Hemodynamics Monitoring Review Flashcards
(143 cards)
1
Q
AANA Standard 9 (A-E)
A
Monitoring and Alarms.
- Monitor, evaluate and document patient’s physiologic condition as appropriate for procedure and anesthetic technique
- pitch and threshold alarms are turned on and audible
- document BP, HR RR at least every 5 minutes for all anesthetics
-A. O2- Continou monitor oxygen by observation and pulse oximetry. Talk to surgical team regarding fire
B. Ventilation: Continuous monitor ventilation by clinical observations and expired CO2 during moderate sedation, deep sedation or general. Verify intubation of trache by auscultation, chest rise, and expired CO2.
C. Cardiovascular- monitor pt hemodynamics status HR and invasive monitoring as appropriate
D. Thermoregulations: monitor body temp and active measure to facilitate normothermia. When MH triggering agents used, monitor temp and recognize s/s immediately
E. Neuromuscular- when nMB agent administered, monitor response to assess depth of blockade and degree fo recovery
2
Q
Required Monitors by AANA
A
EKG, BP, TEMP, PULSE OX, ETCO2
3
Q
Cornerstone monitoring:
A
Physical assessment. I.e.:
- Inspection, auscultation, palpation
- Chest rise/fall
- Auscultate breath sounds preop, after intubation, and when ventilators parameters change
- Direct palpating of pulse when monitored value questioned.
- Direct observation beating heart in cardiac six
- Inspection of mucous membrane, skin color and turf or
- Inspect six field for blood loss. UOP observation
- Evalute JVD
- pupillary response
4
Q
Precocial or Esophageal stethoscope
A
Minimally invasive, cost effective and continuous monitor
- Continual assessment breath and heart sounds
- sensitive monitor for broncospasm, airway obstruction and changes in hr/rhythm
- High detection for venous air embolism
5
Q
Speed EKG paper
A
25 mm/sec
6
Q
1 SQUARE horizaontal on EKG
A
1 SQUARE= 0.4 sec. 0.5 cm = 0.20 seconds long
1mm or 0.1 mV high
7
Q
EKG purpose
A
Detect arrhythmia Monitor HR Detect ischemia Detect electrolyte changes Monitor pacemaker function
8
Q
3 lead EKG
A
RA, LA, LL leADS I, II, III. No ANTERIOR view of heart, Only rhythm monitor
9
Q
Lead I
A
RA TO LA
10
Q
Lead II
A
RA TO LL
11
Q
Lead III
A
La to LL
12
Q
5 lead EKG
A
RA, LA, RL, Chest lead 7 views of heart. V1 preferred for arrhythmia monitoring
13
Q
AVF
A
Center to LL
14
Q
AVR
A
CENTER TO RA
15
Q
AVL
A
CENTER TO LA
16
Q
V1
A
4TH Intercostal space to right of sternum (septal view of hear)
17
Q
V2
A
4th intercostal space to left of sternum (septal view of heart)
18
Q
V3
A
Directly b/w V2 and V4(anterior view of heart)
19
Q
V4
A
5th intercostal space and L midclavicular line (anterior view of heart)
20
Q
V5
A
Level with V4 at left anterior ancillary line (lateral view of heart
21
Q
V6
A
LEVEL with V5 at L midaxillary line (lateral view of heart)
22
Q
5 principle indicators of Ischemia detection
A
1) ST segment elevation >= 1mm
2) T wave flattening or inversion
3) development of Q waves
4) ST segment depression, flat or downslope >1mm
5) PEAKED T waves
6) Arrhythmias
23
Q
Inferior Wall ischemia. Which vessel, which leads?
A
RCA. Change in II, III, avf
24
Q
Lateral wall ischemia. Which vessel/leads?
A
Circumflex branch of LCA,. I, AVL, V5-V6
25
Anterior wall ischemia
LCA, V3-V4
26
Septal ischemia
Left descending coronary artery (LAD) V1, V2
27
Normal PR
0.12-0.2 SEC
28
QRS
0.08-0.10 sec
29
QT
0.4-0.43 sec
30
RR interval
0.6-1sec
31
Blood pressure based on what law?
Ohm’s Law. V=IR. V=blood pressure. Blood flows x resistance
32
Systolic BP
Peak pressure generated with changes in systolic ventricular contractions. Changes reflect myocardial o2 requirements
33
Diastolic BP
Trough pressure during diastolic ventricular relaxation. Changes in DBP reflect coronary perfusion pressure
34
Pulse pressures
SBP-DBP
35
MAP
Weighted average of arterial pressure during pulse cycle. MAP = SBP + 2(DBP)/3 OR MAP DP+(1/3) (SP-DP)
36
Palpation non-invasive blood pressure measurement
Palpating return of arterial pulse when occluded cuff is deflated. Underestimates Sys pressure. Only measures SBP
37
Doppler BP
Based on shift in frequency of sound waves. Only measure SBP
38
Auscultation
Using sphygmomanometer, cuff and stethoscope. Listening to Kortokoff sounds d/t turbulent flow. Estimation of SBP and DMP
39
Oscillometry
Senses oscillations/fluctuations in cuff pressure produced by arterial pulsations when deflating BP cuff. 1st oscillation is SBP. Last is DBP. Automated cuffs work this way.Derives MAP, SBP, DBP by algorithm
SBP and DBP algorithm vary by manufacturer.
Less reliable than values for MAP
Oscillometry methods often underestimate systolic an overestimate diastolic significantly reducing PP calculations
40
How should the NIBP Cuff fit?
Width is 40% circumference of extremity. Length should encircle 80% extremity
Applied snugly, with bladder centered on artery and residual air removed
41
Falsely high BP MEASUREMENT caused by...
- Cuff too small,
- too loose,
- extremity below level of heart.
- Arterial stiffness- HTN, PVD
42
Falsely low BP
- Cuff too large
- Extremity above level of heart
- Poor tissue perfusion
- Too quick deflation
43
Erroneous BP measurements with
Dysrhythmia, tremor/shivering
44
Complications of NIBP measurement
```
=Pain
-Petechia and ecchymoses
-limb edema
-venous stasis
- peripheral neuropathy
- compartment syndrome
—- pt with peripheral neuropathy, arterial or venous insufficiency, severe coagulopathies or recent use thrombolytics more prone to complications
```
45
What does arterial line measure?
Systemic arterial pressure waveform from ejection of blood from LV into aorta during systole, with peripheral runoff during diastole
Transducer to convert generated pressure into electiv signal to provide a waveform
46
Complications Risk of Arterial line
```
Overall low risk.
Increased risk:
- vasospastic arterial dx
- previous arterial injury
-thrombocytes is
-protracted shock
-high dose vasopressin administration
- prolonged cannulation
-infection
```
47
Allen tat
Occlude both radial and ulnar arteries, have pt make tight fist. Then have patient open hand, release ulnar artery and watch for color to return to palm with radial artery occluded
48
Indications for a line
- elective and deliberate hypotension
- wide swings intra op BP
- risk of rapid BP changes
- rapid fluid shifts
- titration vasoactives
- end organ dx
- repeated blood sampling
- failure of indirect BP measurement
49
Zeroing a line transducer
Phlebostatic axis at 4th intercostal space mid axillary line.
50
What will Aline reading be if transducer is high/low
High transducer= low readings
Low transducer= high reading
20 cm diff makes 15 mmHg difference in arterial line
51
As arterial line location changes...
Further away from heart, more defined systolic peak. Diacritic notch is further out on downslope
52
What to check for with Overdamped
```
Looks connections
Air bubbles
Kinks
Blood blots
Arterial spasm
Narrow tubing
```
Overdamped wave form will appear flat
53
What to check/look for if Underdamped
```
Will show peaked wave with whip
Catheter whip or artifact
Stiff non-compliant tubing
Hypothermia
Tachycardia/dysrhythmia
```
54
Square wave test
2 oscillations only before normal waveform
55
Aline complications
```
Distal ischemia, psuedoaneuysm
Hemorrhage
Arterial mobilization
Infection
Peripheral neuropathy
Misuse of equipment
```
```
Nerve damage
Thrombosis
Air embolus
Skin necrosis
Loss of digits
Vasopasm
Retained guide wire
```
ASA closed claims 54% r/t radial artery (ischemic injury, radial nerve or retained wire fragment) others were related to femoral artery (thrombotic/hemorrhagic events)
56
Aortic stenosis shows as what on a line?
Slow upstroke (pulsus tardus) and narrow pulse pressure (pulsus parvus)
57
Aortic regurgitation shows as what on a line?
Double peak (biferiens pulse) with wide PP
58
Hypertrophic CMP on Aline?
Spike and dome
59
Pulsus alternans
Alternating pulse pressure amplitude. Seen in sys lV failure
60
Pulsus paradoxes
Seen in cardiac tamponade. Exaggerated decreases in sys BP with inspiration
61
Type of law pulse oximeter uses?
Beer- Lambert Law
62
Wavelength of pulse ox?
660 (unoxygenated) and 940 nm (oxygenated)
63
When in pulse ox inaccurate?
```
Malposition of probe
Dark nail polish
Different hemoglobin
Dyes
Electrical interference
Shivering
```
64
Ocyhemoglobin dissociation curve
Affinity of o2 to hgb
65
Left shift
Wants to hold onto o2 (Alkalosis, hypocardbia, hypothermia,
66
Right shift
Let’s go of o2 readily. Acidosis, hypercarbia, hyperthermia
67
CVC indications
```
CVP monitoring
PA monitoring
Transvenous cardiac pacing
Temporary HD
Drug admin of chemo, vasopressors, hyperalimentation.
Prolonged abs
Rapid infusion of fluids
Aspiration of air emboli
```
Basic nursing care
Blood sampling
Diagnostic measurements
PACING
68
Preferred site for cvc
RIGHT IJ
69
Where should CVC be?
Ideally, tip just within SVC, just above junction of VC and RA, parallel to vessel walls
Inferior border of clavicle, above level of 3rd rib. T4/T5 interspace. Carina
70
Contraindications of CVC
R atrial tumor
Contralateral pneumothorax
Infection at site
71
Complications of CVP monitoring
```
Mechanical injury (vascular injury , arterial and venous, CARDIAC TAMPONADE)
Respiratory compromise (airway compression, pneumonia)
Nerve injury
Arrhythmia
Thromboembolic (PE, VT)
Infection
Misinterpretation of data
RETAINED GUIDEWIRE
```
Captain CV
72
Normal CVP in awake, breathing
2-7 mmHg
73
Normal CVP with mechanical ventilation
Rises 3-5 mmHg
5-12 normal
74
CVP waveform peaks?
A,c,v
75
CVP waveform descents?
X,y
76
Cardiac cycle phases
```
Atrial contraction
Isovolumetric contraction
Ventricular ejection
Isovolumetric relaxation
Ventricular filling
```
77
“A” wave on CVP
- Caused by atrial contraction. -Follows p wave on EKG.
- At end diastole.
- Corresponds with atrial kick and causes filling of RV
78
“C” wave CVP
- Due to isovolumetric contraction (right side) which causes closing of tricuspid valve and bulges back into right atrium.
- Occurs in early systole
79
“X” descent in cvp
- Systolic decrease in atrial pressure due to atrial relaxation
- Mid-systolic event
80
“V” wave in CVP
- Ventricular ejection which drives venous filling of atrium.
- Late systole with triscupid valve CLOSED
- Occurs just after t wave in EKG
81
Y Descent in CVP
Diastolic decrease in atrial pressure due to flow across open tricuspid valve
-early diastole
82
Size of pA cath
7 for. 110 cm in length with 4 lumens
83
Indications of PA cath
- LV Dysfunction
- valvular dx
- plum htn
- CAD
- ARDS
- Shock/sepsis
- ARF
- Sx procedures
84
PA cath complication
```
-Arrhythmia (vfib, RBBB, CHB)
Catheter knotting
Balloon rupture
Pneumonia
Pa rupture
Infection
Damage to cardiac structures
```
85
Normal vena cava distance with PA
15
86
RA distance with PA
15-25
87
RV distance
25-35
88
PA distance
35-45
89
Wedged PA distance
40-50
90
How do PA wedge waveform compare to CVP?
More damping through pulmonary system so less distinct waveforms., Events come much later. (Line up with t wave more or less)
91
PCWP waveform a wave
Contraction of left atrium. Small deflection unless resistance to blood moving as with mitral stenosis
92
PCWP C waveform
Due to rapid ris in LV pressure in early systole. Mitral valve bulges into LA
93
PCWP v waveform
Blood enters LA during late systolie
94
Prominent v wave on PCWP
Shows mitral insufficiency d/t large blood going back into LA DURING SYSOTLE
95
SV normal
60-90
96
SVR normal
800-1200 dynes, 10-20 wood units
97
PVR normal
0.5-3
98
MVO2
70-80
99
Co NORMAL
4-6.5
100
SBP NORMAL
90-140
101
DBP normal
60-90
102
MAP normal
70-105
103
Systolic pressure variation
5
104
PPV
10-13%
105
RV PRESSURE
15-30/8
106
PA pressure
15-30/5-15
107
Mean PA pressure
9-20
108
PCWP normal
6-12
109
LA Pressure
4-12
110
SPO2
95-100
111
Co
4-8 L/MIN
112
CI
2.4-4 L/MIN/M2
113
Peak inspiratory pressure normal
15-20
114
TV normal
6-8 mL/kg of IBW
115
ETCO2 normal
35-40 mmHg
116
ICP normal
5-15 mmhg
117
BIS normal (awake)
80-100
118
What is standardized gain on EKG?
1mV= 10 mm calibration
Therefore 1 mm ST segment change is accurately assessed
119
How does oscillometry BP work?
Senses oscillations/fluctuations in cuff pressure
1st oscillation correlates with SBP
MAXIMAL degree of detectable pulse is the mAP
Oscillations cease at DBP
With oscillometry methods underestimate systolic and overestimate diastolic
Underestimate mean values during HTN
Overestimate mean during hypotension
120
How long do you want to see color return in the Allen test?
6-10 seconds
121
4 ways of NIBP (General)
Palpation
Doppler
Auscultation
Oscillometry
122
How can you improve system dynamics and accuracy with arterial line?
```
Minimize tube length
Limit stop cocks
No air bubbles
Mass of fluid small
Use non compliant, stiff tubing
```
123
When does the systolic upstroke of the arterial line start?
180 seconds after R wave.
124
What happens during interval b/w r wave and upstroke of arterial line?
Depolarization of ventricular myocardium
Isovolumetric left ventricular contraction
Opening of aortic valve
Left ventricular ejection
Propagation of aortic pressure wave
Transmission of the signal to pressure transducer.
125
What are the actions for damped waveforms on Aline?
```
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable
```
126
Talk about pulse pressure variation
PPV is calculated as diff between maximal PPmax and PPmin pulse pressure during single respiratory cycle, divided by average of these two values
PPmax 150-70= 80
PPmin 120-60= 60
PPV= PPmax-PPmin/((PPmax+PPmin)/2)
(80-60)/((80+60)/2)= 29%
Normal 9-13% >13% needs fluids <9% should not receive intravascular expansion if 9-13, uncertain if volume would be helpful or not
In order to measure PPV accurately: TV 8-10mL/kg, PEEP >5, regular cardiac rhythm, normal intraabdominal presure, closed chest
127
What happens with blood flow in heart during positive pressure ventilation?
Increase in lung volume compresses lung tissues, displaces blood within pulmonary venous reservoir into left heart chambers, this increases LV PRELOAD. Increase in intrathoracic pressure also decreases after load.
This increase in LV preload and LV afterload, produces an increase in LV SV, increase in CO, and arterial pressure.
128
What does ASA/AANA standards for basic monitoring require for pulse ox?
Variable Pitch tone must be audible when in use
129
What is the relationship between Sao2 AND pao2?
SaO2 is function of PaO2. The relationship b/w the two is described by O2Hb dissociation curve.
Curve is not linear, which means Sao2 CANNOT discriminate between normoxic and hyperoxic conditions.
SPO2 accuracy is reduced at values Lower than 70-75%
130
What is the gold standard for SaO2 measurements when pulse ox inaccurate/unobtainable?
Co-oximetry
131
Explain why the LIJ site is not preferred for CVC
- Cupola of pleura is high on left, increasing risk fo pneumothorax
- Thoracic duct might be injured during procedure as it enters venous system at junction of LIG and SCL vein
- LIJ is often smaller than right
- Injury might incur on right lateral walll of suprerior vena cava as the catheter transverse the left brachiocephalic vein and enter the SVC perpendicularly
132
How much blood remains in ventricle after ventricular systole?
50-60mL of blood or ESV (end systolic volume)
133
Size of pa Cather? Lumens?
```
7 French (introducer is 8.5 for)
110 cm length marked at 10 cm
```
```
4 lumens
-distal port PAP
Second port 30 cm more proximal to CVP
3rd lumen balloon
4th wires for temp thermistor
```
134
Size of CVC catheter?
7 French, 20 cm length
135
Uses of TEE in OR
```
Unusual causes of acute hypotension
Pericardial tamponade
Pulmonary embolism
Aortic dissection
Myocardial ischemia
Valvular dysfunction
Valvular function
Wall motion
```
136
7 cardiac parameters observed
1) Ventricular wall characteristics and motion
2) Valve structure and function
3) Estimation of end-diastolic and end-systolic pressure and volumes
4) CO
5) Blood flow characteristics
6) Intracardiac air
7) Intracardiac masses
137
Complications TEE
Esophageal trauma
Dysrhythmia
Hoarseness
Dysphagia
137
Types of cardiac output monitoring
```
Thermodilution
Continuous thermodilution
Mixed venous oximetry
Ultrasound
Pulse contour
```
138
Arterial oxygen content
16-20. Normal 18
139
Tell me about pulse ox
Method of measuring hemoglobin oxygen saturation (SPO2)
- Non invasive
- Measures transmission of light through a solution to the concentration of the solut in the solution (application of beer lambert law)
-Uses wavelengths of 660 (unoxygenated) and 940 (oxygenated)
Pulse oximeter is composed of light emitters and a photodectector
Use- hypoxemia and detection of perfusion
140
Effect of methylene blue on SPO2 relative to Sao2?
Decrease
141
Carboxyhemoglobinemia will do what to SPO2?
Increase
142
Methemoglobinemia will do what to SPO2
Constantly reads 85%
