Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
129 Cards in this Set
- Front
- Back
|
what is the purpose of monitoring?
|
determine if physiological homeostasis is maintained during anesthesis.
Monitors don't tell you what to do, but the efficacy of what your interventions |
|
|
What must always be monitored?
|
EKG, SPO2, BP Respiration
|
|
|
What must be monitored in special situations?
|
ETCO2 in all generals, temperature
|
|
|
What should we monitor if given a choice
|
ETCO2
|
|
|
What is considered negligence with regard to monitoring?
|
those who omit a monitor, the use of which is well established in the community and would have prevented damage to a patient. MAC not required to have ETCO2 monitoring
|
|
|
What is ASA standard I for anesthetic monitoring?
|
A qualified anesthesia personnell shall be present in the room--why no other provider can do our job.
Can step out of the room but must be observing patient remotely, ie MRI, radiation |
|
|
What is ASA standard 2
|
During all anesthetics,the patients OXYGENATION, VENTILATION, CIRCULATION, and TEMPERATRE shall be CONTINUALLY evaluated on general anesthetic
Ensure adequate oxygen concentration in the inspired gas and the blood durin ALL anesthetics |
|
|
How do we measure inspired oxygen?
|
Oxygen anzylyzer with low oxygen concentration alarm in use
|
|
|
When do you have to have an SPO2 monitor on a patient?
|
In general, on ALL anesthetics performed; When pulse ox used, VARIABLE PITCH pulse tone and LOW THRESHOLD alarm shall be audible. Patient shall be illuminated and exposed enough to assess color
|
|
|
Under general anesthesia, what are the ventilation monitoring requirements?
|
Evaluation is required for: Qualitative clinical signs such as CHEST excuresion, OBSERVATION of reservior breathing bag, and AUSCULTATION of breath sounds. CONTINUAL monitor for presence of expired CO2 unless invalidated by the nature of the patient, procedure or equiptment. Quantitaive monitoring of the VOLUME of the EXPIRED gasis strongly encouraged
|
|
|
How is correct placement verified after an ETT or LMA is inserted?
|
By identification of CO2 in expired gas. Cotinual end-tidal CO2 analysi, in use for the time of placement, until extubation or transfer to PACU using CAPNOGRAPY, CAPNOMETRY, or Mass Spectrometry; When CAPNOGRAPY/CAPNOMETRY is utilized the end tidal CO2 alarm shall be AUDIBLE to the CRNA
|
|
|
What other monitor needs to be in place in the mechanically ventillated patient?
|
A device that is capable of detecting disconnection of components of the breathing system. Device must give an AUDIBLE signal when alarm threshold is exceded
|
|
|
How is ventilation monitored during regional anesthesia?
|
Continual observation of qualitative clinical signs and/or monitoring for the presence of exhaled CO2
|
|
|
With regard to circulation what monitors are required during anesthesia?
|
EKG continually displayed from the begining of anesthesia until preparing to leave the anesthetizing location.
An arterial BP and HR determined at least q5minutes AND at least one of the following: Palpation of the pulse, auscultaion of the heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound periperal pulse monitoring, or pulse pleysmography or oximetry. |
|
|
When should body temperature be monitored?
|
when clinically significant changes in body temperature are INTENDED, ANTICIPATED or SUSPECTED
BOARD** In MAC cases only has to be AVAILABLE, isn't required |
|
|
What are the categories of montoring devices?
|
Non-invasive, Minimally invasive, penetrating, Invasive and highly invasive
|
|
|
What does noninvasive monitoring include?
|
Visual inspection, passive sensing of surface temperature, infrared emissins, external auscultauion, palpation, passive adn active electrical sensing with surface electrodes, surface ultrasound, gas sampling using skin surface probes
|
|
|
What is considered minimally invasive monitoring?
|
Cutaneous neelde EEG/ECG, Neuromuscular monitoring, IV injections, and blood samples from peripheral veins
|
|
|
What are penetrating monitoring devices?
|
Tempanic membrane probe for temperature monitoring, Pharangeal or esophageal probe for temp. or CV monitoring
Stomach tubes for pH or oralgastric evacuation Uterine probe for fetal monitoring Standard Foley catheter for urine measurement |
|
|
What are invasive monitors?
|
Arterial catheters, CVC adn probes, Suprapubic urine sampling
|
|
|
What are HIGHLY invasive monitors?
|
Intercardiac probes for pressure monitoring and sampling
trasn cardiac probes (PA caths) for pressures and flows Atrial or ventricular pressure monitoring Subarachnoid pressure monitors, ICOP pressures and flow monitors |
|
|
What are the hazards of noninvasive monitors?
|
skin irritation, and potiential for burns when equiptment imporperly grounded
|
|
|
What are the hazards of minimally invasive monitors?
|
may produce infectionand bleeding hazards. Discomfort from peripheral nerve stimulators
|
|
|
What are the hazards of penetrating monitors?
|
may be dangerous when they trigger reflexes (vagal-fainting--what is that called?) Perforation or infection particualarly common after trasnurethral bladder catheterezation
|
|
|
What are the hazards of invasive monitoring?
|
require special skill for placement. Bleeding, infection, blood clot formation and occution of the vessel lumen with subequent ischemia in distal arteries are possible with arterial catheter placement.
Infection, clot formation, bleeding adn pneumothorax are primary risks associated with central lines |
|
|
What are the hazards of HIGHLY invasive monitors?
|
highest risk, intra/trasncardica probes increase cardiac arrythmias, perforation, clot formation adn bleeding.
Neurological monitoring with subarachnoid or intracranial extradural probes can cause infection and produce significant patient disomfort |
|
|
What is a fundamental concept critical to understand when analysing all the monitors available to the anesthetist?
|
Treat the patient not the monitors!!
Observation of the patient via means such as cap refill, palpation of peripheral pusles and UOP can enable the assessment of the circualtor system and confirm the more objective and sophisticated data gleaned from electronic monitoring devices. |
|
|
What diagnostic uses does monitoring the pts HR and rhythm have for the anesthetist?
|
Finding Rate and rhythm disturbances
Ischemic Heart disease Evaluating chamber size finding Heart block Determining electrolyte and/or drug effects Pericardial disease and Excercise tolerance |
|
|
What are rate and rhythm disturbances?
|
bradycardia/ tachycardia, can be diagnosed as to SITE of ORIGIN, etiology, and clinical importance; SVT can be separted from vetricualr rhytms and decisions about therapetuc interventions made pereoperatively
|
|
|
How is Ischemic heart dz found on an EKG?
|
Previous MI or myocaridal ischemica can be diagnosed form QRS complex and ST segment of EKG. Acute changes indicating ischemia must always be sought out during perioperative period.
|
|
|
Why is chamber size evaluated via EKG important diagnostically?
|
Specific chamber elargements tend to be associated with certain diseases, such as LVH with HTN and LA enlargement with mitral STENOSIS
|
|
|
What types of Heart blocks can be diagnosed via EKG?
|
Especially important are combinations of BBB of the conduction system, 1st degree, 2nd degree, and 3rd degree blocks as well as different types of hemiblocks can be diagnosed
|
|
|
What EKG changes are important to monitor with regard to Electrolyte and/or drug effects?
|
conditions such as hypokalemia and digitalis effect may be important n anesthetic managemtn
|
|
|
Can Pericardial disease be evaluated via EKG?
|
Yes. pericarditis and pericardial effusion are assciated with characteristic EKG abnormalities
|
|
|
What are Exercise tolerance tests used for?
|
to diagnose ischemic heart disease or rhythm disturbances.
|
|
|
What are EKGs used for intraoperatively?
|
Arrhytmia detection, Ischemia detection, Electrolyte changes, Pacemaker function
Arrythmia detection***most important** |
|
|
What lead is used to evaluate disrrhytmias?
|
Lead II
|
|
|
What lead is used for ischemia?
|
V5
|
|
|
How often should pacemakers be monitored duiing surgical procedures?
|
Continually. This is especially importan when the surgical procedure will be done near the pacemaker wires or unit when elecrocautery will be used
|
|
|
Postoperatively how are EKG monitors used?
|
To detect arrythmias and diagnos ischemia or infarction.
|
|
|
Describe the cardiac contraction in terms of the ions that are involved.
|
Sodium ions enter the cell and begin the depolarization.
Calcium ions follow and extend the depolarization even further Once calcium stops moving INward, potassium ions move OUT and repolarization begins |
|
|
What is the absolute refractory period?
|
period after depolarization where absolutely no stimulatoin can cause another action potential. From startof QRS to mid T wave according to slide
|
|
|
What is the relative refractory period?
|
During this period it is possible to cause another contraction, but the intensity of the contraction will be RELATIVE to TIME in this period....starts at mid T wave.
|
|
|
When is the potential zero?
|
When the ventricular muscle is eithe completely depolarized or repolarized. There is NO flow of current along the tissue at that point
|
|
|
What does the P-wave represent?
|
atrial depolarization; the impulse across the atria to the A/V node
|
|
|
What does the QRS wave represent?
|
ventricular depolarization; the impulse as it travels across the ventricles
|
|
|
What does the T-wave represent?
|
the repolarization of the ventricles
|
|
|
Where does ventricular depolarization start?
|
At the ventricular septum and the endocardial surfaces of the heart.
|
|
|
How does the current flow?
|
It flows positivley from the base of the heart to the apex
|
|
|
What electrical event happens at the very end of depolarization?
|
The current reverses for 1/100th second and flows toward the outer wall sof the ventricles near the base---the S wave
|
|
|
Describe the principles of vectorial analysis of EKGs
|
The current in the heart flow from the area of DEpolarization to POLarized areas.
The electrical potential generated can be represented by VECTOR The arrowhead points in the positive direction |
|
|
What is the normal range of the QRS axis?
|
-30 to +90
|
|
|
What is the range for a LEFT axis deviation?
|
-30 to -90
Superior and LEFTward |
|
|
What is the range for a RIGHT axis deviation?
|
+90 to +150
Inferior and RIGHTward |
|
|
How do you determine QRS axis?
|
Find the ISOELECTRIC lead if there is one
QRS axis is PERPENDICULAR to that leads orientation There are 2 perpendiculars to each ISOelectric lead, choose the one that best fits the direction of the other EKG leads Lead aVF is the ISO electric lead 2 perpendiculars are 0 and 180; Lead I is positive....oriented to the left Therefore the axis has to be 0 |
|
|
What EKG changes will you see in a Left Axis Deviation?
|
Lead aVR is the smallest and isoelectric lead
Two perpendiculars are -60 and +120 Leads II and III are mostly negaive..moving away from the leg The axis therefore is -60 |
|
|
What EKG changs will you see in a RIGHT axis deviation?
|
Lead aVR is closest to being isoelectric (slghlty more positive than negative
the 2 perpendiculars are -60 and +120 Lead I is mostly negative and lead III is mostly positive Therefore the axis is close to +120 because aVR is slightly more postive, the axis is slightly beyond +120; closer to the positive right arm for aVR |
|
|
What do axis deviations tell you?
|
what cells are in good condition. The axis is going to deflect into the cells capable of being depolarized.
|
|
|
What are causes for left axis deviation ( > = -30, lead II mostly negative)?
|
LAFB; rS complex in leads II, III, aVF, small qu in leads I and/or aVL and axis -45 to -90
Some cases of INFERIOR MI with Qr complex in lead II (making lead II 'negative') INFERIOR MI + LAFB in same patient (QS or qrS complex in lead II) Some cases of LVH **MOST COMMON*** some cases of LBBB Ostium Primum ASD and other endocardia CUSHION defects some cases of WPW (large negative DELTA wave in lead II) |
|
|
What are causes of RIGHT axis deviation (> = +90. lead I is mostly negative)
|
LPFB, rS complex in lead I, qR in leads II, III< and aVF....HOWEVER, must first exclude causes of R heart overload; theses will also give same EKGk picure of LPFB
many causes of R heart overload and Pulmonary HTN **MOST COMMON**** HIGH LATERAL wall MI with Qr or QS complex in leads I and aVL Some cases of RBBB Some cases of WPW Children, teenagers,adn some young adults |
|
|
What is the methodological approach for reading EKGs
|
RATE: slow or fast, are atrial and ventricular rates the same?
RHYTHM: is the rhythm regular or irregular P / QRS waves: morphology, is there a p before every QRS, a QRS before every P INTERVALS: are the P-P and R-R intervals regular or irregular, are the PR and QRS intervasl within normal limits |
|
|
Describe Sinus Rhythms
|
Originate in the SA node, travel through entire conduction system without inhibition. INCLUDE:
a conducted p wave P-R interval between 0.12-0.2 QRS width between 0.04-0.12 ALL QRS preceded by P wave |
|
|
Describe SINUS bradycardia
|
Rate less than 60 bpm
P-R interval 0.12-0.2 QRS duration 0.04-0.12 |
|
|
How do you calculate rate/
|
R-R intervals
|
|
|
Describe SINUS tachycardia
|
Rate 100-150 bpm
PR 0.12-.2 QRS 0.04-.12 |
|
|
What is SINUS arrhytmia
|
Rate 60-100
PR interval 0.12-.2 QRS 0.04-0.12 PERIODIC IRREGULARITY, varies with inspiration |
|
|
What are the atrial dysrhytmias?
|
PAC's
A-fib A-flutter: Simple flutter, 2:1 block, Variable block |
|
|
Describe PAC
|
Upright normal P wave
Narrow QRS (0.04-0.12 ms) Morphology different than other P waves; not treatable |
|
|
Describe A-fib
|
SA node or INTERNODAL pathways suffer STRESS ( volume overload/depletion) or damage
Atria can initiate impluses from other portions of the ATRIAL tissue NO P WAVES**** Narrow QRS IRREGULAR rhythm This is only a problem if pt is hemodynamically unstable |
|
|
Describe A-flutter
|
Has a distinct saw-tooth pattern of P waves
|
|
|
What is a 2:1 block?
|
Atrial flutter that there are 2 p waves followed by 1 QRS
|
|
|
What is a Variable flutter block?
|
Extremely common block with as few as 1 and as many as 6 P waves between each QRS complex
|
|
|
What is the clinical significance for patients with a-flutter?
|
Atria generally don't have time to fill completely, the PRELOAD is reduced and CO suffers
Erratic and turbulent blood flow Forms transmural clots which may become dislogdged and clog small vessels |
|
|
What are the AV node blocks?
|
1st degree
2nd degree--Type I wenckebach, Type II Mobitz) 3rd degree |
|
|
What is a 1st degree HB?
|
Generally benigh
Characterized by CONSTANT PR interval greater than 0.2 seconds Rhytm is otherwise NORMAL Rate can be brady to tachy Ordinarlily NO symptoms associated with 1st degree |
|
|
What is a 2nd degree Type I HB?
|
Distinguished by a REPEATING cycle of increasing PR intervals with and eventual drop of the QRS
Typically R-R becomes shorter until the dropped beat Generally not dangerous, pt may complain of palpitations or skipped beats |
|
|
What is a 2nd degree Type II HB?
|
Mobitz
consitant PR interval with frequently NON-conductive p waves QRS may be widened depending on location of the block Wide QRS indicate that ventricles are depolarizing from an action potential in the VENTRICULAR tissue, rather than from ABOVE the AV junction Usually NOT a good sign. Tendancy to worsen to a 3rd degree block this is where you see axis deviations Need a pacer, atropine available, electrolyte abnormalities |
|
|
Describe 3rd degree HBs.
|
ABSOLUTLEY NO conduction through the AV node
Atria are beating at their intrinsic rate (60-80) and ventricles are beating at their intrisic rate of (20-40) QRS complex will often be WIDE, but depending on hte origin they may be narrow P-P interval and R-R interval will each be REGULAR and consistant, P-P will be faster than R-R and no relationship between the 2 AKA Atrioventricular dissociation. |
|
|
Describe PJC.
|
An extra impulse sent by the AV node that spreads up to the atria and dow to the ventricles.
Distinguished from PACs by the P-waves; PAC have fairly NORMAL looking p waves, PJCs are deflected and deflect up toward the base of the heart; may occur with a Monstorous QRS complex and may be hidden. |
|
|
What does upward deflection represent?
|
deploariztion
|
|
|
What does downward deflection represent
|
repolarization
|
|
|
What are junctional escape complexes?
|
If NO stimuls reaches the AV node, the cells assume the SA node never fired
The AV jxn will reach each automatic threshold and generate and action potential. UNLIKE PJC, complexes will appear late in the rhythm Otherwise they posess the same deformity, inverted/absent P waves QRS will remain narrow because the impulses originate above the ventricles. |
|
|
what are ventricular rhythms?
|
The rhytm that originates in the purkinjie fibers becomes blocked increasing the QRS time to >0.12 seconds. these rhythms include:
PVCs, V-tach and V-fib |
|
|
Describe PVCs
|
Describe PVCs
|
|
|
There are UNI focal and Multifocal PVCs
Unifocal all have same focus, therefore same morphology Multifocal arise from multiple focci, each of which has uniqu morphology, often a repeating sequence make an effort to note the number and sequence of focii |
How do you describe the frequency of PVCs?
|
|
|
Bigeminy--each PVC followed by a normal contraction
Trigeminy--2 normal QRS followed by a PVC Couplets--2 PVC's in a row |
When can ROT phenomena occur?
|
|
|
In very fast rhytms, and after ectopic beats like PACs, PJCs, and PVCs
|
Describe V-tach.
|
|
|
Ventricles depolarize very quiclky without regard to the atria
Defined as 3 or more PVCs in a row PULSE: Pulses will be weak and CO low Pulse for some beats...this is ominous No pulse--may or may not be any contraction at all, but if there's no pulse, pt's in trouble...duh |
What is the most common fata dysrhytmia in adult patients?
|
|
|
Describe v-fib
|
represents a chaotic depolarization of random ventricular cells
NO pulse associated with thsi rhythm Described as course or fine; course is a littler better than fine |
|
|
How do you recognize an AMI?
|
ST elevation > 1mm
3 contiguous leads |
|
|
What does downward deflection represent
|
repolarization
|
|
|
What are junctional escape complexes?
|
If NO stimuls reaches the AV node, the cells assume the SA node never fired
The AV jxn will reach each automatic threshold and generate and action potential. UNLIKE PJC, complexes will appear late in the rhythm Otherwise they posess the same deformity, inverted/absent P waves QRS will remain narrow because the impulses originate above the ventricles. |
|
|
what are ventricular rhythms?
|
The rhytm that originates in the purkinjie fibers becomes blocked increasing the QRS time to >0.12 seconds. these rhythms include:
PVCs, V-tach and V-fib |
|
|
Describe PVCs
|
Describe PVCs
|
|
|
There are UNI focal and Multifocal PVCs
Unifocal all have same focus, therefore same morphology Multifocal arise from multiple focci, each of which has uniqu morphology, often a repeating sequence make an effort to note the number and sequence of focii |
How do you describe the frequency of PVCs?
|
|
|
Bigeminy--each PVC followed by a normal contraction
Trigeminy--2 normal QRS followed by a PVC Couplets--2 PVC's in a row |
When can ROT phenomena occur?
|
|
|
In very fast rhytms, and after ectopic beats like PACs, PJCs, and PVCs
|
Describe V-tach.
|
|
|
Ventricles depolarize very quiclky without regard to the atria
Defined as 3 or more PVCs in a row PULSE: Pulses will be weak and CO low Pulse for some beats...this is ominous No pulse--may or may not be any contraction at all, but if there's no pulse, pt's in trouble...duh |
What is the most common fata dysrhytmia in adult patients?
|
|
|
Describe v-fib
|
represents a chaotic depolarization of random ventricular cells
NO pulse associated with thsi rhythm Described as course or fine; course is a littler better than fine |
|
|
How do you recognize an AMI?
|
ST elevation > 1mm
3 contiguous leads |
|
|
How is ischemia reflected on an EKG?
|
Tall or inverted T wave(infarct) and ST segment may be DEPRESSED
|
|
|
How is injury refected on an EKG?
|
An elevated ST segment, T wave may be invert
|
|
|
How is an ACUTE infarction represented on an EKG?
|
Abnormal Q wave, ST segment may be elevated and T wave may be inverted
|
|
|
How is an infarction (AGE UNKNOWN) represented on an EKG?
|
abnormal Q wave, ST segment and T wave returned to normal
|
|
|
What location of the heart does V5 represent?
|
lateral portion of the heart; you'll see changes in Anteriolateral, Lateral MI
|
|
|
What location of the heart does V1/V2 represent?
|
Septum; changes seen in Septal MI and Anterioseptal MI?
|
|
|
What location of the heart does V3/V4 represent?
|
Anterior: changes seen in Anerior, Aneroseptal, Anterolateral MIs
|
|
|
What leads show changes in an INFERIOR MI?
|
II, III, aVF
|
|
|
What leads are affected in an Lateral MI?
|
I, aVL, V5, V6
|
|
|
What area of the heart does V7-9 represent?
|
posterior
|
|
|
What coronary artery is affected most often in an INFERIOR MI?
|
RCA; Posterior descending brand or Left coronary artery, crircumflex branch may also be affected.
|
|
|
What coronary artery is affected during LATERAL MI?
|
Left coronary artery; LAD--diagonal branch and/or circumflex branch
|
|
|
What is arterial blood pressure?
|
the measurement of arteiral blood pressure----it is a surrogate for the monitoring of blood flow.
|
|
|
What does the flow of blood (blood pressure) equate to?
|
Tissue perfusion and oxygenation. Flow depends on vascular resistance; Ohm's law. flow = Pressure/resistance
|
|
|
If the pressure and resistance are high how will flow be affected?
|
Flow will be low; thus arterial blood flow can be viewed a s apredicor but not a meausr of organ perfusion
|
|
|
If you improve blood pressure do you improve perfusion?
|
No nessisarily....have to fix undrlying cause and does not equate to oxygen delivery.
|
|
|
When are NON-invasive BP monitors used?
|
ALL anesthetics require BP monitoring no matter how trival. Frequency depends on pt condition.
Usually q 3-5 minutes and q 1 minute during emergencies. |
|
|
What are some some complications of nonivasive BP monitoring?
|
Nerve plasies and extensive extravasation of IV administered fluids?
|
|
|
What is non-invasive IV BP accuracy dependant on?
|
Depends on proper cuff size, bladder halfway around the extremity, width 20-50% greater then thediameter of the extremity.
|
|
|
Are there any contraindications for non-invasive BP monitoring?
|
BP cuffs are best avoided in extremities with vascular abnormalities or with IV lines
|
|
|
What does underdampening do?
|
It causes a FALSELY high SBP and falsely LOW DBP
|
|
|
What does overdampening do?
|
Causes falseely LOW SBP and falsely HIGH DBP
|
|
|
How does PEEP affect intrapulmonary pressure?
|
PEEP increase intrapulmary pressure, can cause Pul HTN,
|
|
|
What does a wave for CVP tracings represent.
|
a wave represent atrial contractions
|
|
|
What does the x descent represent on CVP waveform?
|
decrease in atrial pressure as the atrium begins to relax
|
|
|
What does the c wave on CVP waveform repesent?
|
caused by the bulging of closed tricuspid valve into the atrium
|
|
|
What does x 2 descent represent.
|
Caused by further relaxation of the atria, and downward movement of Tricuspid valve during LATER stages of ventricular contraction
|
|
|
The CVP v wave represents?
|
An INcrease in atrial pressure that occurs while the atria fills against a closed tricuspid valve: Tricuspid REGURG leads to larger v wave and the disappearance of x descent
|
|
|
The CVP y descent represents?
|
A drop in pressure as the ventricles relax. the tricuspid valve OPEN. Atrial pressure HIGHER than ventricular. pressure, blood passivley enters ventricle
|
