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Anesthesia > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

0
Q

What are the Minimal Standard Monitors to Be Used?

A

1 .Electrocardiogram (HR and rhythm)

  1. Blood pressure
  2. Precordial stethoscope
  3. Pulse oximetry
  4. Oxygen analyzer
  5. End tidal carbon dioxide
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1
Q

What is the purpose hemodynamic monitoring?

A 
A.  Assess homeostasis, trends
B.  Observe for adverse reactions
C.  Assess therapeutic interventions
D.  Manage anesthetic depth
E.  Evaluate equipment function
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2
Q

What are the Minimal Standard Monitoring Information On Graphic Display?

A
  1. Electrocardiogram
  2. Blood pressure
  3. Heart rate
  4. Ventilation status
  5. Oxygen saturation
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3
Q

What the basic hemodynamic monitoring?

A 
•Stethoscope
•ECG
•BP
–Invasive
–Non-invasive
•CVP
•PAP and PCWP
•TEE
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4
Q

What can you tell me about Esophageal or precordial stethoscope?

A
  • Continual assessment of breath sounds and heart tones
  • Esophageal used in intubated patients only placed 28-30 cm into esophagus
  • Very sensitive monitor for bronchospasm and changes in pediatric patients
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5
Q

What is an eletrocardiogram and what is the purpose?

A

1) Recording of electrical activity of the heart. Standard- every patient, continuous monitoring, from beginning of anesthesia until leaving anesthetizing location.

2)–detect arrhythmias 
–monitor heart rate
–detect ischemia
–detect electrolyte changes
–monitor pacemaker function
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6
Q

What can you tell about 3 lead ECG?

A

Electrodes RA, LA, LL
Leads I, II, III
3 views of heart (no anterior view)

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7
Q

What can you tell me about 5 lead ECG monitoring?

A

1) Electrodes RA, LA, LL, RL, chest lead
2) Leads I, II, III, aVR, aVL, aVF, V lead
3) 7 views of heart

V5 electrode is place at the 5th intercostal space in the left anterior axillary line. This 5-lead configuration allows the clinician to monitor seven differents ECG leads ( I,II, III, aVR, aVL, aVF, V5). The 5 leads system is preferred.
Lead II is usually best for monitoring P waves enhancing diagnosis of dysrhythmias and detecting inferior wall ischemia.
Lead V5 is most sensitive for detection of anterior and lateral ischemia. By monitoring leads II and V5 simultaneously the most information can be obtained.

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8
Q

What are the factors that can cause artifacts on the ECG?

A

Loose or misplaced ECG wires or electrodes, improper electrode placement or adhesion, Motion (shivering, tremor, hiccuping, diaphragmatic mvt); OR equipment (electrocautery, Cardiopulmonary bypass pump) ; pt contact surgeon or nurses or anesthesia personnel.

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9
Q

What can you tell me about Gain Setting and Frequency Bandwidth?

A

1) Gain should be set at standardization
–1 mV signal produces 10-mm calibration pulse
–A 1-mm ST segment change is accurately assessed

2) Filtering capacity should be set to diagnostic mode
–Filtering out the low end of frequency bandwidth can distort ST segment

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10
Q

What is the Difference between diagnostic and monitoring modes for intraoperative electrocardiography?

A

the diagnostic mode uses ST segment and T wave analysis to diagnosis ischemia accurately. The diagnostic mode filters out frequencies below 0.14 Hz but often results in excessive baseline drift and artifact.
The monitoring mode is used to filter out the baseline drift and artifact introduced in the ECG signals. This mode filter out all frequencies below 4.0 Hz which helps remove most of the OR interference. The monitoring mode can introduce artificial elevation and depression of the ST and T wave segments.

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11
Q

What are the 5 principles ECG Indicators of Acute Ischemia?

A

1) ST segment elevation , ≥1mm
2) T wave inversion
3) Development of Q waves
4) ST segment depression, flat or downslope of ≥1mm
5) Peaked T waves

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12
Q

Tell me about Coronary Anatomy and ECG change during Myocardial Ischemia?

1) Posterior/Inferior wall ischemia
2) lateral wall ischemia
3) Anterior wall ischemia
4) Anterioseptal ischemia

A

1) (Posterior)/ Inferior wall ischemia (right coronary artery) Changes in Lead II, III, AVF
2) Lateral wall ischemia (circumflex branch of left coronary artery) Changes in Lead I, AVL, V5-V6
3) Anterior wall ischemia (left coronary artery) Changes in Lead I, AVL, V1-V4
4) Anterioseptal ischemia (left descending coronary artery) Changes in Lead V1-V4

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13
Q

What are some Erroneous BP Measurement with NIBP?

A 
1) Falsely high BP
–Cuff too small
–Cuff too loose
–Extremity below level of heart
–Arterial stiffness- HTN, PVD
2) Falsely low BP
–Cuff too large
–Extremity above level of heart
–Poor tissue perfusion (auscultatory)
–Too quick deflation (ausculatory)

3) Also- improper cuff placement,dysrhythmias,tremors/shivering

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14
Q

What are some complications of NIBP?

A

1) Edema of extremity
2) Petechiae/ bruising
3) Ulnar neuropathy
4) Interference of IV flow
5) Altered timing of IV drug administration
6) Pain
7) Compartment syndrome

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15
Q

What are some indications for invasive IABP?

A

1) Elective deliberate hypotension
2) Wide swings in intra-op BP
3) Risk of rapid changes in BP
4) Rapid fluid shifts
5) Titration of vasoactive drugs
6) End organ disease
7) Repeated blood sampling
8) Failure of indirect BP measurement
Massive fluid shift, intracranial sx, CVA, . Morbid Obese.

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16
Q

In a normal arterial pressure waveforms, what information can you get from the rate of upstroke, downstroke, area under the curve, dicrotic notch, and exaggerated variations in size with respirations?

A

1) Rate of upstroke-contractility
2) Rate of downstroke-SVR
3) Exaggerated variations in size w/ respirations-hypovolemia
4) Area under the curve-MAP
5) Dicrotic notch- closure of aortic valve

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17
Q

What is the difference between underdamped and overdamped?

A

1) Underdamped system: continues to oscillate for 3 to 4 cycles; it overestimates the Systolic and underestimate the diastolic blood pressure.

2) Overdamped system: settles to baseline slowly without oscillating; it underestimates the SBP and overestimates the DBP.
In both cases, the MAP is accurate.

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18
Q

What is distal pulse amplification?

A

arterial BP waveforms as they travel through the arterial tree to periphery— distal pulse amplification
SBP peak increases
DBP wave decreases
MAP not altered
Dicrotic notch becomes less and appears later

Difference of central waveform from peripheral waveform: as the arterial pressure is transmitted from the central aorta to the peripheral arteries the waveform is distorted. Transmission is delayed, high frequency components such as dicrotic notch are lost, the systolic peak increases, and the diastolic trough decreases. The changes in the SBP and DBP results from a decrease in the arterial wall compliance and from resonance. SBP in the radial artery may be as much as 20-50 mmHg higher than the pressure in the central aorta.

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19
Q

What can you do to minimize artifacts?

A

1) Rigid connection tubing
2) lines kept free of kinks, clots, and bubbles, which can causes overdamping of the system
3) only one stopcock per line to minimize air introduction
4) flush the mechanical coupling system; balance the transducer.

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20
Q

What are some IABP complications?

A

1) Nerve Damage , distal ischemia,
2) Hemorrhage/ Hematoma
3) Infection increase with duration of catherization
4) Thrombosis increase with duration of catherization and increase size
5) Air embolus
6) Skin necrosis
7) Loss of digits
8) Vasospasm
9) Arterial aneursym
10) Retained guidewire

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21
Q

What is Central Venous Catheters?

A

CVP is hydrostatic pressure generated by the blood within the R atrium or great veins of the thorax. It reflect Preload of RV. And best indicator of RA preload

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22
Q

What are the indications for CVP ?

A

1) Measuring right heart filling pressures
2) Assess fluid status/blood volume
3) Rapid administration of fluids
4) Administration of vasoactive drugs
5) Removal of air emboli
6) Insertion of transvenous pacing leads
7) Vascular access
8) Sample central venous blood
9) Pulmonary artery catheters

23
Q

What are the 2 factors that regulate CVP?

A

1) the volume of the blood returning to the heart from systemic circulation.
2) the ability of the RV to pump the returning blood through the pulmonary circulation. .
The ideal point to measure CVP is at the level of the tricuspid valve because at the point the hydrostatic pressure cause by changes in position are almost zero. CVP is representative of R V preload only. If an individual is healthy and the R and L Ventricles are functioning identically than maybe CVP equals or parallels the preload for the LV.

24
Q

What are the insertion sites for Central venous catheters?

A

1) Right internal jugular vein
2) Left internal jugular vein
3) Subclavian veins
4) External jugular veins
5) Femoral veins

25
Q

What is the right techniques for insertion of Central venous catheters?

A

Internal Jugular approach: locate the point at which the sternal and clavicular heads of the sternocleidomastoid muscle join. Palpate the carotid artery at the level of the cricothyroid membrane. The needle will be lateral to the carotid pulsation and at the point of joint sternal and clavicular head of the sternocleidomastoid muscle. Insert the needle at 30 degree angle to the skin and advance toward the ipsilateral nipple until the IJ is entered while aspirating.
18 or 20 gauge needle is introduced into the vessel. A guide wire is threaded through the needle and into the vein. The needle is removed, leaving the guide wire in place. The cath is then passed over the guide wire and into the vessel. Finally the guide wire is removed.
The tip of the cath should be within either the atrium or VC near the cava-atrial junction.

26
Q

What are some Central Venous Catheters contraindication?

A

1) R atrial tumor
2) Infection at site
3) Uncorrected diathesis
4) Pneumothorax or hemothorax on contralateral side.

27
Q

What are some Central Venous Catheters relative contraindication?

A

1) Positive end expiratory pressure (PEEP) mechanical ventilation
2) Only one functioning Lung.

28
Q

What are some Central Venous Catheters risks associated with poor technique?

A 
–Air or thrombo-embolism
–Dysrhythmia
–Hematoma
–Carotid puncture
–Pneumo/hemothorax
–Vascular damage
–Cardiac tamponade
–Infection
–Guidewire embolism

The Carotid puncture is the most common complications with IJ approach. Pneumothorax may occur and is more common with subclavian and low anterior IJ approach. Hemothorax is associated with subclavian vein approach.
Late complications include infection, vascular damage, hematoma formation, dysrhythmia, and extravascular catheter migration.

29
Q

What is the mean RA pressure in a spontaneously breathing patient?

A

1-7 mmHg

30
Q

What is the rises in the mean RA pressure during mechanical ventilation?

A

3-5 mmHg

31
Q

What does “a wave” means in the CVP waveform?

A
  • The peak of the “a” wave coincides with the point of maximal filling of the right ventricle
  • Therefore, this is the value which should be used for measurement of RVEDP
  • Should be measured at end-expiration.

“a” wave: represent the increase in atrial pressure which occurs during atrial contraction
•Caused by atrial contraction (follows the P-wave on EKG)
•End diastole
•Corresponds with “atrial kick” which causes filling of the right ventricle

32
Q

What does the “c wave” represent in the CVP waveform?

A

1) Due to closure of the tricuspid valve and isovolemic ventricular contraction; results in the tricuspid valve “bulging” back into the atrium.
2) Before total relaxation is completed, the “c” wave occurs, which is caused by the bulging of the tricuspid valve into the atrium during the early phase of RV contraction.

3) Atrial pressure decreases after the “a” wave as a result of atrial relaxation
4) The “c” wave is due to right ventricular contraction; tricuspid valve closed bulges back into the right atrium
5) Occurs in early systole (after the QRS on EKG)

33
Q

What does the “x descent” represent in the CVP waveform?

A

1) Atrial pressure continues to decline during ventricular contraction due to atrial relaxation
2) “Systolic collapse in atrial pressure”
3) Mid-systolic event
“x” descent is decrease in atrial pressure as the atrium begins to relax.

34
Q

What does the “v wave” represent in the CVP waveform?

A

1) Atrial filling
2) Reflects venous return against a closed tricuspid valve.
3) V wave represent the increase in atrial pressure that occurs while the atrium fills against a closed tricuspid valve.
4) The last atrial pressure increase is caused by filling of the atrium with blood from the vena cava
5) Occurs in late systole with the tricuspid still closed
6) Occurs just after the T-wave on EKG

35
Q

What does the “y descent” represent in the CVP waveform?

A

1) After ventricular relaxation, the tricuspid valve opens due to the venous pressure, and blood flows from the atrium into the ventricle.
2) The y descent is the fall in atrial pressure following opening of the tricuspid valve.
3) Y descent represents a drop in pressure as the ventricle relaxes, the tricuspid valve opens and blood passively enter the ventricle.
4) Decrease in atrial pressure as the tricuspid opens and blood flows from atrium to ventricle
5) “Diastolic collapse in atrial pressure”

36
Q

What are some indications for Pulmonary Artery Pressure Monitoring?

A

1) LV dysfunction
2) Valvular disease
3) Pulmonary HTN
4) CAD
5) ARDS/ resp failure
6) Shock/sepsis
7) ARF
8) Surgical procedure: cardiac, aortic, OB

37
Q

What are some complications of Pulmonary Artery Catheter?

A

1) Arrhythmias (including V-fib, RBBB, complete heart block)
2) Catheter knotting
3) Balloon rupture
4) Thromboembolism; air embolism
5) Pneumonthorax
6) Pulmonary infarction
7) PA rupture is the most serious complications
8) Infection (endocarditis)
9) Damage to cardiac structures (valves, etc.)
10) Relative Contraindications– WPW syndrome, Complete LBBB ( because of the risk the cath may cause RBBB as it passes through the right ventricle and thus lead to complete heart block.

38
Q

What are the distance from the right internal jugular vein to the following distal structures?

1) vena cava and RA junction
2) Right atrium
3) right ventricle
4) Pulmonary artery
5) Wedge (pulmonary artery)

A

1) 15 cm
2) 15-25 cm
3) 25-35 cm
4) 35-45 cm
5) 40-50 cm

39
Q

1) Tell me how to perform a wedge pressure?

2) and how to float a PA catheter?

A

1) inflate the balloon and advance the cath till it wedge itself into a small branch of pulmonary artery. If the ballon is inflated, the pressure monitored distal to the balloon reflects the pulm capillaries pressure, pulmonary venous pressure, and left atrial pressure.
2) As the cath enters the central vein, a CVP waveform is present. As the cath passes the tricuspid valve, a right ventricular waveform is apparent. As the cath goes through the Pulmonic valve into the main PA, the pulm arterial waveform is seen. With continued catheter advancement the balloon wedges into small branch of a pulmonary artery and the waveform reflects PCWP.

40
Q

What point during cardiac cycle should PCWP be determined?

A

the wedge pressure tracing should be analyzed for the point that correlates with the end of the LV diastolic period. This point correlates with the point on the pressure tracing after the A wave but before the C wave.

41
Q

1) What does a prominent “v wave” means in the CVP and PSWP waveform?
2) What is the CVP waveform indication for A.Fib?

A

1) Tricuspid regurgitation or mitral insufficiency

2) Absence of a normal “a wave” component

42
Q

What is thermodilution and how do you perform it?

A

The thermodilution method involves injecting a known volume of fluid with a known temperature (colder than blood) into the proximal or Right atrial port of the PA cath and monitoring the temperature change produced by the cold fluid at the distal end of the PA cath. The change in temp of the blood over time is inversely proportional to blood flow. A computer is used with the determination of CO.

43
Q

What are some methods of Cardiac Output Monitoring?

A

1) Thermodilution
2) Continuous thermodilution
3) Mixed venous oximetry
4) Ultrasound
5) Pulse Contour

44
Q

What is the normal range and average value of CO L/min?

A

4-6.5 (5)

45
Q

What is the normal range and average value of SV ml?

A

70-90 (75)

46
Q

What is the normal range and average value of SVR in wood units and dynes*sec/cm5?

A

1) 10-20 (18) wood units

2) 800-1600 (1200) dynes*sec/cm5

47
Q

What is the normal range and average value of PVR in wood units and dynes*sec/cm5?

A

1) 0.5-3 (1) wood units

2) 40-180 (80)

48
Q

What is the normal range and average value of Arterial Oxygen content mL/dL?

A

16-20 (18)

49
Q

What is the normal range and average value of Mixed venous Oxygen content mL/dL?

A

13-15 (14)

50
Q

What is the normal range and average value of Mixed Venous Oxygen saturation %?

A

70-80 (75)

51
Q

What is the normal range and average value of Oxygen consumption mL/min?

A

200-250 (225)

52
Q

What are some factors that can distort CVP and PAOP waveforms?

1) loss of a waves
2) Giant a waves
3) large v waves

A

1) Loss of a waves
–A fib
–Ventricular pacing

2) Giant a waves “Cannon” a waves
–Junctional rhythms
–Complete HB
–Mitral stenosis
–Diastolic dysfunction
–Myocardial ischemia
–Ventricular hypertrophy
3) Large v waves
–Mitral regurgitation
–Acute increase in intravascular volume
53
Q

What are the seven cardiac parameters observed with transesophageal echocardiography?

A

1) Ventricular wall characteristics and motion
2) Valve structure and function
3) Estimation of end-diastolic and end-systolic pressures and volumes (EF)
4) CO
5) Blood flow characteristics
6) Intracardiac air
7) Intracardiac masses

54
Q

When do we use Transesophageal echocardiography?

A

1) Unusual causes of acute hypotension
2) Pericardial tamponade
3) Pulmonary embolism
4) Aortic dissection
5) Myocardial ischemia
6) Valvular dysfunction

55
Q

What are some complications related to transesophageal echocardiography?

A

1) Esophageal trauma
2) Dysrhythmias
3) Hoarseness
4) Dysphagia

•Most complications in awake patients

Anesthesia (5 decks)

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