Minimal Standard Monitors
1 .Electrocardiogram (HR and rhythm)
2. Blood pressure
3. Precordial stethoscope
4. Pulse oximetry
5. Oxygen analyzer
6. End tidal carbon dioxide
document q5 min minimum
Minimal Standard - On Graphic Display
2. Blood pressure
3. Heart rate
4. Ventilation status
5. Oxygen saturation
a stethoscope that is placed on the chest (just the bell part) that is attached to tubing with an ear piece on the other end
used for continuously listen to breath sounds and heart tones throughout the case.
You can quickly pick up on changes in patient condition (loss of breath sounds, loss of heart tones, etc).
used in peds 100% of the time
used for continuous assessment of a pt's breath sounds and health sounds
placed inside of the ETT - pt has to be intubated
28-30 cm into the esophagus
what is it? what it is not?
Recording of electrical activity of the heart
does NOT tell you about circulation
NOT a pulse rate monitor
EKG - what do you use it for?
- – Detect arrhythmias
- – Monitor heart rate
- – Detect ischemia
- – Detect electrolyte changes
- – Monitor pacemaker function
5 Principle ECG Indicators of Acute Ischemia
- ST segment elevation , ≥1mm
- T wave inversion
- Development of Q waves
- ST segment depression, flat or downslope of ≥1mm
- Peaked T waves
Lead I, AVL, V1-V4
Anterior wall ischemia (left coronary artery)
Lead I, AVL, V5-V6
Lateral wall ischemia
(circumflex branch of left coronary artery)
Lead II, III, AVF
(Posterior)/ Inferior wall ischemia
(right coronary artery)
How far is an esophageal stethoscope inserted into the esophagus?
This allows us to hear heart sounds and BS internally.
What are precordial and esophageal stethoscopes useful for?
Continuous assessment of heart and breath sounds.
Very sensitive monitor for bronchospasm and changes in pediatric patients
How often should we have a regular stethoscope available?
At all times
What 4 general things are continually evaluated?
Oxygenation, ventilation, circulation, and temperature
Considerations in deciding what type of monitoring to use
6) Skill level
Types of hemodynamic monitoring used
EKG, BP (NIBP and IABP), CVP, PAP, PCWP, TEE, stethoscope
What can the EKG tell you?
- Heart rate
- electrolyte imbalances
- pacemaker function
Aspects of the 3 Lead EKG
Electrodes used: RA, LA, LL
Leads: I, II, III
Number of views of the heart: 3
Aspects of the 5 lead EKG
Electrodes used: RA, LA, RL, LL, chest
Leads: I, II III, AVL, AVR, AVF, V lead
Number of views of the heart: 7
Posterior / inferior wall ischemia is seen in these leads and is due to a blockage in this artery
II, III, AVF
Lateral wall ischemia is seen in these leadsand is due to a blockage in this artery
I, AVL, V5-6
Left circumflex coronary artery
Anterior wall ischemia is seen in these leadsand is due to a blockage in this artery
I, AVL, V1-4
Left coronary artery
Anterioseptal wall ischemia is seen in these leads and is due to a blockage in this artery
Left anterior descending coronary artery
Value of the length and width of each EKG box
0.1mV and 0.04s
How to calculate HR based on EKG lead
1500/# boxes between R waves
How should the gain be set in order to accurately assess the ST segment?
At standardization (1mV signal gives a rise of 10mm).
This setting also fixes the ratio of the QRS complex to the ST segment size so that a 1mm change in the ST segment can be accurately assessed.
If the wrong gain setting is used, ST changes may be under or over-diagnosed.
What filtering mode should the EKG be on for accurate ST assessment?
Filtering out the low end of frequency bandwith (which can happen on monitor mode) can lead to ST distortion (either elevation OR depression)
This part of BP correlates to the point of the most demand on the heart
The pulse pressure changes as you move from where to where
From the central arterial system to the periphery.
The pulse pressure widens due to wave reflections in the vasculature.
These factors can cause a falsely high NIBP reading
- Cuff too small
- cuff below the level of the heart
- loose cuff
- arterial stiffness (HTN, PVD)
These factors can cause a falsely low NIBP reading
- Cuff too large
- cuff above the level of the heart
- poor tissue perfusion
- deflation is too rapid
Fals NIBP reading can also occur with
- Cardiac dysrhythmia
- improper cuff placement
This type of NIBP reading only gives you SBP
It measures the return of arterial pulse during deflation.
This is simple, inexpensive, and underestimates the SBP.
This NIBP reading only gives you SBP but measures it fairly reliably
Measures it by a shift in frequency of sound waves that is reflected by RBCs moving through an artery.
This NIBP method estimates both SBP and DBP
Auscultation with a sphygmomanometer.
Measures BP by auscultation Karotkoff sounds created by turbulent blood flow though the artery created by the mechanical deformation from the BP cuff.
This method is unreliable in patients with HTN.
Rate of a-line upstroke tells you about
Rate of a-line downstroke tells you about
Changes in SBP correlate with changes in ____
Myocardial O2 demand.
Automated cuffs work by this mechanism
Complications of NIBP measurement
- Ulnar nerve damage
- compartment syndrome
- edema of the extremity
- bruising / petechiae
- interference of IV flow
- altered timing of IV drug administration
Indications for IABP monitoring (invasive)
- Deliberate hypotension
- Risk of rapid BP changes
- Wide swings in BP intra-op
- Rapid fluid shifts
- Titration of vasoactive drugs
- End organ disease
- Repeated blood sampling
- NIBP measurement failure
What test has to be done before radial a-line placement?
Rate that NS moves through the a-line system to prevent clot formation
How can a-line dynamics and accuracy be improved?
- Remove bubbles
- calibrate at the level of the heart
- minimize tube length
- limit the number of stop-cocks
- use non-compliant stiff tubing
- make sure the mass of the fluid used is small
Where should the a-line be calibrated?
Supine patients- midaxillary line (right atrium)
Sitting patients- level of the ear (circle of willis) because we are concerned about CBF
Exaggerated variations in a-line tracing size with respirations indicates
The area under the a-line curve tells you
The dicrotic notch indicates the closure of this valve
How is RVEDP measured with CVP tracing?
The a wave (end diastole) correlates with maximal filling of the right ventricle
What is the a wave?
Contraction of the right atrium, which results in increased RAP (since there is no pressure difference between the vena cava and the atrium)
The a wave follows this on the EKG
The p wave.
This CVP wave is the atrial kick (atrial contraction)
The a wave
results in the filling of the right ventricle
What is the c wave a reflection of?
Isovolumetric contraction of the right ventricle, resulting in the bulging back of the tricuspid valve into the RA
atrial pressure decreases after "a" wave d/t to relaxation - the little blip in pressure is related to the tricuspid valve bulging back
The c waves follows this waveform on the EKG
The QRS complex.
The c wave occurs in early systole
The x descent occurs during
Mid-systole. The x descent follows the c wave.
atrial pressure continues to decline cause atria relaxes (while the ventricle is contracting)
aka "systolic collapse in atrial pressure
The v wave reflects what?
Venous return into the RA against a closed tricuspid valve
return of blood into the right atrium from vena cava
(encompasses a portion of the RV systole)
When does the V wave occur during the cardiac cycle and EKG?
At the end of systole with the tricuspid valve still closed, and it occurs just after the T wave.
What does the y descent reflect?
Passive ventricular filling after ventricular relaxation - tricuspid valve opens and blood flows from atrium into the ventricle
The y descent reflects a fall in RAP due to this.
This is referred to the "diastolic collapse in atrial pressure" - occurs in early diastole
What happens to IABP readings as they move further into the periphery?
Distal pulse amplification!
This causes increased SBP, decreased DBP, and increased pulse pressure.
MAP remains unchanged.
The dicrotic notch becomes less and less apparent and appears later in the tracing (takes longer for the pressure wave to reach the transducer).
Complications of IABP measurement
- Nerve damage
- retained guidewire
- air embolus
- arterial aneurysm
- vasospasm (usually self-limiting)
- skin necrosis
- loss of digits
Are fluids able to be given faster through a PIV or central line?
Indications for getting central access
- Need more vascular access (unable to get enough PIVs) and need to rapidly give fluids - vascular access
- give vasoactive meds
- monitor CVP - measuring right heart filling pressure
- assess fluid status/blood volume
- sample venous blood
- remove air emboli
- pulmonary artery access
- insertion of transvenous pacing leads
Why is the right IJ preferred to the left
- It provides a more direct route to the heart
- the dome of the lung is higher on the left
- has the least aount of complications
- left IJ takes a little turn - more challenging placement
Typical central venous catheter size
If anesthesia places a central line, is placement confirmed with an x-ray?
if placed in the IJ:
- No, it is confirmed with blood aspiration from all 3 ports. X-ray is taken after surgery if decided to be kept in
if placed in the subclavian:
- Systolic upstroke
- systolic peak pressure
- systolic decline
- dicrotic notch aortic valve closure)
- diastolic runoff
- end-diastolic pressure
match the waves with appropriate location
- brachial artery
- radial artery
- femoral artery
- dorsalis pedis
Where should the tip of the central line be located?
Tip in the SVC, just above the junction of the vena cavae and RA and parallel to the vessel walls.
- bellow the inferior border of the clavicle at the level and above the 3rd rib
- the T4/5 interspace or the level of the carina or R mainstem bronchus.
identify the waveform's location
When is a central line contraindicated?
R atrial tumor
Infection at site
Central line risks
usually d/t poor technique
- air embolism
- guidewire embolism
- carotid puncture
- dysrhythmia - watch your EKG
- vascular damage
- cardiac tamponade
What does CVP measure?
right sided pressures
CVP measures the RAP (because it's right at the RA junction), which is a measure of right ventricle preload
results from ebbs and flows of blood in the right atrium
Normal mean RA pressure in a spontaneously breathing patient is ______
and it rises about _______ during mechanical ventilation
Size of pulmonary artery catheters and number of lumels
- 7-9 french
- 4 lumens
- distal is for PAP
- second is 30cm more proximal for CVP
- third is for balloon
- fourth is for the thermistor wires)
- distal is for PAP
- second is 30cm more proximal for CVP
- third is for balloon
- fourth is for the thermistor wires)
Indications for PAP monitoring
- Unstable cardiac patients
- LV dysfunction
- Pulmonary HTN
- ARDS/resp failure
- Valvular disease
- Surgical procedures, such as cardiac, aortic, or OB
- big cases that have lots of fluid shifts
Complications of pulmonary artery catheters
- Arrhythmias (v-fib, RBBB, complete heart block)***
- PA rupture****
- Balloon rupture
- Pulmonary infarction
- Thromboembolism/air embolism
- Catheter knotting
- Damage to cardiac structures (valves)
- Infection (endocarditis)
Relative contraindications to a PA catheter
Distance from right IJ to various structures
vena cava/RA junction, RA, RV, PA, PA wedge
SVC/RA junction- 15cm
PA Wedge 45-50
If you go beyond these measurements and don't see the proper waveform, you may be coiling the catheter
When might the a wave be larger than normal
When might the v wave be larger than normal?
Mitral/tricuspid insufficiency, causing blood to reflux into the atrium during systole.
Remember that the v wave reflects atrial filling during late systole
Ways that we can measure CO
- continuous thermodilution
- pulse contour
- mixed venous oximetry
"a" waves may be lost with
Giant a waves ("Cannon" a waves) may be caused by
- Junctional rhythms
- complete HB
- mitral stenosis
- diastolic dysfunction
- myocardial ischemia
- ventricular hypertrophy
Large V waves may be caused by
Acute increase in intravascular volume
7 things you can observe with TEE (cardiac parameters)
- Ventricular wall characteristics and motion
- Valve structure and function
- Measurement of EDV and ESV
- Blood blow characteristics
- Intracardiac masses
- Intracardiac air
When is the use of TEE indicated?
- Pericardial tamponade (for trauma)
- Unusual causes of acute hypotension
- Aortic dissection
- Myocardial ischemia
- Valvular dysfunction
Overall, if someone is still very unstable and unresponsive to our treatments, we can use TEE to get a better overall picture of our patients- checking to see what the actual structural problem might be
Complications of TEE
- Esophageal trauma
- Hoarseness (upper airway issues)
Most complications are reported in awake patients
Invasive IABP measurement - what is it
Involves percutaneous insertion of catheter into an artery, which is then transduced to convert the generated pressure into an electrical signal to provide a waveform
Invasive IABP measurement - advantages
– Generates real-time beat to beat BP
– Allows access for arterial blood samples
– Measurement of CO/ CI/ SVR
how do you do an Allen's test?
occlude ulnar and radial artery
release ulnar artery
check for collateral flow
what do you use Pulmonary Artery Pressure Monitoring for?
Direct assessment of:
- Intracardiac pressures (CVP, PAP, PCWP)
- Estimate LV filling pressures
- Assess LV function
- Mixed venous oxygen saturation
- PVR and SVR
measures the left side of the heart
PA catheter "a" wave (PCWP) - what is it?
contraction of the left atrium
Normally it is a small deflection unless there is resistance in moving blood into the left ventricle as in mitral stenosis
PA catheter (PWCP) v wave - what is it?
blood enters the left atrium during late systole
rapid rise in the left ventricular pressure in early systole, causing the mitral valve to bulge backward into the left atrium, so that the atrial pressure increases momentarily