Kevin's Invasive and Noninvasive Monitoring Lecture (SIUE Nurse Anesthesia)
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| True or False. Pulse Ox tone is only needed for general anesthesia cases? | False. Tone is standard for all cases.
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| List the 4 monitoring modalities required for all cases. | 1) Pulse Ox
2) EKG
3) NIBP
4) etCO2 (with all deep sedation and GA cases)
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| What are the purposes for the following colored ports on a PA catheter? Blue, yellow, white, red. | 1) blue = CVP
2) yellow = PA machine
3) white = infusion port
4) red = balloon port
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| How much air should be infused into the balloon port? | 1.5 mL.
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| Should the balloon be inflated or deflated for insertion? | inflated. protects the myocardium from puncture.
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| How far away is the proximal infusion port from the tip of PA cath? | 30 cm
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| How far away is ventricular infusion port from tip of PA cath? | 20 cm
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| What is the purpose of the distal port of PA cath? Should it be flushed while in the patient? | Port where mixed venous samples and PAP are obtained. Should never be flushed when in patient.
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| Name some indications for PA catheter use. | Patient with cardiovascular disease
Surgery with cross clamping of aorta
Resp Failure
PE
Pneumonectomy
Significant fluid shifts (burns, AAA)
Sepsis
Continuous infusion inotropes or vasodilators
Pulmonary HTN
Cor Pulmonale
Bleomycin
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| Name some relative contraindications for PA cath. | 1) Left bundle branch block (risk complete heart block from stimulating rt ventricle)***
2) Wolff-Parkinson-White Syndrome
3) Ebstein’s Malformation (tachy arrhythmias)
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| List the distances to the junction of VC & RA for the common insertion sites of PA cath. | Subclavian 10 cm
Right Internal Jugular Vein 15 cm
Left Internal Jugular Vein 20 cm
Femoral Vein 40 cm
Right Median Basilic Vein 40 cm
Left Median Basilic Vein 50 cm
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| What are the distances to the structures from the VC to the PAWP starting from the RIJ. (Be able to calculate is insertion site is changed) | junction venae cavae & right atrium 15cm
right atrium 15-25cm
right ventricle 25-35 cm
pulmonary artery 35-45 cm
pulmonary artery wedge position 40-50 cm
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| What are the normal values for the rt atrial pressures and what do they estimate? | 1-10 mmHg. RVEDP.
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| What are the normal values for the rt ventricular pressures? | 15-30 mmHg / 0-8 mmHg
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| Name two ways you know the PA cath tip is in the RV. | 1) increased systolic pressure
2) dicrotic notch
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| Name two ways you know the PA cath tip is in the PA. | 1) increased diastolic pressure
2) dicrotic notch
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| Name two ways you know the PA cath tip is in the PAOP. | 1) decreased systolic pressure
2) disappearance of dicrotic notch
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| On a PA waveform what does the upstroke mean? | opening of pulmonic valve
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| On a PA waveform what does the dicrotic notch mean? | closure of pulmonic valve
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| What can cause elevated CVPs? | 1) RV failure
2) Tricuspid stenosis or regurgitation
3) Cardiac tamponade
4) Constrictive pericarditis
5) Volume overload
6) Pulmonary HTN
7) LV failure
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| What can cause elevated PAPs? | 1) LV failure
2) Mitral stenosis or regurgitation
3) Left-to-right shunt
4) ASD or VSD
5) Volume overload
6) Pulmonary HTN
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| When should PCWP be determined? | During expiration (pleural pressures equal atmospheric pressures)
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| What can cause elevated PAOP? | 1) LV failure
2) Mitral stenosis or regurgitation
3) Cardiac tamponade
4) Constrictive pericarditis
5) Volume overload
6) Ischemia
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| Name 4 complications with PA cath insertion. | 1) PA perforation/hemorrhage
2) Arrhythmia
3) Coiling
4) Complications associated with any CVC (PTX, cannulation of carotid, etc.)
5) Endocarditis
6) Bacteremia
7)Thrombogenesis
8) Pulmonary infarction
9) Pulmonary valve damage
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| What are the treatments for arrhythmia associated with PA cath insertion? | 1) reposition catheter
2) lidocaine IVP
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| What is the minimum frequency for BP monitoring for anesthesia? | 5 minutes
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| For NIBP measurement, is the MAP directly measured or calculated? | Directly measured. SBP and DBP are calculated.
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| How is the appropriate size for BP cuff determined? | height of cuff should be 40-50% of arm circumference.
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| What happens if cuff is too big/small? | too big = underestimation of BP
too small = overestimation of BP
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| What changes occur to BP when cuff placed more distally? | higher systolic and lower diastolic (wider pulse pressure)
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| Name two types of cases where cuff should be placed on lower extremities. | 1) bilateral mastectomy
2) thyroid case (surgeon will bump into BP cuff if it is on arm)
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| List 5 complications with NIBP. | 1) Damage peripheral nerves
2) Compartment syndrome
3) Mechanical problems
4) Artifacts
5) Damage underlying tissues
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| What method is gold standard for BP measurement? | arterial line
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| Indications for arterial line placement. | AAA
carotid endarterectomy
craniotomy
CABG
thoracic sx
obesity
labile BP
extreme high or low BP
shock
trauma
increased ICP
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| List preferred arterial line locations. | 1) radial (#1 tie)
2) ulnar (#1 tie)
3) femoral (#2)
4) axillary
5) dorsalis pedis (low complication rate but not as accurate)
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| Allen's Test | return of flow within 5 to 15 sec.
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| What happens to BP when transducer too low? | false increase BP
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| What happens to BP when transducer too high? | false decrease BP
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| How much flow of NS does transducer allow? | 3 ml/hr
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| True or False. Positive Allen's test means collateral flow? | False. NO SUCH THING AS POSITIVE OR NEGATIVE. DOCUMENT AS POSITIVE COLLATERAL FLOW INSTEAD.
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| Name 3 physiological parameters which arterial BP can give. | 1) volume status
2) contractility
3) SVR
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| True or False. SBP will increase and systolic waveform will have a sharper increase when SVR is increased. | False. Overall BP will improve, but the systolic will be decreased because there is more resistance to flow, therefore CO will decrease and SBP will be less.
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| What is the upstroke of arterial pressure waveform called? | anacrotic limb
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| What can the anacrotic limb tell about the patient? | 1) contractility
2) SVR
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| When does the anacrotic limb occur in relation to the EKG? | After the QRS
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| What does a sharp upstroke on an arterial pressure waveform show? | 1) good contractility
2) lower SVR
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| How does under dampening affect arterial pressure waveform? | overestimation of SBP and MAP
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| How does over dampening affect arterial pressure waveform? | underestimation of BP
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| What can cause over dampening? | 1) flexed wrist
2) low pressure on flush bag
3) clot
4) kink
5) air in tubing
6) tubing too long
7) tubing too compliant (using regular IV tubing instead of pressure tubing)
8) leak or disconnection of arterial line system
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| What are the risk of arterial line insertion? | Infection
Thrombus formation
Hematoma
Vasospasm
Embolization
Injury to adjacent nerves & veins
Ischemia
Loss of limb secondary to poor collateral circulation
Iatrogenic injuries
Acute blood loss
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| What can a TEE diagnosis? | 1) systolic wall motion abnormalities (MI)
2)vascular aneurysms
3) calculate ejection fraction
4) ventricular preload
5) measuring blood flow within heart chambers & across valves
6) intra-cardiac air
7) intra-cardiac masses
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| What happens to sound waves as they travel through tissue? | Become attenuated. Decrease in energy due to conversion into heat as they are reflected back. Amount of change correlates with density of tissue.
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| Is BIS a standard of care for anesthesia? | No
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| What do the BIS number correlate to with regards to anesthetic state? | 100 = awake
90-70 = light/moderate sedation
70-60 = deep sedation (low recall)
60-40 = general anesthesia
40-10 = deep hypnotic state
10-0 = flat-line EEG
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| What value should the BIS be kept above? | 40
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| What can cause the BIS to suddenly increase? | 1) increased stimulation
2) decreased anesthetic level
3) muscle twitching
4) shivering
5) pacemaker
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| What can cause the BIS to suddenly decrease? | 1) decreased stimulation
2) agent recently increased
3) neuromuscular blocking drug given
4) hypothermia
5) sudden significant drop in BP or other ischemia signs
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| When should the BIS be used? | Use with paralytics to ensure no recall.
Elderly patient,you can tell if you are over sedation the patient/run lower amount of agent.
Make sure deep enough to not move on surgical stem. if no paralytics.
Hypothermia
Can show signs of CVA sooner.
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| When should temperature be continually monitored? | 1) all pediatric patients
2) large volumes blood/IV fluids administered
3) deliberately cooling/warming patient
4) hypothermic patients
5) hyperthermia expected (fever, infection, allergic reaction)
6) surgical procedure
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| How does spinal anesthetic cause hypothermia? | creates generalized sympathectomy that leads to vasodilation and increased gradient heat loss. (peripheral heat insulates the core)
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| What is hypo/hyper/normothermia? | normothermia = core temp 37o C
hyperthermia = core temp >38o C
hypothermia = core temp < 36o C
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| What body part is dysregulated, causing loss of temp during regional and general anesthesia? | hypothalamus
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| When is temperature loss the greatest during anesthesia? | 1st hour
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| Name risk of hypothermia during anesthesia. | 1) wound infection
2) delayed healing
3) increased O2 consumption
4) increased sickling
5)increased MI incidence
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| How many phases of temp loss and describe them. | Phase 1: core temp decrease 1-2 degrees C in 1st hour.
Phase 2: core temp gradually declines over 3-4hr.
Phase 3: core temp equilibrates
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| What is the temp difference between core and periphery? | 2-4 degrees C.
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| Where is the best place to monitor temp? | Pulmonary Artery (unless open heart or bypass sx)
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| Where should esophageal temp probe be placed? | lower 1/3 of esophagus.
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| Where is the second best place to monitor temp? | urinary catheter
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| Is rectal temp same, lower, or higher then other central temps? | higher. also has lag time.
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| Why is tympanic temp good choice for site? | shares blood supply with hypothalamus
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| Does the axilla correlate well with core temp? | No.
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| When should the precordial stethoscope be used? | for every pediatric surgical case
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| What does precordial stethoscope measure? | continuous breath sounds and heart sounds.
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| Where should the precordial stethoscope be placed? | over the suprasternal notch.
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