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Perf Monitoring > test 9 continued > Flashcards

test 9 continued Flashcards

(45 cards)

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1
Q

Morbid Neurological Outcomes type 1

A

 Cerebral Death
 Non-fatal strokes
 New Transient ischemic attack (not causing permanent damage but is an indicator for bad things down the road)

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2
Q

Morbid Neurological Outcomes type 2

A

 New intellectual deterioration

 New seizures upon discharge (more seizures after surgery)

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3
Q

Type I Predictors

A

 Advanced age is the single greatest
 < 60 : 1% risk
 > 70 ; 4 to 9% risk
 Aortic atherosclerosis (calcified aorta)
 History of prior neurologic events – 15%
 Carotid stenosis
 # of GMEs

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4
Q

Type II Predictors

A

 Low cardiac output states/hypotensive states
 GMEs (size)
 Atrial arrhythmias
 Systolic Hypertension
 Diabetes mellitus (lack of control of glucose)
 Pulmonary Disease
 Excessive Alcoholism

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5
Q

Prevalence of CVS Complications

A

 Neuro Impairment: 6.1% (stroke, coma, seizures)
 Post-Op Delirium: 10-60%
-neurologic dysfunction after bypass results in a longer length of stay
-post-op psychometric testing scores 100%

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6
Q

when does the Incidence of Neurologic Dysfunction happen most in surgery (single greatest neurological stress)

A

-filling of the heart because there are many pocket inside the heart that have chances of bubbles

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7
Q

Surgical Technique to decrease Atheroembolism

A

 Epiaortic ultrasound
 Single Cross Clamp
 No touch techniques
 Paying attention

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8
Q

How do Perfusionists

Contribute

A

 Focal (embolism)
 Hypoperfusion
 Inflammation
 Global

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9
Q

How do Perfusionists

Contribute globally

A 
 Complete
    Cardiac Arrest
    Deep Hypothermic Circulatory Arrest
 Incomplete
    Hypotension
    Inadequate CPB flow
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10
Q

Factors Affecting Blood Oxygenation

A
  • Tailoring Oxygen Delivery

- Tailoring Oxygen Consumption

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11
Q

Tailoring Oxygen Delivery

A
  • Mean Arterial Pressure
  • CO2
  • Cardiac Index and Pump Flow
  • Hematocrit
  • Mechanical Issues
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12
Q

Tailoring Oxygen Consumption

A
  • Anesthetic Agent and Depth

* Temperature

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13
Q

Brain Monitoring

A

 Neurological exam
 Blood Pressure monitoring (doesn’t tell what is actually happening)
 EEG – Electroencephalogram
 BIS – Bispectral Index
 TCD – Transcranial Doppler
 ICP – Intra-cranial pressure monitoring
 SjVO2 – Saturation of Jugular Venous Oxygen
 SvO2 – Saturation of Venous O2 (global)
 rSO2 – REGIONAL SATURATION OF OXYGEN

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14
Q

Ways to help prevent brain injury

A

 EEG: Electroencephalogram
 BIS Monitoring: Bispectral Index
 Cerebral Oximetry

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15
Q

What is an Electroencephalogram (EEG)?

A
  • large footprint so rarely used
  • a lot of leads and need someone to read it
  • reads electrical activity on the surface of the brain but does not measure what is going on deeper in the brain
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16
Q

Alpha and Beta waves of EEG

A

-patient is awake

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17
Q

Theta and Delta waves of EEG

A
  • patient descends into sleep or a coma

- are not normally seen in awake patients unless pt has past cerebral injury

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18
Q

common abnormalities of EEG waves

A

15% of population show abnormalities due to old injuries

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19
Q

Clinical Usage

Study These Flashcards
A 
 Main Reason
    EPILEPSY (number 1 usage)
    Brain Tumors
    Stroke
    Focal brain disorders
 Secondary reason
    Diagnosis of coma
    Encephalopathies
    Brain death
20
Q

Disadvantages in the OR

Study These Flashcards
A

 Analysis is complex
 Distracting anesthesiologist from patient care
 any other electrical activity will affect this (machinery, skeletal and cardiac myofibrils)

21
Q

Bispectral Index (BIS)

Study These Flashcards
A

 Processed EEG information as a measure of sedative effects of anesthesia medications
 Information displayed every 10-15 seconds
 Graphical trend and numerical value
-cheap and easy to interpret

22
Q

BIS Monitoring

Study These Flashcards
A

 Allows anesthesia the ability to access the complicated EEG information during the case
 Uses easy numbering system to identify depth of anesthesia

23
Q

How does bispectral index work (4 things correlated)

Study These Flashcards
A
  1. degree of high frequency activation
  2. degree of low frequency synchronization
  3. degree of periods near suppression
  4. degree of periods completely suppressed
24
Q

BIS index

Study These Flashcards
A

 The index is a number

between 1 and 100 (100= wide awake)

25
Association between clinical states and BIS values
```  100 Awake  80 Light/Moderate Sedation  60 General Anesthesia  40 Deep Hypnotic State  20 Burst Suppression  10 Flat Line EEG -a BIS below 70 the pt will not remember things ```
26
Target BIS values
 Need to be tailored for each individual  Using opioid anesthesia (40-60)  Using opioid anesthesia on pump (Normally 25 to 35, TARGET to titrate to 45 - 55)
27
If the BP starts to increase, what is another thing you could do other than turn down your flow
-turn up the gas anesthetic
28
Why is the BIS important to us
 BIS helps us maintain our hemodynamics (doesn't tell a lot about the brain)  Reduction in primary anesthetic use  Reduction in emergence and recovery time  Improved patient satisfaction
29
Disadvantages of BIS
 It is a trending device  We can’t be responsible to treat the level of sedation  Often monitor only faces anesthesia
30
Transcranial Cerebral | Oximetry
 measures not only surface, but down into the brain. Non-invasive and measures the oxygen metabolism in terms of how much oxygen the brain is pulling off of each hemoglobin.
31
The INVOS System clinical benefits
 Noninvasive, continuous, direct, real time measurements of the oxygen hemoglobin extraction done by the brain  Site-specific (regional) measure vs systemic; often signals earlier warning of reversible ischemia  Need to set a BASELINE otherwise you don't know if you are high or low  Not a trending device, it tell you if have a problem  Major improvement on Major Organ Morbidity or Mortality percent
32
Adult Applications of INVOS to Date
```  Cardiac surgery  Vascular surgery  Cardiac cath lab  Neurology / Neurosurgery  ER / traumatic brain injury  General surgery  Spinal injury ```
33
Pediatric Applications of INVOS to | Date
 Cardiac surgery  ECMO (Extracoporeal Membrane Oxygenation)  Cardiac Cath lab (at times)  Neurology / Neurosurgery  Still being studied – must convince the caregivers that the data is useful  Sensors are improving (much work to do)
34
Placement of the Sensors
* Clean area with alcohol - let it dry * Attach sensors above the eye brows * Connect to machine * SET BASELINE (very important to set baseline before anesthesia induction and nasal oxygen)
35
How optical technology works
- Infrared shoots through the head and the different levels of oxygenated hemoglobin absorb the infrared light - it tracks out the surface absorption and the deeper absorption
36
INVOS measures adequacy of cerebral perfusion giving you
- supply of blood to the brain - supply of O2 to the brain - any inflow or outflow obstructions
37
Cerebral Inflow Issues
* Head Position * Heart Position * Arterial Obstruction (Carotid Disease, Clamp, Hand, Sponge) * Cannula Malposition
38
1. Cerebral rSO2 detects O2 supply issues associated with inflow obstructions
1. rule out mechanical cause (head position or cannula position)
39
2. Cerebral rSO2 detects O2 supply issues associated with oxygen delivery
- Increase blood pressure - Increase FiO2 - Increase cardiac output (pump flow) - Increase hematocrit
40
3. Cerebral rSO2 detects O2 supply issues associated with oxygen delivery: decrease demand (cerebral metabolism)
- Increase anesthetic | - Decrease temperature
41
cerebral supply issues
* Low FiO2 * Low Hgb * Low MAP * Pump Flow * Spasm
42
rSO2 Target & Thresholds | Intervention threshold
-rSO2 < 50 or 20% drop from baseline -need to start making people aware -look at the 3 step algorithm
43
rSO2 Target & Thresholds | Critical threshold
-rSO2 < 40 or 25% drop from baseline -longer your values below critical thresholds, are related to your cerebral outcomes
44
Regional Oximetry
- not invasive | - not just trending values, actually gives real time things that are happening
45
What you can do to protect your patient’s brain?
 Medical History  Monitor for cerebral ischemia  Use filters on heart lung machine for embolic phenomena  Use glucose free fluids to avoid significant hyperglycemia  Maintain controlled temperature  Maintain appropriate perfusion pressure and flow during CPB  Consider pharmacologic brain protection  Utilize brain hypothermia during periods of reduced flow or perfusion pressure  Perform left ventricular de-airing methods  Ensure high normal postoperative blood pressures

Perf Monitoring (6 decks)

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