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Intro To Anesthesia > Hemodynamic monitoring > Flashcards

Flashcards in Hemodynamic monitoring Deck (67):
1

IABP complications

  1. Nerve damage
  2. hemorrhage/hematoma
  3. infection
  4. thrombosis
  5. air embolus
  6. skin necrosis
  7. loss of digits
  8. vasospasm
  9. arterial aneurysm
  10. retained guidewire

2

ECG complex

  • each box, 0.04 seconds

3

CVC contraindications

  1. R atrial tumor
  2. Infection at site

4

ECG indicators of acute Ischemia

  1. ST segment elevation >/= 1mm
  2. T wave inversion
  3. development of Q waves
  4. ST segment depression
  5. Peaked T waves

5

CVC size 

7 french

20 cm length

*not confirmed by xray in OR, aspirate blood from all ports

6

SaO2

ratio of oxyhemoglobin to all functional hemoglobin. 

7

dichrotic notch

aortic valve closure

happens later in waveform the further art line is 

8

Distance from RIJ to Wedge (pulmonary artery)

40-50 cm

9

PAP waveforms

Same as CVP but for left side 

10

Cardiac output monitoring techniques

  1. thermodilution
  2. continuous thermodilution
  3. mixed venous oximetry
  4. ultrasound
  5. pulse contour

11

Pulmonary artery pressure monitoring

Measures left side of heart. Line goes through SVC, RA, RV to PA

12

Transesophageal echocardiography Complications

  1. esophageal trauma
  2. dysrhythmias
  3. hoarseness
  4. dysphagia

*more complications in awake patients

13

Changes in lead V1-V4

Anterioseptal ischemia

left descending coronary artery

14

Leveling art line

  • Mid axillary line in supine pts
  • level of ear (circle of willis) in sitting patients

15

Anterior view of heart

V3, V4

16

5 Lead ECG

  • Leads I, II, III, aVR, aVL, aVF, V
  • 7 views of the heart

17

Risks of CVC

air or thrombo-embolism

dysrhythmia

hematoma

Carotid puncture

pneumo/hemothorax

vascular damage

cardiac tamponade

infection

guidewire embolism

 

18

Complications of NIBP

  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

19

Transesophageal echocardiography 

7 cardiac parameters observed:

  1. ventricular wall characteristics and motion (look for ischemia)
  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

20

CVC location

Tip within the Superior Vena Cava (SVC), just above the junction of SVC and RA

  • below the inferior border of clavicle and above the level of 3rd rib

21

Things that can distort CVP and PCWP

  • loss of waves
    • afib, ventricular pacing
  • Giant a waves "cannon" a waves
    • junctional rhythms
    • complete HB
    • mitral stenosis
    • diastolic dysfunction
    • myocardial ischemia
    • ventricular hypertrophy
  • Large v waves
    • mitral/tricuspid regurgitation and acute increase in intravascular volume
    • tamponade/pericarditis (both squeezing the heart)

22

Distance from RIJ to RV

25-35 cm

23

NIBP cuffs

  • bladder width should be approximately 40% of the circumference of the extremity
  • Bladder length should encircle 80% of extremity
  • applied snugly, bladder centered over the arter and residual air removed. 

24

DBP

  • trough pressure during diastolic ventricular relaxation
    • changes reflect coronary perfusion pressure

25

PAP assessment

  • Intracardiac pressures (CVP, PAP, PCWP/PAWP)
  • estimate LV fillin gpressures
  • assess LV function
  • CO
  • mixed venous oxygen saturation
  • Pulmonary Vascular resistance (PVR) Systemic  vascular resistance (SVR)

26

CVP monitoring

Right atrial pressure = Right ventricle preload

normal = 1-7 mmHg

with mechanical ventilation = 4-10 mmHg

27

Distance from RIJ to PA

35-45 cm

28

CVP waveform

  • "a" wave is point of maximal filling of RV and should be used for RVEDP
    • machines "average" the measurement
    • Should be measured at end-expiration. 
  • "c" closure of tricuspid valve and V contraction, tricuspid "bulges" back into the atrium slightly increasing the pressure

29

Changes in Lead I, AVL, V5-V6

Lateral wall ischemia

circumflex branch of left coronary artery

30

Thermodilution

Using known amount of known temperatured solution to inject in catheter in RA.  Thermister on cathether (swan-ganz) measures change in temperature. Used to assess cardiac output

31

AANA minimal standard required monitors and monitoring information (on graphic display)

  1. ECG (HR and rhythm)
  2. Blood pressure
  3. pulse ox
  4. Oxygen analyzer
  5. end tidal carbon dioxide
  • ECG
  • BP
  • HR
  • ventilation status
  • O2 sat

*Must document minimum of every 5 minutes!!

 

**Variable pitch tone must be audible with use of Pulse ox

32

Insertion sites of Central venous catheters

  • right internal jugular (most common for anesthesia)
  • left internal jugular vein
  • subclavian veins
  • external jugular veins
  • femoral veins

33

Septal view of heart

V1, V2

34

3 Lead ECG

3 views of the heart, no anterior view

35

most important lead for ischemia

V

*all V leads

36

PCWP

Pulmonary Capilary wedge pressure

a wave: contraction of Left atrium

*usually a small deflection unless there is resistance moving blood into LV like in mitral stenosis.

c wave: rapid rise in LV pressure in early systole, causing mitral valve to bulge backward into LA, so atrial pressure increases momentarily

v wave: blood entering LA during late systole

*prominent v wave reflects mitral insufficiency causing large amounts of blood to reflux into the LA during systole

37

distance from RIJ to RA

15-25 cm

 

38

BP Oscillometry

Senses oscillations/fluctuations in cuff pressure produced by arterial pulsations while deflating a BP cuff

  • 1st oscillation correlates with SBP
  • maximum/peak oscillations occurs at MAP
  • oscillations cease at DBP

 

39

Transesophageal echocardiography uses:

  1. unusual causes of acute hypotension
  2. pericardial tamponade
  3. pulmonary embolism
  4. aortic dissection
  5. myocardial ischemia
  6. valvular dysfunction

40

most important lead for rhythm changes

II

41

Falsely high PB

  • cuff too small
  • cuff too loose
  • extremity below level of heart
  • arterial stiffness- HTN, PVD

42

Changes in Lead I, AVL, V1-V4

Anterior wall ischemia

Left coronary artery

43

Lateral view of heart

I, aVL, V5, V6

Lead I = RA-LA

44

Pulse pressure

SBP-DBP

As location of BP moves out peripherally, you get exaggerated SBP and wider pulse pressure. 

45

PAP catheters

  • 7 or 9 french
  • 110 cm length
  • 4 lumens
    • distal port PAP
    • second port 30 cm more proximal CVP
    • third lumen balloon
    • fourth wires for temp

 

46

Distance from RIJ to Vena cava and RA junction

15 cm

47

Calculate MAP

SBP+2(DBP) / 3

48

low CVP reading

hypovolemia/shock

49

CVC indications

  1. measuring right heart filling pressures
  2. assess fluid status/blood volume
  3. rapid administration of bolus
  4. administration of vasoactive drugs
  5. removal of air emboli
  6. insertion of transvenous pacing leads
  7. vascular access
  8. sample central venous blood

50

Standard 2

  1. Oxygenation
  2. ventialtion
  3. circulation
  4. temperature

*Continually evaluated

51

inferior view of heart

II -RA-LL

III  - LA-LL

aVF-  LA+LL-RA

52

PAP complications

  1. arrhythmias
  2. catheter knotting
  3. balloon rupture (can rupture pulmonary vasculature
  4. thromboembolism; air embolism
  5. pneumothorax
  6. pulmonary infarction
  7. PA rupture
  8. infection
  9. damage to cardiac structures (valves, etc)
  10.  

53

SBP

  • peak pressure generated during systolic ventricular contraction
    • changes correlate to changes in myocardial O2 requirements

 

54

Esophageal stethescope

  • Intubated patients only
    • 28-30 cm
  • shows temp too
  • used in every pediatric case. 
    • very sensitive to bronchospasm

55

Indications for Art line

  1. elective deliberate hypotension
  2. wide swings in BP
  3. rapid fluid shifts
  4. titration of vasoactive drugs
  5. end organ disease
  6. repeated blood sampling
  7. failure of NIBP

56

Standard 1

Qualified provider must be with pt the entire time

SRNA

CRNA

MDNA

AA- need direct in room supervision

57

Precordial stethescope

taped to chest and used for continual assessment of heart and lung sounds.

 

58

Allen test

block radial and ulnar arteries, pt pump fist, release ulner artery first to make sure it can refill hand if radial artery gets "trashed" by art line. 

59

Falsely low BP

  • Cuff too large
  • extremity above level of heart
  • poor tissue perfustion
  • too quick deflation

 

*improper cuff placement, dysrhythmias, tremors/shivering

60

Arterial pressure waveform

*the more distal the art line, the SBP will increase, DBP will decrease, MAP same, dichrotic arch is later

61

Art line sites

  1. radial
  2. ulnar
  3. brachial
  4. femoral
  5. dorsalis pedis
  6. axillary

62

to improve accuracy of art line

and forms of erro

  1. minimize tubing length
  2. limit stopcocks
  3. no air bubbles
  4. use non-compliant stiff tubing
  5. calibrated

forms of error: Dampening and overshooting

63

PAC indications

LV dysfunction

valve disease

Pulm HTN

CAD

ARDS/resp failure

shock/sepsis

AFR

Cardiac sugeries

64

high CVP readings

fluid overload

right heart failure

PE

tension pneumo

65

Pulse Oximeter

  • measures hemoglobin saturation
  • pulses red and intrared LED on and off several hundred times per second
    • absorption of intrared light in blood--algorithm used to compute ration of infrared light signal and saturation

66

Changes in Lead II, III, AVF

(posterior)/ Inferior wall ischemia

Right coronary artery

67

Purpose of ECG

  1. detect arrhythmias
  2. monitor heart rate
  3. detect ischemia
  4. detect electrolyte change
  5. monitor pacemaker function