is the normal compressibility of the CVC
30-50%
37
What does increased CVC compressibility on inspiration mean
Hypovolemia
38
The CVC collapses during inspiration or expiration
Inspiration
39
What does decreased CVC compressibility on inspiration mean
Hypervolemia
40
Why does the aortic diameter not change in intravascular volume
because the aorta has a thicker and more rigid vessel wall than the CVC -NOT affected by the respiratory cycle
41
Normal CVC:Ao ratio is
1:1
42
What is a better marker of hypovolemia than CVC measurement
CVC: Ao ratio not affected by breathing cycle, but could be affected by changes in abdominal pressure Static marker
43
What is the preferred view for cardiac POCUS
right parasternal short and long axis
44
What is evaluated when doing cardiac POCUS
-Subjective/objective assessment of cardiac contractility -Left ventricle internal diameter in diastole (LVIDd) -Ventricular wall thickness/flattening -Atrial lumen size and LA:Ao rato Normal LVID depends on weight
45
What does an increased left ventricle internal diameter in diastole mean
patient might be hypervolemic
46
a measurement that used pressure to assess volume status based on the notion that CVP=RAP=RVEDV considerable debate as to accuracy/utility
Central Venous Pressure
47
What factors affect central venous pressure relationship to volume
1) Venous Return 2) Venomotor tone 3) Intrapleural pressure 4) Right atrium function 5) Cardiac output considerable debate as to accuracy/utility -confounding factors, technical issues, repeatability
48
Methods to assess cardiac output
1) PAC thermodilution- gold standard for assessing CO via placement of Swan-Ganz catheter, injection of cold saline from proximal port, temperature measured at tip in PA, speed of temperature depends on CO 2) Transthoracic Doppler- noninvasive CO monitoring, doppler ultrasound probe to detect aortic blood flow, corss-sectional area of vessel predicts stroke volume (SVxHR=CO)
49
noninvasive CO monitoring, doppler ultrasound probe to detect aortic blood flow, cross-sectional area of vessel predicts stroke volume (SVxHR=CO)
Transthoracic Doppler (USCOM)
50
gold standard for assessing CO via placement of Swan-Ganz catheter, injection of cold saline from proximal port, temperature measured at tip in PA, speed of temperature depends on CO
PAC thermodilution
51
What are the indications to get PCV and total proteins
-Abnormal (pale, red, yellow) mucous membranes -Shock (investigating cause) -Fluid balance -Sick animaal Anemia (regen or non-regen) or polycythemia vera
52
PCV =
PCV= Hct= 3xHb
53
When getting PCV and total proteins, what else should you assess
serum color
54
With blood loss, both PCV and TP are decreased but why is PCV >TP
because of splenic contraction
55
With dehydration, will both PCV and TP be increased or decreased
increased
56
If you have increased albumin, its because _______ while increased total protein is likely _________
albumin: dehydration TP: hyperglobulinemia
57
Why should we not use the term "total solids"
because the total protein level is estimated by refraction produced by combined plasma concentration of its solutes- aka the total solids Protein does not equal oncotic pressure
58
What are the indications for measuring blood glucose
-minimum data base -shock -known diabetic patient -seizuring puppy/kitten -monitoring hypo/hyperG
59
Where you do sample for a blood gluocse measurement
vein capillary (ear, paw pads, elbow callus and outer lip)
60
What should you consider when measuring blood glucose
important to use animal validated for small animals determine whole BG concentrations so needs erythrocytes (humans contain different amount of glucose compared to animals in RBCS) so use species specific code (GlucoPet, AlphaTrack 2)
61
Why should you never use the term dyspnea
because it is a sensation and patients are unable to verbalize they are in respiratory distress say respiratory distress instead
62
ability of CO2 to exit the body
ventilation
63
decreased tissue perfusion of O2
hypoxia and perfusion
64
decreased of PaO2
hypoxemia
65
physical examination of respiratory distress is
increased respiratory rate and effort
66
What constitutes an animal with increased respiratory effort
orthopneic posture -elbow abduction -neck extension -open mouth breathing -nasal flaring * -cyanosis
67
When a patient is in respiratory distress, what should you start with
Pulse oximetry
68
In regards to respiration, what should you be looking for on a physical exam
1) Resp rate 2) Resp Efforts (Elbow abduction, neck extension, open mouth breathing, nasal flaring, cyanosis) 3) Respiratory patterns 4) Audible breathing sounds 5) Use of stethoscope for respiratory sounds
69
Used as a non invasive surrogate for PaO2 but not directly related
Pulse oximetry
70
Pulse oximetry is accurate at
+/- 2/4 percentage points which may be significant at the steeper part of the curve
71
When is pulse oximetry less accurate
SaO2 <85% but you still know the patient is hypoxemic
72
What is normal pulse oximetry
>98%
73
SaO2 of 95% = PaO2 of
80mmHg
74
SaO2 of 90% = PaO2 of
60mmHg
75
How can pulse oximetry be used as threshold for client communication
97%-100%: normal, look for look alikes 95-95%: may be able to be treated as outpatient 90-95%: will usually/probably need to be hospitalized <90% may need to be mechanically ventilated
76
What are the 5 causes of hypoxemia
1) Low partial pressure of PiO2 (altitude, empty O2 tank, faulty anesthetic equipment, housefire) 2) Hypoventiliation 3) Low V/Q 4) No V/Q (shunt) - pulmonary or anatomic- no ventilation to perfused lung units 5) Diffusion Impairment - pulmonary fibrosis
77
What might cause low PiO2 leading to hypoxemia
altitude empty O2 tank fault anesthetic equipment House fire
78
what might cause a diffusion impairment leading to hypoxemia
pulmonary fibrosis
79
What are the 8 places where respiratory distress can arise from
1) Upper 2) Lower 3) Parenchyma (water, blood, pus, tissue) 4) Chest wall- including muscular fatigue and neurologic 5) Diaphragm/Abdomen- including muscular fatigue and neurologic 6) Pleural space - air, fluid, tissue 7) Vascular- PTE 8) look alikes- non respiratory causes: anemia, shock, pain sepsis
80
What are some non-respiratory causes of respiratory distress
anemia shock stress pain sepsis
81
occurs due to high PCO2 where the CO2 takes up space in the alveoli and contributes to hypoxemia
Hypoventilation
82
T/F: PvO2 is a marker of oxygenation
False
83
difference between PAO2 and PaO2
A-a gradient
84
the A-a gradient should be _________ in an animal with normal lungs, no abnormal anatomic shunts, breathing 21% oxygen at sea level
<10 mmHg
85
What is the basis of defining hypoxemia
PaO2
86
What do you need to assess hypoxemia
arterial blood gas with a known FiO2
87
the ratio of PaO2 to FiO2 with FiO2 expressed as a decimal (400-500)
P/F ratio
88
You should only use the P/F ration when there is
stable PCO2 and variable FiO2 influenced by PCO2
89
What decreases P/F ratio
decreased lung function - useful to assess pulmonary function
90
How do you calculate A-a gradient
{[(Pb-Ph20)x FiO2] - PaCO2 (1/RQ)} - PaO2 simplied if room air at sealevel A-a = 150-1.1xPaCO2 - PaO2
91
The FiO2 should be about
400-500
92
What is the simplified A-a gradient if on room air at sea level
A-a = 150-1.1xPaCO2 - PaO2
93
Why is PaCO2 slightly lower than at sea level
due to compensation for the low PaO2 (to maintain normoxia) Normal PaCO2 in CO is 30-40mmHg instead of 35-45 mmHg at sea level
94
What allows the movement of air in and out of the respiratory system to properly ventilate
1) Diaphragm: main muscle of inspiration- phrenic nerve (C3-C5) 2) Rib cage and related msucles 3) Abdominal muscles- forced expiration 4) Accessory muscles- neck, nares
95
what innervates the diaphragm and allows it to be the main muscle of inspiration
Phrenic nerve (C3-C5)
96
What are the indications to use a capnometry/ capnography
-Breath by breath surrogate for PaCO2/ PVCO2 -ROSC in CPR
97
What is a normal caponmetry reading
PETCO2 = 30-40mmHg usually 5mmHg difference between PvCO2 > PaCO2 > PETCO2
98
How much does PvCO2, PaCO2, and PETCO2 differ
usually a 5mmHg difference
99
What is the limitation of capnometry and canopgraphy
needs the patient to be intubated
100
What are the phases of capnography
I: inspiratory baseline II: Expiratory upstroke III: Expiratory plateau EtCO2- end expiration IV: Expiratory Downstroke
101
What is the alpha angle of the capnograph
the angle between phase II (expiratory upstroke) and Phase III (expiratory plateau) allows you to assess ventilation/perfusion of the lung V/Q mismatches will have an alpha angle greater than 90 degrees
102
What alpha angle tells you there is a V/Q mismatch
when it is greater than 90 degrees
103
What is the beta angle in the capnograph
the angle between the end expiration and the expiratory downstroke used to assess rebreathing, if rebreathing occurs the angle is greater than 90 degrees
104
What beta angle tells you that rebreathing is occuring
if the angle is greater than 90 degrees
105
You perform a venous blood gas on a dog. the PvCO2 is 62mmHg. Is the dog hypo or hyperventilating
Hypoventilation - CO2 is high
106
You perform a venous blood gas on a dog. the PvCO2 is 62mmHg. Is this dog most likely acidemic or alkalemic
Acidemic
107
You perform a venous blood gas on a dog. the PvCO2 is 62mmHg. What is most likely cause of ventilation disorder
Upper-Airway Obstruction
108
What are the 3 main reasons for respiratory acidosis
1) Brain doesnt work 2) Muscle doesnt work 3) Upper-Airway obstruction
109
You should calculate the anion gap if there is
a metabolic acidosis
110
Decreased pH and increased PCO2
Respiratory acidosis
111
Increased pH and decreased pCO2
Respiratory alkalosis
112
Decrease pH and HCO3
metabolic acidosis- do an anion gap
113
Increased pH and HCO3
metabolic alkalosis
114
What is the rule of 4s for normal blood gas values
pH= 7.4 +/- 0.04 HCO3= 24 +/- 4 base exess/deficit= 0 +/- 4 PCO2= 40 +/- 4 Anion gap = 14 +/- 4 Na = 144 +/- 4 K= 4 +/- 0.4
115
loss of ECF = ______ while loss of ICF=_______
ECF: dehydration ICF: free water loss
116
What factors can you use to evaluate fluid balance
1) Physical Exam 2) Body weight 3) Urine specific gravity 4) Urine output 5) PCV-TP
117
Hydrated/volume repleted animals have a USG of
1.008-1.012 (isostenuric) if unreliable with impaired concentrating ability the kidney disease or renal injury
118
What should urine output be? Used as an indicator of renal perfusion/volume status
minimum of 1-2ml/kg/hr *may not be indicative of perfusion in other tissues
119
Increased albumin has one rule out which is
dehydration ... but it can be influenced by anemia, protein losss, etc.
120
If both PCV-TP are elevated then
its usually a marker of dehydration/hemoconcentration
121
Causes of hyperthermia
1) Fever (pyrexia) -Infectious -Inflammatory -Neoplasia -Drug induced (opioids, ketamine in cats) 2) Exposure/failure to dissipate -airway obstruction -external heat source
122
What are causes of hypothermia
-Shock -Anesthesia -Exposure (ie cold) -Renal failure -Hypothyroidism
123
What might cause hyperkalemia
urinary obstruction AKI Addisons reperfusion injury
124
What electrolyte disturbance is common in ICU, especially on IV fluids
Hypokalemia- secondary to diuresis and/or decreased intake
125
What is the main goal of focused ultrasound
find free fluid
126
What are the 4 quadrants of abdominal POCUS
1) SubXyphoid -Liver and between liver lobes -Gallbladder -Pleural/pericardial space thru diaphragm -Caudal vena cava distension 2) Bladder- and neck, beware of colon shadow 3) Right kidney- most ocmmon fluid location 4) Left kidney- spleen
127
What can you see in the sub-xyphoid view when doing abdominal POCUS
-Liver and between liver lobes -Gallbladder -Pleural/pericardial space thru diaphragm -Caudal vena cava distension
128
What are the indications for focused abdominal US
trauma shock collapse acute abdomen non-invasive rapid repeatable
129
What is the primary goal of thoracic ultrasound **
best to rule out pneumothorax
130
When doing thoracic POC ultrasounds, what is the best view to ruling out pneumothorax
caudo-dorsal- highest point on the thoracic wall
131
When doing thoracic POC ultrasounds, what does the caudo-dorsal view assess
rules out pneumothorax
132
When doing thoracic POC ultrasounds, what does the cranioventral view assess
the cardiac site 1) Pleural or pericardic fluid -Subjective volume assessment 2) LA and Ao ratio quick peak 3) Check the heart and pericardial space
133
When doing thoracic POC ultrasounds, what does the subxiphoid view assess
may be superior for the detection of pericardial (and pleural effusion) fluid
134
What can you see when doing focused thoracic ultrasounds
Gator sign Glide sign A-line
135
Lack of glide signs on thoracic POCUS indicate
pneumothorax
136
What do shred/Clines on thoracic POCUS indicate
consolidation of lung tissue
137
What do B-lines indicate
wet lungs
138
How do you calculate the anion gap
AG = UA - UC = (Na+K) - (Cl + HCO3) Normal in dogs = 18 +/-6 and 20 +/-7 cats
139

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