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Week 3- Hemodynamic Monitoring Flashcards

(64 cards)

1
Q

Name Standards for Basic Anesthesia Monitoring

A
  • Oxygenation- skin color, Fio2, ABG
  • Ventilation-Breath sounds, chest rise,
  • Circulation- BP, invasive cath (Aline, PA), Pulse ox
  • Temperature
  • *All Continually Evaluated**
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2
Q

Basic Monitoring Techniques

A
  • Inspection
  • Auscultation
  • Palpation
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3
Q

Stethoscope

A
  • Continual assessment of breath sounds and heart tones
  • Precordial placed on chest surface
  • Esophageal placed 28-30 cm into esophagus
  • Very sensitive monitor for bronchospasm, airway obstruction, changes in HR/ rhythm
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4
Q

Purpose of ECG

A
  • Heart rate
  • Electrolyte changes
  • Arrhythmias
  • Pacemaker function
  • Ischemia
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5
Q

Explain the difference between 3Lead and 5Lead ECG?

A
  1. 3 Lead:
    - Electrodes RA, LA, LL
    - Leads I, II, III
    - 3 views of heart (no anterior view)
  2. 5 Lead:
    - Electrodes RA, LA, LL, RL, chest lead
    - Leads I, II, III, aVR ,aVL, aVF, V lead
    - 7 views of heart (adds anterior view)
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6
Q

Gain Setting and Frequency Bandwidth

A

*Gain should be set at standardization
-1 mV signal produces 10-mm calibration
pulse
- A 1-mm ST segment change is accurately
assessed

*Filtering capacity should be set to diagnostic
mode
- Filtering out the low end of frequency
bandwidth can distort ST segment

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7
Q

Indications of Acute Ischemia

A
  1. ST segment elevation, flat, depression, or downslope , ≥1mm
  2. Peaked T wave, and T wave inversion
  3. Development of Q waves
  4. Arrhythmias
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8
Q

In what leads will you see Ischemia to the Posterior/ Inferior Wall (RCA)?

A

Changes in LEAD II, III, AVF

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9
Q

In what leads will you see Ischemia to Lateral Wall (Circumflex branch of LCA)?

A

Changes in Lead I, AVL, V5-V6

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10
Q

In what leads will you see Ischemia to the Anterior Wall (LCA)?

A

Changes in the V3-V4

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11
Q

In what leads will you see Ischemia to the Anterio-septal wall (LDA)?

A

Changes in Lead V1-V2

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12
Q

What lead is best for Ischemia Detection?

A

V5

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13
Q

What lead is best for Arrhythmia Detection?

A

II

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14
Q

How do you calculate a MAP?

A

MAP-time weighted average of arterial pressure during a pulse cycle

MAP= SBP + 2 (DBP) ( OR) DBP + 1/3 (SBP-DBP)
———————
3

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15
Q

Systolic BP

A
  • Systolic BP-peak pressure generated during systolic ventricular contraction
  • Changes in SBP correlate with changes in myocardial O2 requirements
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16
Q

Diastolic BP

A
  • Diastolic BP-trough pressure during diastolic ventricular relaxation
  • Changes in DBP reflect coronary perfusion pressure
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17
Q

Pulse Pressure

A

Pulse pressure=SBP-DBP

Normal is 30-40

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18
Q

Non-Invasive BP Measurement

A
  1. Palpation- palpating the return of arterial pulse while on occluded cuff is deflated
    - Underestimates systolic pressure, simple, inexpensive, measures only SBP.
  2. Doppler- based on shift in frequency of sound waves that is reflected by RBCs moving through an artery
    - Measures only SBP reliably.
  3. Auscultation- using a sphygmomanometer, cuff, and stethoscope; Korotkoff sounds due to turbulent flow within an artery created by mechanical deformation from BP cuff (unreliable in HTN pts-usually lower)
    - Permits estimation SBP and DBP
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19
Q

Oscillometry

A

oscillations/fluctuations in cuff pressure by arterial pulsations on cuff deflation

  • 1st oscillation correlates with SBP
  • Maximum/ peak oscillations occurs at MAP
  • Oscillations cease at DBP
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20
Q

Automated BP Cuffs work by what mechanism?

A

Oscillometry: measure changes in oscillatory amplitude electronically, derives MAP, SBP, DBP by using algorithms.

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21
Q

What should the size of your NIBP cuff be?

A

-Bladder width is approximately 40% of the
circumference of the extremity

  • Bladder length should be sufficient to encircle at least
    80% of the extremity

-Applied snugly, with bladder centered over the artery and residual air removal

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22
Q

False High BP with….

A
  • Cuff too small
  • Cuff too loose
  • Extremity below level of heart
  • Arterial stiffness- HTN, PVD
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23
Q

False Low BP with ….

A
  • Cuff too large
  • Extremity above level of heart
  • Poor tissue perfusion
  • Too quick deflation

Note: Erroneous BP with with dysrhythmias, tremors/shiverying

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24
Q

Invasive BP- IABP (A- lines): how does it work? What does it measure?

A

Percutaneous insertion of catheter –> artery –> transduced -> convert generated pressure –> electrical signal –> waveform

  • Generates real-time beat to beat BP
  • Allows access for arterial blood samples
  • Measurement of CO/ CI/ SVR
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25
Indications for A-line
"FEWER RRT" ``` F- Failure of indirect BP E- Elective Hypotension W- Wide shifts in OR BP E- End organ damage R- Rapid fluid shifts ``` R- Rapid change in BP R- Repeated blood samples T- Titration of vasoactive meds
26
A-lines: gauge, sites
-Small angiocatheter- 20 gauge - Sites of insertion include radial, ulnar, brachial, femoral, dorsalis pedis, axillary - Radial artery most common (Allen’s test)
27
A-line Transducer
Transducer system- continuous flush device System dynamics and accuracy improved by minimizing tube length, limit stop cocks, no air bubbles, the mass of fluid is small, using non compliant stiff tubing -calibration at level of heart (mid-axillary line/right atrium or meatus of ear/circle of Willis if concerned about cerebral perfusion as in sitting pt)
28
Dicrotic Notch signifies what?
Closure of Aortic Valve
29
Complications with IABP...
"THIN SLAVER" T- Thrombosis H- Hematoma I- Infection N- Nerve damage ``` S-Skin necrosis L- Loss digits A- Arterial Aneurysm V- Vasospasm E- Embolism (Air) R- Retained Guidewire ```
30
What is a Pulse Oximeter and how does it work?
- Measuring hemoglobin saturation (Spo2) - MUST ALWAYS have variable pitch tone - noninvasive *****BOARD Question: HOW does it work? -Pulses red and infrared LEDs on and off several hundred times per second -Blood absorbs the infrared light (algorithm to compute a ratio of infrared signal and saturation)
31
Pulse Oximetry: Uses, Sites, Inaccuracies
1. Uses: - Detection of hypoxemia, perfusion 2.Sites: fingers, toes, nose, ear, tongue, cheek ``` 3.Inaccuracy Malposition of probe Dark nail polish Different hemoglobin Dyes Electrical interference Shivering ```
32
Indications of CVC?
"BRAVE PFIV" ``` B- Blood samples R-Right <3 filling pressure A- Assess fluid status V- Vasoactive drugs E- emboli (Air) removal ``` P- PAC (pulm art cath) F- Fluid administration I- insertion of transvenous pacer leads V- Vascular access
33
Main Insertion sites for CVC?
``` ****Right internal jugular vein Left internal jugular vein- higher risk of pneumo Subclavian veins- risk for pneumo External jugular veins Femoral veins-infection ```
34
Size CVC
- 7 french - 20 cm length - Multiport catheters most common
35
Where is CVC tip located?
* **Ideally, tip within the SVC, just above junction of venae cavae and the RA*** - parallel to vessel walls - positioned below the inferior border of clavicle and above the level of 3rd rib, the T4/T5 interspace, the carina, or takeoff right main bronchus
36
Confirming CVC placement in OR
- Placement usually not confirmed by XRAY in OR - Aspirate blood from all ports - After surgery, XRAY
37
Risks of CVC
Poor technique "Please Help! CVC DIE" Please- Pneumo/Hemothorax Help- Hematoma C- Carotid puncture V- Vascular damage C- Cardiac tamponade D- Dysrhythmias I- Infection E- Embolism (Air, Thrombo, Guidewire)
38
Contraindications CVC
"RIP" R- Right atrial tumor I- Infection at site P- Pneumothorax
39
CVP wave results from
results from ebbs and flows of blood in the right atrium.
40
CVP measures...
RAP= RV preload
41
CVP in spontaneously breathing pt
2-7mmHg
42
How much with CVP rise due to Mechanical Ventilation?
3-5mmHg
43
Name 5 Phasic Events for CVP waveform
3 Peaks: 1. A wave- maximal filling of R ventricle = RVEDP 2. C wave 3. V wave 2 Descents: X, Y
44
Measuring CVP
- should be done at end-expiration | - Machine= average of measurement
45
A Wave (CVP)
``` - Caused by atrial contraction (follows the P-wave on EKG) -end diastole - Corresponds with “atrial kick” which causes filling of the right ventricle **Peak is where you get the CVP measurement from** ```
46
C Wave (CVP)
- Atrial pressure decreases=atrial relaxation - right ventricular contraction: tricuspid valve closed bulges back into the right atrium - Inearly systole (after the QRS on EKG)
47
X Descent (CVP)
-Atrial pressure continues to decline during ventricular contraction due to atrial relaxation - “Systolic collapse in atrial pressure” - Mid-systolic event (Tricuspid valve now closed)
48
V Wave (CVP)
-Last atrial pressure increase is caused by filling of the atrium with blood from the vena cava - Occurs in late systole with the tricuspid still closed -Occurs just after the T-wave on EKG
49
Y Descent
-Decrease in atrial pressure as the tricuspid opens and blood flows from atrium to ventricle - “Diastolic collapse in atrial pressure”
50
Right-sided heart catheter (PAWP monitoring) used for direct bedside assessment of :
"CLIP M" C- CO L- LV filling pressure/function I- Intracardiac pressure (PAP, CVP, PCWP) P- PVR/SVR, pacing options M- Mixed venous O2 saturation
51
PAP Monitoring looks at what side of the heart?
LEFT
52
PAP Catheters
- SIZE 7 french (introducer is 8.5) - LENGTH: 110 cm length marked at 10 cm intervals * **Rarely used anymore*** - 4 lumens 1. distal port PAP 2. second port 30 cm more proximal CVP 3. third lumen balloon 4. forth wires for temp thermister
53
Indications for PAP Monitoring/Cath?
"PASS CLAV" P-Pulm HTN A- ARDS/ Resp Failure S- Sepsis/Shock S- Surgery (Cardiac, Aortic, OB) C- CAD L- LV dysfunction A- ARF V- Valvular dz
54
Complications of PA Catheter
"BAKE HEART CIPP" B-Balloon Rupture A- Arrythmias (V-Fib, RBBB, LV Heart block) K- Knotting Catheter E- Embolism (Air/Thrombo) Heart- Cardiac Structure damage C-Contraindication (WPW syndrome, LBBB) I- Infection (Endocarditis) P- PA RUPTURE P- Pneumothorax
55
Distances from RIJ vein to Distal Structures
``` Vena Cava and RA junction 15cm from skin RA 15-25cm RV 25-35cm PA 35-45cm Wedged pulmonary capillary 40-50cm ```
56
A Wave (PCWP)
-contraction of the LA Normally a small deflection unless there is resistance in moving blood into the left ventricle (mitral stenosis)
57
C Wave (PCWP)
- rapid rise in the LV pressure in early systole - mitral valve to bulge backward (closure) into the left atrium - atrial pressure increases momentarily
58
V Wave (PCWP)
-blood enters the LA during late systole.
59
Prominent V wave is indicative of...
-mitral insufficiency causing blood reflux into the LA during systole.
60
Cardiac Output Monitoring
"TUMP" T- Thermodiluation (Continuous) U- Ultrasound M- Mixed Venous Oximetry P- Pulse Contour
61
TEE: What are the 7 Cardiac Parameters Observed?
"VIBE VIC" V- Ventricular wall motion and characteristics I- Intracardiac Air B- Blood flow E- Est. Diastolic/Systolic End Pressure and volume (EF) V- Valvular structure and function I- Intracardiac Masses C- CO
62
TEE uses in the OR:
"WAV at THEM" W- Wall motion A- Aortic dissection V- Valvular function/dysfunction T- Tamponade (Cardiac) H- Hypotension (Acute) E- Embolism (Pulm) M- Myocardial Ischemia
63
Complications of TEE
"Don't Eat Hot Dogs" D-Dysrhythmias E- Esophageal trauma H- Hoarseness D-Dysphagia
64
Complication of NIBP
"I CUP PIE" I- IV drug administration (alt timing) C- Compartment syndrome U- Ulnar Neuropathy P- Petechiae/ Bruising P- Pain I- IV flow interference E- Edema