What is Standard I for monitoring?

What is Standard II for monitoring?

How do you ensure adequacy of circulation? 

How frequently is the standard for evaluation?

The prescence of a qualified provider to be present in the OR at all times. Continuously monitor pt and modify anesthesia baed on obs and pt responses.

An oxygen analyzer, low concentration O2 alarm, quantitative assessment of oxygenation (SPO2), Physical diagnostic of ventilation (chest rise) Encouraged In GA pts: tidal volume (TV), and capnography. (ETCO2)

Continuos ECG and and BP at least q 5 minutes.

Pulse Quality via Palpitation. Radial Pulse=MAP >60 Femoral may be palpated at lower

precordial??

If a patient has an ETT or LMA what tools are REQUIRED ?

Is temperature a required monitor? 

What monitors are required for conscious sedation?

What is the best monitor?

1) Qualitative ID of ETCO2 (capnography)

2) No, it must be Available, when changes in a pts temperature is required or anticipated, the continuous temp should be done.  

3) BP cuff with Stethoscope and Pulse Oximetry

 4) Vigilant Provider

What can a  precordial do for you?

What things you can auscultate, palpate and visualize?

Ausculate (hear and quality of breath sounds, heart rate, )

Temp and HR/pulse , Respiration (chest rise), and circulation (visualize/palp)

1) FiO2 (inspired oxygen)

2) Airway Pressure

3) Oximetry

4) Blood Pressure

5) Heart Rate

need to continuosly monitor BP/vasoactive meds

ASA class III or IV/ or "sick pts"

Frequent Blood Draws

ABG evaluation needed

Expected blood loss high or monitoring Hct with expected transfusion

Vascular cases/hypotensive technique/thoracic

What are some contraindications to arterial lines?

Where is the first place you attempt? Where is the last?

Pt refusal, infection, ischemia, thrombus

Radial, Dorsal Pedis, Femoral

Brachial is Last, b/c there is no collateral circulation

What does the Allens test do/test for?

how do you do it?

Which artery has collateral circulation?

patency of ulnar circulation before cannulation

compress both radial and ulnar arteries while pt tightens fist. Releasing pressure on each respective artery determines the dominant vessel supplying blood to the hand.

Both rad & uln have collateral circulation. Predominant cirulation is ulnar.

Pros-use for healthy pts, sort cases

Cons-bladder cuff size (too big/small)

Flow dependent for reading

Motion, Interrupts IV infusion (Injury), Cuff deflation rate slow to get mesurement, Hydrostatic measurement errors.

What are some Pros/Cons to Arterial cannulation?

What is a con to both arterial and BP cuff?

Pros; continous BP, Good for sick pts/difficult cases, access for blood draws/ABG's

Cons: Nerve dysfunction, Thrombosis, Ischemia, Hematoma, Infecion, Hydrostatic errors.

Hydrostatic errors

For art line placement clean or sterile towels and prep?

What is the technique we are trained to do called, who developed it and how is it done? 

Sterile towels and prep Betadyne or Chloraprep

Seldinger Technique by Dr. Sven-Ivar Seldinger

1) 20 G needle transects (cuts through) artery

2) Remove Needle

3) draw cannula back until free blood flow

4) pass guidewire down needle into artery

5)Thread cannula over the wire 

Thrombus, Arterial laceration, hematoma, loss of distal perfusion, nerve disfunction from dissection, Infection, errors in monitoring (over/underdampened), Failed attempts (most common)

Medication Infusion

If your arterial line waveform is short and flattened what does that mean?

What if it is tall and spiked?

1) Overdampened

(flex position/armboard)

2) Underdampened

(air bubble)

When evaluating the Arterial Line Waveform, what is the Tf?

T1?

T2?

Ti?

Tt?

(look at waveform)

Tf- Foot, the onset of ejection (systole)

T1-First Shoulder, Peak FLOW

T2-Second Shoulder, Peak PRESSURE

Ti-dichrotic notch, the aortic valve closure, end of ejection, precedes diastole onset

Tt- Pulse Duration

What does the rate of the upstroke on the arterial line tell you?

What is occuring if you see a decrease int he upstoke?

1) Contractility

2) Decrease in pulse

What does the rate of the downstrope indicate?

If you have vaiations in your size during respiration, or a low dichrotic notch what does that indicate?

How is the MAP calculated?

SVR-Systemic Vascular Resistance

variations with respiration and low dichrotic notch indicate hypovolemia

calculated by integrating area under pressure curve

MAP-CVP

________

C.O. X 80

When positioning your pt for an arterial line for

Radial-

Femoral-

Brachial-

20-30 degrees rotate shoulder, palms up, dorsiflex wrist.

ABduct leg 30-40 degrees and externally rotate hip

Fully extend elbow- avoid hyperextension

 Plantar Flex the Foot

What should be used for awake pts when inserting CVC?

How can you improve success with inserting catheters?

Local anesthetic

Ultrasound guidance

technique- catheter over needle

catheter through needle

Seldinger technique

Surgical Cutdown (surgery)

What are the four steps for the Seldinger technique for the CVC?

1) venepuncture w/ introducer needle

2) soft tip guide wire passed through needle, needle removed

 3) Dilator over guide wire, remove quide wire

CXR needed to confirm placement

Straight shot, apical pleura is not as high, avoids thoracic duct. Sternocleomastoid (two heads of sternomastoid and clavicle) Aim to the ipsilateral nipple

below clavicle

insert needle below medial 2/3 and lateral 1/3 of clavicle. Aim for supra sternal notch, passes behind clavicle about 4-5 cm

Look at the normal CVP waveform and compare to EKG. Where are a,c, x, v, y waves? when do they occur in sync with  EKG? 

what is + a wave?

cannon a waves?

+ c wave

-x descent?

+v wave

-y descent

a wave- increased atrial pressure during R atrial contraction (with P wave on ekg)

cannon a waves- atria contracting alone, heart block

 c wave- tricuspid valve elevation during early ventricular contraction (end of QRS)

x descent-  filling of ventricle during  systole

 (before T wave)

v wave- blood filling right atrium against closed ticuspid valve (T wave on EKG)

y- opening of tricuspid blood flowing into R ventricle. (before p wave)

What are some early complications with central lines

late complications?

Early: hemorrhage, air embolus, pneumothorax, carac arrhythmias, pericardial tamponade, failure

Late: Thrombosis, Infection

What % of central ines become infected/colonized?

what % get  catheter-related sepsis?

What is usually the organism?

How can you prevent?

10%

2%

Staphylococcus

aseptic technique, adequate care, closed system, dedicated lines for parental nutrition, antimicrobial coating of lines

HYPNOSIS- (asleep)/brain activity/drug effects on brain

0-100, 40-60 is anesthesia range, <40 poor outcomes

cost $15 strip/ 70% hospitals use/trauma and cardiac/ 1-2 pts per 1000/50% pts w awareness have psychological problems

How many protein globulins are on hemoglobin?

What are the three hemoblogin groups?

4- with 1 heme group

Heme A (Adult)

Heme F (Fetal) Neborn-replaced after 1 year

Heme S (Sickle) doesnt bind O2

Oxyhemoglobin- (O2Hgb) oxygen

Reduced Hemoglobin (RHb( No O2 :(

Methemoglobin (MetHb): Ferric form Hgb (Fe3+)

Carboxyhemoglobin (C0Hb) carbon monoxide attatched

(meth and carboxy in pathological conditions)

Dysfuntional Hemoglobins include:

SulfaHemoglobinemia

Methehemoglobinemia

Carboxyhemoglobinemia

What does each do?

Sulfa- hydrogen sulfide alters O2 affinity, (acetaminophen, phenacetin and trinitrotoluene)

Methe- alters normal iron Fe to ferric form, hgb cant carry O2, pt blue in color, (from nipride, nitroglycerin, prilocaine, benzocaine), GDP6 methe ezyme to break methe is reduced) Its reversible!

Carboxy- CO (carbonMONoxide) binds hgb. from smoking, cars, furnaces, Bright RED tounge and blood

Henrys law and plasma

how much blood is transported in plasma?

Amount of gas dissolved in a liquid is proportional to the partial pressure exerted by gas

1-3% 0.3cc/ml blood

How do you calculate the Oxygen Content of blood?

Oxygen Content: (1.37 X Hb X SaO2) + (0.003 x PaO2)

On the oxyhemoglobin curve, what is the Y axis?

The X axis?  L shift? R shift? (baby/mom/anesthesia state)

 What is P50?

Y axis= (% saturation) SO2=  90%

X axis= (partial pressure) PO2= 60

L shift- alkalosis fetus holding on to O2, Meth, Sulfa, COHg

R  shift- acidosis- pregnant giving up O2 to baby, Inhaled anesthetic , sickle cell, Thalassemia

P50 is partial pressure of oxygen when saturation is 50% (y axis) normal adults, P50 is 27 (x axis)

What do pulse oximeters measure? how?

What does red light measure?

blue light? What is the law phenomenen called?

Plethysmography (measures arterial pulsations)/oximetry

red-saturated-absorbed by infrared

blue-unsaturated- deoxygenated absorbs more red light.

two colors differ on how they absorb light.  Lambert-Beer Law

How does plethysmography identify arterial blood pulsations? Can it record volume changes in organs? What will a greater blood flow do to your waveform? What is the waveform similar to?  What other information can it give you? 

identifies pulsating arterial blood, vs venous via light absorption

records changes in volume of blood vessel, organ, or extremity, greater blood flow=increased size waveform, it is similar to arterial waveform.

heart rate and perfusion to area (e.g finger/hand)

What is SaO2?

SpO2?

saturation of arterial oxygen

saturation of arterial oxygen by pulse oximetry

Electrocautery, Bypass sx, contrast dye, MRI, excessive ambient light, Anemia Hgb <5, Hypoxemia, Acrylic nails.

Carboxyhemoglobin will give a FALSE high!

10% dissolved in plasma

25% bound to proteins (Hgb)

65% as bicarbonate ions

Attaches at different binding site than O2, causes conformational change and increases release of O2, Ph decreased, H+ ion increases

Bohr effect

What is CO2 and byproduct of?

PACO2

PaCO2

ETCO2

What is lower? ETCO2 or PaCO2?

cellular metabolism

Alveolar, arterial, end tital CO2 (during expiration)

ETCO2 is lower because of dilution of gas sample as it travels from pt to capnogram. (e.g. ETCO2 of 40 on capnogram is really CO2 of 50!)

Measures CO2 partial pressure as a waveform

Gives CO2 on inspiration and expiration

Gives digital number (25-70)

method: diverting- from small side port of ETT aspirated in tubing to measuring device. Beam of infared light measures CO2 vs pts gas.

mass spectrometry

What else can capnography help you monitor?

circulation-hypovolemic/cardiac shock, pulmonary embolism

ventilatory- kincked tubing, functioning ventilator,

rebreathing of CO2, exhausted absorber, incompetent valves,

helps u 2 determine if u need to make changes in vent or adequacy of spontaneous ventilation

oxygen delivery

inhaled anesthetic levels

other gases (N2)

Know CO2 waveforms

What is Phase 1

Phase 2

Phase 3

Phase 4?

Phase 1: CO2 exhalation-moving dead sace gas

Phase 2: expiratoy upstroke, bronchiole emptying

Phase 3: Expiratory/Alveolar Plateau; CO2 gas expired

ETCO2 measured at beginning of phase 4/end of phase 3.

Phase 4: inspiratory downstroke

What are 8 ASA guidelines?

Ambu Bag, Oxygen, Oral & Nasal Airways, BP cuff w stethoscope, Pulse Oximetry

Record including, procedure, drugs, vital signs

Documentation of complications

Status upon discharge

Deep Anesthesia is a form of conscious sedation, its a controlled state with decreased LOC, LOSS of protective reflexes, NO response to noxious stimuli, MAY be INDISTINGUISHABLE from general anesthesia.

PUT IN AN ORAL AIRWAY

What happens with hypoxia and advancing age?

What are some CV effects of hypoxia?

Hypoxia sensitivity decrease with age, older pts more at risk, but even kids can be predisposed to hypoxia

Tachycardia, stimulated by chemoreceptors,

DECREASED PVR and ABP, SaO2

limits uptake of oxyen and PREVENTS compensation,

inability to increase CO

diminished CV reserve

Inability to dilate coronary arteries

No oxygen stores in brain-brain has a high resting O2 consumption, (20%) dependent on glucose for aerobic degredation to CO2 and H20

Congestion in

-pial vessels

-cortex

-gray areas

-basal ganglia

What are symptoms of hypoxia?

What does hypoxia do to the pulmonary circulation?

Psychomotor poor judgement, loud, HA, precordial pain, n/v tachycaria, cyanosis

Pulmonary Vacsoconstriction

Increases pulmonary blood flow

Increases vascular resistance

What are effects of hypercarbia in the CNS?

hypercarbia in the myocardium?

At what range do these changes occur?

Increased-CO, CI, HR, SV, Myocardial Contractility

(body doesnt like-almost like frightened)

Decreased-PVR, Ejection time

Increase of 10 mmHg, decreases contraction by 50%, HR increases 26%

Myocardial depression occurs at 56-65

Decreased contractility

Fatigued Diapragm

Relaxes esophageal spinchter tone (aspiration risk)

1) Environment-equipment, monitor, life line! (who you call if you need help)

2) Procedure-diagnostic or therapeutic? length, position, surgical support

3) Patient- ASA risk, Allergy, monitoring requirements, etc.

What are the 6 components to the chain of infection?

1) Agent (bacteria, chlamydia)

2) Reservior (humans, organic matter)

3) Portal of Exit (sneeze, open lesions, diarrea)

4) Transmission (Contact, droplet)

5) Mode of entry (ingest, inhale)

6) Host- YOU, HCW, pts

What is a spore? what is it resistant to?

What does an antiseptic do?

resting stage bacteria, resists heat, dry and disinfection

antiseptics destroy microbes on skin

What are the steps in Deconatamination? What does it provide?  What do the three steps kill? What Level is used for endoscopes?

What does sterilization do? What is the most effective sterilization?

Makes surface incapable of transmitting microbes

consists of cleaning, disinfection AND sterilization.

Cleaning-soap and water

Disinfection- removes all bacteria EXCEPT SPORES

High Level- Cidex for endoscopes

Sterilization is complete destruction! Steam is the most effective and least expensive

What is the difference between airborne and droplet isolation?

Droplet is only universal with surgical mask

Airborne is for droplets e.g. measles use N95 mask, reverse flow room or HEPA filter.

0.3% / 0.9%

Symptomatic <500 t cells

 >500 immune competence

>5000 more likely symptomatic disease

What are some anesthesia related to treatment?

GI?

Blood?

Lungs?

Skeletal/NM?

 What NDMA is especially dangerous?

Neuro

Dehydration-create electrolyte imbalances

Thrombocytopenia- have blood ready

Pneumonia-delay sx until clears if possible

Muscle relaxants may be irreversible (bc wasting)

Succinylcholine-increases K

Neuro-high ICP

Splash-mucous membrane- no treatment or basic drug regimen

Moderate: Basic Drug

Severe; drugs within 1-2 hrs exposure for 4 weeks, liver fxn tests