Term
| What are the 4 essential features of monitoring? |
|
Definition
1.observation and vigilance
2.Instrumentation
3.Interpretation of data
4.Initiation of corrective therapy if indicated |
|
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Term
| The most important aspect of monitoring is ________. |
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Definition
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Term
| T/F. There are times in anesthesia that it may be acceptable to go under the standards of care, such as emergencies. |
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Definition
|
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Term
|
Definition
| qualified anesthesia personnel shall be present in room throughout entire anesthetic (MAC, General, or Regional) |
|
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Term
|
Definition
| During all anesthetics patients oxygenation, ventilation, circulation, and temperature shall be continually evaluated |
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Term
| What is the single most important monitoring device other than the anesthetist? |
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Definition
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Term
| How do we ensure adequate oxygenation? |
|
Definition
| Inspired oxygen analyzer (if on vent), pulse ox, visual inspection of color, cap refill, etc. |
|
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Term
| How do we ensure adequate ventilation? |
|
Definition
Auscultation, chest excursion, ETCO2**
If on vent you must have disconnect alarm and volume monitoring alarms on! |
|
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Term
| How do we ensure adequate circulatory function? |
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Definition
| EKG, BP & HR q5min, palpation of pulse, heart sounds, monitor aline tracing if available, ultrasound peripheral pulse monitoring, pulse ox, visualization of pt |
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Term
Which monitoring device should you put on first?
Which should come off last? |
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Definition
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Term
| What is an oxygen analyzer |
|
Definition
| device on inspiratory limb of ventilator that measures % of O2 being delivered to patient. |
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Term
| What are the main instances in which you would see 30% or less oxygen given to a patient? |
|
Definition
1. Heliox
2. mix of 70% N2O and 30% O2
3. have patient on RA d/t airway surgery with bovie |
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Term
| What does pulse oximetry measure? |
|
Definition
| The % of hemoglobin saturated with oxygen |
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Term
| Which absorbs more infrared light, oxyhemoglobin or deoxyhemoglobin? |
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Definition
|
|
Term
| which absorbs more red light, oxyhemoglobin or deoxyhemoglobin? |
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Definition
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|
Term
A) Red light--> deoxyhgb (__nm)
B) Infrared light-->oxyhgb (__nm) |
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Definition
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Term
| What will the O2 sat show up as if the patient has methemoglobinemia? |
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Definition
| ~85% regardless of what actual o2 saturation is. |
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Term
| True or False. Methemoglobin absorbs infrared and red light equally |
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Definition
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Term
| What patients have high levels of carboxyhemoglobin? |
|
Definition
| Smokers, burn patients (smoke inhalation), people in urban populations |
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Term
| What factors alter pulse ox readings? |
|
Definition
| Hypothermia (local vasoconstriction), hypotension, bright light, shivering, methylene blue, venous congestion, nail polish, metHgb, carboxyHgb, motion/electrical interference, malposition |
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Term
Does CarboxyHgb has an absorption spectrum similar to oxyhemoglobin or deoxyhemoglobin?
Why is that significant? |
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Definition
| oxyhemoglobin, so will cause pulse ox to OVERREAD O2 sat in someone with high level of carboxyhemoglobin in arterial blood. |
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|
Term
| What will someone with late signs of carboxyhemoglobinemia look like? |
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Definition
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Term
| What is the Beer-Lambert law? |
|
Definition
| Relates the concentration of a solute to the intensity of light transmitted through a solution |
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Term
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Definition
| A form of hemoglobin in which the iron in the heme group is in the ferric state (Fe3+) (due to oxidation) instead of the normal ferrous state (Fe2+) and cannot carry oxygen. |
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Term
| What are the causes of methemoglobin? |
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Definition
| Can be congenital or acquired. If acquired it is caused by nitrobenzene, benzocaine, prilocaine, and dapsone. |
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Term
| What are the signs & symptoms of methemoglobinemia? |
|
Definition
| Brownish gray cyanosis, tachypnea, metabolic acidosis (all r/t tissue hypoxia), LOC in 50-60% cases |
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|
Term
| Treatment for methemoglobinemia |
|
Definition
Spontaneous reversal occurs without treatment about 2-3 hrs after last local anesthetic dose.
Immediate reversal is methylene blue 1 mg/kg (turns Fe3+ in heme to Fe2+) |
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|
Term
| T/F. Blood pressure is a measurement of end organ perfusion. |
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Definition
| False. It is an INDICATOR, but not a direct measurement. |
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|
Term
| Where should you avoid putting a blood pressure cuff? |
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Definition
| Arm where someone has had a mastectomy with lymph node involvement, vascular access sites, surgical sites, sites with injury/neuropathy |
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|
Term
| How tight should you put the BP cuff? |
|
Definition
| You should be able to slip one finger underneath the cuff |
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|
Term
| How do you determine what size BP cuff to use on someone? |
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Definition
| The cuff should be 20% greater than the diameter of the limb and cover 2/3 of ther upper arm or thigh. |
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Term
| Will an over-sized cuff give you falsely high or low readings? |
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Definition
| Will give you falsely low readings. An undersized cuff will give you falsely high readings |
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|
Term
What happens to BP readings as you put the cuff more distal?
What does this mean for pulse pressure? |
|
Definition
The more distal the cuff is, the HIGHER the systolic pressure will read and the LOWER the diastolic pressure will read.
Pulse pressure will WIDER. |
|
|
Term
| How does BP reading change depending on where the cuff is in relation to heart (higher/lower)? |
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Definition
| The it will change by ~0.7 mmHg for each cm off the horizontal plane of the heart. If the cuff is higher, the reading will be lower and vice versa |
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|
Term
| How fast should you deflate a BP cuff? |
|
Definition
| 2-3 mmHg per heart beat OR 3-5 mmHg per second |
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|
Term
| What are Korotkoff sounds? |
|
Definition
| sounds produced from volatile or turbulent blood flow against arterial walls during the measurement of BP (using the classic method with a stethoscope and sphymomanometer) |
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Term
| Automatic BP cuffs measure ____________. |
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Definition
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|
Term
| What is the point at which oscillations is maximal during automatic BP cuff measurement? |
|
Definition
|
|
Term
| How do you calculate MAP? |
|
Definition
| [systolic + (diastolic x 2)]/3 |
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|
Term
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Definition
| Test used to determine adequacy of ulnar collateral flow and integrity of radial artery. Performed before arterial puncture/cannulation. |
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|
Term
| How soon should hand return to pinkish color after releasing pressure from ulnar artery? What if it does not return in that amount of time? |
|
Definition
5-6 secs.
DO NOT cannulate/puncture radial artery in the arm. |
|
|
Term
| Where should the transducer for an aline be leveled in a patient in the seated position? Why? |
|
Definition
| to the mid ear (circle of willis). So we have an indication of cerebral perfusion/pressure. |
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|
Term
| What is the technique for arterial cannulation? |
|
Definition
1. apply armboard and hyperextend thumb/wrist
2. palpate radial artery
3. clean site/dry
4. 1-2% lidocaine skin wheal (with TB syringe or 25g catheter)
5. sterile gloves
6. Insert needle at 45 deg. angle--> flashback --> flatten angle--> advance guidewire (if applicable)--> adv. catheter over guidewire/needle--> occlude above site--> attach tubing--> suture/secure |
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|
Term
| What are the complications of arterial cannulation? |
|
Definition
| thrombosis, hematoma, bleeding, vasospasm, air embolism, necrosis/ischemia, nerve damage, infection, intra-arterial drug injection. |
|
|
Term
| What are the parts of an arterial waveform and what does each signify? |
|
Definition
1. slop of upstroke: Myocardial contractility
2. Peak of wave: systolic pressure
3. Dicrotic notch: aortic valve closure
4. Diastolic decay curve: indicates resistance to flow |
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|
Term
| T/F. Mechanical activity happens BEFORE electrical activity on a waveform. |
|
Definition
|
|
Term
| What are the most commonly used EKG leads? |
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Definition
|
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Term
| ST segment depression of ____ and st elevation with ____t waves are of concern. |
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Definition
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Term
| Which lead will give you better diagnosis of arrhythmias and which is most sensitive for ischemia? |
|
Definition
arrhythmias= lead II
ischemia= lead V |
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Term
| What should you always do (related to EKG) prior to induction |
|
Definition
| Make not of baseline rhythm! |
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|
Term
| What should you always do (related to EKG) prior to induction |
|
Definition
| Make not of baseline rhythm! |
|
|
Term
Which lead is best for detecting:
a. inferior wall ischemia
b. anterior&lateral wall ischemia |
|
Definition
|
|
Term
| rank the amount of filtering from greatest to least depending on type of mode you are set at. |
|
Definition
| Filter mode, monitor mode, diagnostic mode |
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|
Term
A. which mode is best for assessing acute changes or pts at risk for ischemia?
B. Which mode can you often miss acute changes in? |
|
Definition
A. Diagnostic mode
B. Filter mode |
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|
Term
| This monitor device is a good tool to use when transporting a patient to and from OR? |
|
Definition
|
|
Term
|
Definition
1. placed in lower 1/3 of esophagus
2. most accurate measure of temp (other than thermoster of PA cath)
3. Do not use in patient with esophageal varices
4. has earpiece to listen to continuous heart and breath sounds |
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|
Term
| Why do patient have trouble remaining normothermic during anesthesia? |
|
Definition
| Because anesthesia blunts the hypothalamus' ability to control body temperature |
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|
Term
| This monitoring device gives the BEST indicator of core temp. |
|
Definition
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|
Term
|
Definition
| measurement of the hydrostatic pressure generated by the blood within the right atrium or great vessels adjacent to RA. |
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|
Term
| CVP is estimated by analyzing what 2 factors? |
|
Definition
| Preload and ability of right ventricle to pump blood through pulmonary circulation |
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|
Term
| CVP is estimated by analyzing what 2 factors?mm |
|
Definition
| Preload and ability of right ventricle to pump blood through pulmonary circulation |
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|
Term
| What is the normal CVP range? |
|
Definition
| 1-15 mmHg (Danelle said more like 6-8 mmHg) |
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|
Term
| Is CVP a reflection of LVEDP? |
|
Definition
| No it is a reflection of Right Ventricular end diastolic pressure (RVEDP) |
|
|
Term
| What are the indications for Central Venous catheters? |
|
Definition
Major operative procedures involving large fluid shifts and / or
blood loss
Intravascular volume assessment when urine output is not reliable or unavailable (i.e. renal failure)
Major trauma
Surgical procedures with a high risk of air embolism, such as
sitting position craniotomies. In addition to monitoring, the central
venous pressure (CVP) catheter may also be used to aspirate intracardiac air.
Frequent venous blood sampling
Venous access for vasoactive or irritating drugs
Chronic drug administration
Inadequate peripheral IV access
Rapid infusion of IV fluids (using large cannulae)
Special Uses: insertion of PA catheters, insertion of transvenous pacing wires, hemodialysis/plasmapheresis |
|
|
Term
| What are the contraindications for CVC? |
|
Definition
Infected tricuspid valve vegetations
Renal cell tumor extension into R atrium
Ipsilateral CAE
Anticoagulation
SVC syndrome
Infection at the site of insertion
Newly inserted pacemaker wires
Presence of carotid disease
Contra lateral diaphragmatic dysfunction
Thyromegaly or prior neck surgery |
|
|
Term
| T/F. CVP parallels Right atrial pressure? |
|
Definition
| TRUE. it is influenced by RVEDP |
|
|
Term
|
Definition
A wave: right atrial contraction (occurs just after P wave on EKG)
C wave: Occurs due to isovolumic ventricular contraction forcing the tricuspid valve to bulge upward into right atrium (happens just after R wave)
V wave: reflects venous return against closed tricuspid valve (just after T wave) |
|
|
Term
| When will you see large V waves? |
|
Definition
| In someone with Tricuspid regurgitation |
|
|
Term
| When inserting an IJ CVC should you stick the needle medial or lateral to the carotid artery? |
|
Definition
|
|
Term
| Landmarks for IJ CVC insertion |
|
Definition
1. find triangle formed by sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle
2. find carotid pulse within that triangle
3. Go lateral to the carotid and aim needle toward ipsilateral nipple
4. follow rest of seldinger technique |
|
|
Term
| What are the complications of CVC's? |
|
Definition
1. arterial puncture with hematoma
2. pneumo/hemothorax
3. nerve injury (brachial plexus, stellate ganglion-horners syndrome)
4. air emboli
5. catheter or wire shearing
6. complications of catheter presence
thrombosis
thromboembolism
infection, sepsis, endocarditis
arrhythmias
hydrothorax |
|
|
Term
| What is the main indication for PA catheter? |
|
Definition
|
|
Term
| What is the technique for PA cath insertion? |
|
Definition
1. seldinger technique for introducer
2. sheath over swan (flushed/checked)
3. insert until ~20 cm
4. inflate balloon and advance until you see RV waveform (30-35 cm)
5. continue to advance to PA (40-45 cm)
6. balloon will wedge at ~50 cm. When you see wedge waveform deflate balloon |
|
|
Term
| What are the contraindications for PA cath insertion? |
|
Definition
1. LBBB- will put pt in complete HB if you damage RBBB during insertion
2. TV or PV stenosis
3. RA or RV mass
4. tetralogy of fallot |
|
|
Term
| What additional complications are associated with PA cath insertion as opposed to CVC insertion? |
|
Definition
| cardiac perforation, cardiac dysrhytmia/heart block, knotting |
|
|
Term
| ______ has reduced the need for reoperation and has facilitated the prevention and early treatment of perioperative complications |
|
Definition
|
|
Term
|
Definition
pharyngeal or laryngeal trauma
dental injuries, esophageal trauma/bleeding, arrhythmias, respiratory distress, hemodynamic instability. |
|
|
Term
| What are the waves of an EEG and what do they mean? |
|
Definition
Alpha: eyes closed but awake
Beta: Normal, awake waveform
Delta: Deep sleep
Theta: Sleep (not deep) |
|
|
Term
| What are EEG waveforms affected by? |
|
Definition
Temperature, BP, and pH
Anesthetics cause a combination of slow frequencies and superimposed fast activity. Also as depth of anesthesia increases, EEG becomes slower |
|
|
Term
|
Definition
<40: cortical suppression
40-65: general anesthesia; deep hypnosis
65-85: sedation
85-100: awake; memory intact |
|
|
Term
| T/F. BIS monitoring has shown to decrease intra-op recall. |
|
Definition
|
|
Term
| In what cases is recall most common? |
|
Definition
| Trauma, cardiac surgery, and emergency OB procedures. |
|
|
Term
| What are evoked potentials? |
|
Definition
Evaluate integrity of neural pathways by monitoring response to stimulus.
Electrical potentials are generated in response to stimulation of a peripheral or cranial nerve and are recorded as they travel from periphery to brain (afferent pathway) |
|
|
Term
| When discussing evoked potentials, what is amplitude and latency? |
|
Definition
amplitude: intensity of response
latency: length of time from stimulation to time it reaches brain. |
|
|
Term
| What happens to amplitude and latency if there is a damaged pathway to brain? |
|
Definition
| amplitude decreases and latency increases. |
|
|
Term
| what is the most common type of evoked potential performed? |
|
Definition
| somatosenory evoked potentials (SSEP): peripheral nerve stimulated, potential recorded over spinal cord or brain |
|
|
Term
What area of the body are we assessing with SSEPs?
What are popular cases where SSEP is performed? |
|
Definition
| Dorsal horn of the spinal cord |
|
|
Term
| What is the sensory portion of our spinal cord?** |
|
Definition
| The posterior/dorsal portion** |
|
|
Term
| What are the 4 types of evoked potentials? |
|
Definition
SSEP: stimulate peripheral nerve and record evoked potential over DORSAL (posterior) spinal cord or brain-- afferent pathway
Brainstem auditory evoked potentials (BAEP): Reflect impulses along auditory pathway (cranial nerve 8)
Visual evoked potentials (VEPs): measure cerebral response to flashing light (not common)
Motor evoked potentials (MEPs): Detect motor function of VENTRAL (anterior) spinal cord-- efferent pathway |
|
|
Term
| which evoked potential is the most RESISTANT to anesthesia? |
|
Definition
| BAEP because hearing is the last thing to go in anesthesia |
|
|
Term
| which evoked potential is the most SENSITIVE to effects of anesthesia? |
|
Definition
|
|
Term
| What surgeries will you see SSEPs performed on? |
|
Definition
TAAA repair (d/t clamping of aorta which supplies spinal cord)
A/P spinal fusions
Harrington rods
complex back surgeries |
|
|
Term
| What surgeries will you see BAEPs performed on? |
|
Definition
posterior fossa craniotomies
acoustic neuromas (CN VIII) |
|
|
Term
| What surgeries will you see VEPs performed on? |
|
Definition
Surgery near optic nerve (CN II)
pituitary tumor resections |
|
|
Term
| What surgeries will you see MEPS performed on? |
|
Definition
TAAA repair (d/t clamping of aorta which supplies spinal cord)
Spinal surgeries |
|
|
Term
| What surgeries will you see MEPS performed on? |
|
Definition
TAAA repair (d/t clamping of aorta which supplies spinal cord)
Spinal surgeries |
|
|
Term
| _______ anesthetics effect all evoked potentials by ________________. |
|
Definition
| Volatile; decreasing amplitude and prolonging latency |
|
|
Term
| What is the GOLD STANDARD of ETT placement and verification? |
|
Definition
|
|
Term
| What is the normal ETCO2 for a healthy patient? |
|
Definition
|
|
Term
| What if no CO2 detected on capnography? |
|
Definition
| assume failure to ventilate |
|
|
Term
| When analyzing ETCO2 waveform, what are the 4 phases you should see? |
|
Definition
phase 1: inspiration (no CO2, breathing in O2) "A-B"
phase 2: Expiratory upstroke (beginning to exhale) "B-C"
Phase 3: Expiratory plateau (static period-- no air moving in or out)"C-D"
phase 4: Inspiratory downstroke (fresh gas entrained; CO2 washed away) "D-E" |
|
|
Term
|
Definition
|
|
Term
| If B-C is leaned over instead of having a rapid upstroke, what could that indicate? |
|
Definition
They are having trouble blowing off CO2:
COPD, kinked tube, foreign body onstruction, emphysema |
|
|
Term
What is a curare cleft?
What does it indicate? |
|
Definition
A dip/V-form in the middle of the ETCO2 waveform caused by spontaneous ventilation.
The patient may soon be ready to extubate or you need to re-paralyze |
|
|
Term
| What are cardiac oscillations? |
|
Definition
| They are normally seen after expiratory phase of ETCO2 waveform (between D-E) and represent changes with each heartbeat--> it is a normal finding |
|
|
Term
| If you intubate, see an initial postive ETCO2 waveform that immediately starts to decline, what most likely happened? |
|
Definition
|
|
Term
| What else could cause a ETCO2 reading from normal to a suddenly low value? |
|
Definition
|
|
Term
| If you saw a suddenly low ETCO2 value and you were thinking P.E. and got an ABG, how should the PaCO2 and ETCO2 compare? |
|
Definition
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