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Intro to Anesthesia: Part A > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

Purpose of hemodynamic monitoring (5 items)

A
  1. Assess homeostasis, trends
  2. Observe for adverse reactions
  3. Assess therapeutic interventions
  4. Manage anesthetic depth
  5. Evaluate equipment function
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2
Q

How we monitor oxygenation (4 items)

A
  1. Pulse ox
  2. Skin color
  3. ABGs
  4. 02 analyzer on machine
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3
Q

How we monitor ventilation (5 items)

A
  1. End tidal CO2
  2. breath sounds,
  3. flow volume loop,
  4. chest rise,
  5. movement of respiratory bag
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4
Q

How we monitor circulation (7 items)

A
  1. Pulse ox,
  2. capillary refill,
  3. pulses,
  4. a line,
  5. skin color,
  6. BP,
  7. HR, heart sounds
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5
Q

Minimal standard for monitoring (5 items)

A
  1. EKG
  2. BP
  3. Temperature
  4. SaO2
  5. ETCO2
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6
Q

Considerations when choosing monitoring (7 items)

A
  1. Indications
  2. Contraindications
  3. Risks/benefits
  4. Techniques
  5. Alternatives
  6. Complications
  7. Cost
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7
Q

Hemodynamic monitoring tools (6 items)

A
  1. Stethoscope
  2. EKG
  3. BP
  4. CVP
  5. PAP
  6. TEE
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8
Q

Types of stethoscopes:

  1. Precordial
  2. Esophageal
A
  1. Placed on surface of chest to read continuously; placement depends on what structure of the heart you want to hear
  2. Only used with intubated pts; goes down esophagus 28-30cm; sensitive for brochospams, obsturction, changes in HR/rhythm
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9
Q

Purpose of EKG (5 items)

A
  1. Monitor HR
  2. Arrythmia detection
  3. detect ischemia
  4. detect lyte changes
  5. monitor pacemaker function
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10
Q

3 lead EKG:

  1. Electrodes
  2. Leads
  3. Views
A

RA, LA, LL.
Leads I, II, III.
3 views, no anterior. No LAD view

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11
Q

5 lead EKG

  1. Electrodes,
  2. Leads
  3. Views
A

RA, LA, LL, RL, chest lead (ususally V1 or V5).
I, II, III aVR, aVL, aVF, V.
7 views

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12
Q

Best lead for

  1. Arrythmia,
  2. Ischemia
A

II.

V5.

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13
Q

Monitor settings for:

  1. Gain
  2. Filtering Capacity
A
  1. Standardization: 1mv signal produces 10mm calibration pulse; will accurately depict 1mm ST changes
  2. Diagnostic Mode: filters out low ECG bandwith, electrical interference
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14
Q

Indicators of acute ischemia on ECG (5 items)

A
  1. ST elevation >1 mm,
  2. Peak T wave/ inversion,
  3. Pathological Q waves,
  4. ST depression, flat or downslope >1 mm.
  5. Arrhythmias
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15
Q

Where inferior wall ischemia shows, artery

A

II, III, AVF

Supplied by Right Coronary Artery

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16
Q

Where lateral wall ischemia shows, artery

A

I, AVL, V5-V6

Circumflex of Left Coronary Artery

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17
Q

Anterior wall ischemia:

  1. Leads
  2. Artery
A
  1. V3-4

2. Left Coronary Artery

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18
Q

Where anteroseptal ischemia shows, artery

A

V1-V2

Left Anterior Descending

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19
Q

Blood pressure correlations:

  1. SBP
  2. DBP
  3. PP
  4. MAP
A
  1. Peak systolic contraction; changes correlate with myocardial O2 demand
  2. Trough pressure during diastole; changes correlate with coronary perfusion pressure
  3. SBP-DBP; correlates with conraction force; narrows in tamponade, widens in hypovolemia
  4. Correlates with organ perfusion; weighted arterial pressure during cardiac cycle
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20
Q

MAP calculation

A

SBP + 2DBP/3

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21
Q

Proper NIBP:

  1. Width
  2. Length
  3. Placement
  4. Limitations
A
  1. 40% of circumference of extremity
  2. Must encircle at least 80% of extremity
  3. Snugly, bladder centered over artery w/ residual air removed
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22
Q

What creates a falsely high BP (3 items)

A
  1. Cuff too small or loose,
  2. extremity below heart,
  3. arterial stiffness in htn or PVD.
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23
Q

What creates a falsely low bp (4 items)

A
  1. Cuff too big,
  2. above heart,
  3. poor tissue perfusion,
  4. too quick of deflation
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24
Q

Complication of NIBP (6 items)

A
  1. Edema of arm,
  2. bruising,
  3. ulnar neuropathy,
  4. interferes IV flow,
  5. pain,
  6. compartment syndrome
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25
Indications for Arterial Line (7 items)
1. Elective hypotension 2. Unstable BP 3. Severe fluid shifts 4. Titration of vasoactive drugs 5. End Organ Disease 6. Frequent ABG sampling 7. NIBP failure
26
How to improve A-line accuracy (6 items)
1. Remove air bubbles, 2. limit tube length, 3. limit stop cocks, 4. small mass of fluid, 5. Use stiff tubing, 6. calibrate at heart
27
Where to zero a line when monitoring: 1. BP 2. CPP
1. Supine- mid axillary line (RA). | 2. Meatus of ear (circle of Willis)
28
A line Waveform Components (6 items)
1. Systolic upstroke (slope=heart contractility) 2. Systolic peak pressure 3. Systolic Decline 4. Diacrotic notch (aortic valve closure) 5. Diacrotic runoff 6. End diastolic pressure *Area under curve=MAP
29
Distal pulse amplification does what
For a line. SBP peak increases, DBP wave decreases, MAP same. Dicrotic notch becomes less and appears later Due to narrowing and stiffening and vessels
30
Arterial Line Complications (6 items)
1. Hematoma 2. Nerve Damage 3. Infection 4. Thrombosis/embolus 5. Vasospasm 6. Retained Guide Wire
31
Indications for CVL (7 items)
1. Measure R heart filling 2. assess fluid status, 3. rapid admin fluids, 4. give vasoactives, 5. remove air emboli, 6. insert transcutaneous pacing leads 7. frequent blood samples
32
CVL: 1. Size, length 2. Insertion points 3. Correct tip positioning 4. Placement confirmation
1. 7 French (apx 14 gauge), 20 cm length 2. RIJ (most common), LIJ, Sublavian, external jugular, femoral 3. Within SVC above junction of SVC and RA; below inferior border of clavicle, above level of 3rd rib, T4 (carina, or RMB) 4. Blood aspiration from all ports, xray (not done in OR)
33
Contraindications to CVL (3 items)
1. Contralateral pneumo 2. RA tumor 3. Infection at site
34
Risks of CVL (8 items)
1. Air or thromboembolism 2. Dysrhythmias, 3. Hematoma, 4. Carotid puncture, vascular damage 5. Pneumo/hemothorax, 6. Tamponade, 7. Infection, 8. Guidewire embolism
35
Normal RAP/Vented RAP
1-7 mmHg in spontaneous breathing; 3-5 mmHg rise w vent | RAP=CVP=RV preload
36
CVP Waveform: A wave
Atrial contraction (follows EKG P); atrial kick; End of diastole
37
CVP Waveform: C wave
Tricuspid valve bluges into atrium during ventricle contraction; occurs early in systole (after QRS on EKG)
38
CVP Waveform: X descent
Systolic collapse in atrial pressure; mid-systolic even
39
CVP Waveform: V wave
Filling of the atrium from the VC; occurs late systole while tricuspid closed (after T wave on EKG)
40
CVP Waveform: Y descent
Diastolic collapse in atrial pressure; drop in atrial pressure as tricuspid OPENS
41
CVP Wave to Cardiac Cycle: 1. A Wave 2. C Wave 3. X Descent 4. V Wave 5. Y Descent
1. End diastole 2. Early Systole 3. Mid Systole 4. Late Systole 5. Early Diastole
42
Pulmonary Artery Catheter Can Assess... (6 items)
1. Intracardiac pressures (PAP, PCWP) 2. Estimate LV pressures 3. Assess LV function 4. CO 5. Mixed venous saturation 6. PVR/SVR
43
PA Catheter: 1. French 2. Length 3. Lumens (4)
1. 7 French (introducer 8.5) 2. 110 cm, marked at 10cm intervals 3. Distal (measures PAP), Proximal (Blue, measures CVP), Balloon, Thermistor port (wires, cant inject)
44
Indications for PA monitoring (5 items)
1. LV dysfunction, 2. valvular disease, 3. pulm htn, 4. CAD, ARDS, shock, sepsis, ARF, 5. cardiac/aortic/OB procedures
45
Complications of PA Catheter (8 items)
1. Arrhythmias (V fib, RBBB, heart block) 2. PA rupture 3. Catheter knotting 4. Balloon rupture 5. Embolism (air/thrombus) 6. Pneumothorax 7. Valve or myocardial damage 8. Infection
46
Contraindications to PA insertion (2 items)
Wpw syndrome, complete LBBB
47
What happens to wave form as PA inserted
CVP wave in RA, more turbulent and higher pressure in RV, SBP same and DBP rises in PA, more compact pressure when wedged
48
PA Catheter Cm Length at: 1. RA junction 2. RA 3. RV 4. PA 5. PA wedge
1. 15 2. 15-25 3. 25-35 4. 35-45 5. >45 (40-50) *Catheter usually secured at skin between 50-60cm
49
PCWP a wave
contraction of the left atrium. small deflection unless there is resistance in moving blood into the left ventricle as mitral stenosis.
50
What c wave is PCWP
rapid rise in the left ventricular pressure in early systole, causing the mitral valve to bulge backward into the left atrium, so that the atrialpressure increases momentarily.
51
What v wave is PCWP.
Blood enters LA in late systole; high v wave is mitral insufficiency due to blood reflux during systole
52
CO Monitoring Techniques (5 items)
1. Thermodilution 2. Continuous Thermdilution 3. Mixed Venous Oximetry 4. Ultrasound 5. Pulse Contour
53
What can cause 1. Loss of A-waves (2 items) 2. Low A-waves 3. High A-waves (4 items)
1. Atrial fibrilation, Ventricular Pacing 2. Hypovolemia 3. Valve insuficency (regurg/stenosis), heart block, JHR, decreases ventricular compliance
54
Causes of large V-waves
1. Valve insufficiency: tricuspid (CVP) or Mitral (PAOP) regurg/stenosis 2. Fluid Overload
55
What does a TEE observe (6 items)
1. Ventricular wall motion/traits 2. Valve structure/function 3. EF 4. CO 5. Blood Flow 6. Intracardiac air/masses
56
Most common things a TEE is used to detect (7 items)
1. Unexpected causes of hypotension 2. Myocardial ischemia 3. PE 4. Aortic dissections 5. Tamponade 6. Valve dysfunction 7. Air embolism
57
TEE complicaitons (4 items)
1. Esophageal trauama 2. Dysrhythmias 3. Dysphagia 4. Hoarsness
58
Types of NIBP (4 items)
1. Palpation 2. Doppler 3. Auscultation 4. Oscillometry
59
NIBP Palpation: 1. Technique 2. Considerations
1. Palpating a pulse while deflating cuff | 2. Only measures SBP but usually UNDERestimates; is cheap, simple
60
NIBP Doppler: 1. Technique 2. Considerations
1. Use dopler on artery w/ cuff | 2. Measures only SBP reliably
61
NIBP Auscultation: 1. Technique 2. Considerations
1. Listen for Korotkoff sounds | 2. Can estimate SBP and DBP; usually underestimates in HTN patients
62
NIBP Oscillometry: 1. Technique 2. Considerations
1. Senses fluctuations in cuff pressure produced by arterial pulsations during deflation: 1st is SBP Max is MAP Cease at DBP 2. Dysrhythmias/, tremors/shivering will give erroneous readings
63
Pulse Oximeter: 1. Mechanism 2. Uses 3. Sites
1. Measures hemoglobin saturation through algorithm to compute absorption of red and infared light in blood; must have VARIABLE PITCH tone when used 2. Detects hyoxemia, perfusion 3. Fingers, toes, nose, ear, forehead
64
Common SaO2 Complications (6 items)
1. Electrical interference 2. Nail polish 3. CO poisoning; methhemoglobinemia 4. Dye (methylene blue) 5. Malpolisitioning 6. Cold extremity, shivering
65
EKG Lead (Poles and Direction) 1. I 2. II 3. III 4. aVF 5. aVL 6. aVR
1. Positive voltage from RA to LA 2. Positive voltage from RA to LL 3. Positive voltage from LA to LL 4. Positive from GCT to LL (+ QRS) 5. Positive from GCT to LA (+/- QRS) 6. Positive from GCT RA (- QRS) *Goldbergs Central Terminal: average of the two remaining leads
66
Components of EKG: 1. P wave 2. PR interval 3. QRS Complex 4. ST interval 5. QT interval 6. T wave 7. RR interval
1. Atrial depolarization; 0.08-0.10 sec 2. Conduction from SA/AV node; 0.12-0.20 sec 3. Contraction of ventricle; 0.08-0.10 sec (under 0.12) 4. Isoelectric line between ventricular depolarization and re-polarization 5. Time taken for ventricular depolarization and re-polarization; 0.40-0.43 sec 6. Ventricular repolarization 7. Represents heart rate; 0.6-1.0 sec
67
Lead Placement: 1. RA, LA 2. V1, V2 3. V3 4. V4 5. V5 6. V6
1. 2nd ICS 2. 4th ICS, R and L of sternum 3. Between V2/V4 4. 5th ICS, MCL 5. Level w/ V4, anterior axillary line 6. Level with v4/v5 at midaxillary line
68
Benefits of A-line
1. Generates realtime beat to beat BP 2. Allows of ABG samples 3. Can calculate CO/CI/SVR

Intro to Anesthesia: Part A (6 decks)

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