• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/106

Click to flip

106 Cards in this Set

  • Front
  • Back
HOW DO YOU MONITOR ADEQUATE CIRCULATION?
EKG continuous.
BP, and HR Q 5 min
ALSO---> palpation of a pulse, auscultation of heart sounds, a-line, ultrasound peripheral pulse monitoring or pulse ox, and adequate visualization of the patient.
WHAT MUST YOU HAVE IF DOING A GENERAL ANESTHETIC?
O2 analyzer with low level limit alarms on.
WHAT DOES AN O2 ANALYZER MONITOR?
It measures the % of O2 being delivered to the patient. Low limit is usually 30%. (usually given with nitrous)
WHAT MUST YOU HAVE IF THE PATIENT IS INTUBATED?
ETCO2, disconnect alarm, and stethoscope.
WHAT DOES PULSE OX MONITOR?
Monitors % of Hgb saturated with O2. Audible pulse flow should be audible, and low limit alarms should be set.
WHAT ARE THE TWO LIGHT EMITTING DIODES AND WHAT DO THEY MEASURE?
Infrared light --> (960nm) OxyHgb
Red light --> (660nm) DeoxyHgb
WHAT DOES BEER-LAMBERTS LAW AND PRINCIPLES OF SPECTROPHOTOMETRY STATE?
Relates the <> of a solute to the intensity of light transmitted through a solution.
WHAT ARE THE FACTORS THAT ALTER READINGS OF A PULSE OX?
-Decreased pulsatile blood flow (hypothermia, hypotension, hypovolemia) - bright lighting, shivering, venous congestion, nail polish, methylene blue, MethHgb, carboxyHgb, motion/electrical interference, mal position.
WHAT IS CARBOXYHGB AND HOW DOES IT MANIFEST?
COHb, exists in smokers and urban polluted areas. May occur in very high <>'s in smoke inhalation.
COHb has an absorption spectrum similar to Oxyhgb (960nm) so most pulse ox's will overread the SpO2 in smoke inhalation patients---> falsely high readings.
CO TOXICITY --> cherry red appearance late sign!!!!
WHAT IS METHEMOGLOBIN AND HOW IS IT MANIFESTED?
metHg, It is normal <1% in humans blood.
Oxidation product of hemoglobin Fe3+ (ferric) that forms a reversible complex with O2 and impairs unloading of O2 to tissues.
(Fe 2+) ferrous is the normal iron in Hgb
Can be congenital or acquired.
acquired--> nitrobenzene, benzocaine, prilocaine, and dapsone.
(Prilocaine) metabolite of o-toluidine, which oxidizes Hgb to metHgb.
METHEMOBLOBIN AND ABSORPTION?
has the same absorption at both the red and infrared wavelengths, this creates a 1:1 ratio.
WHAT DOES THE RATIO 1:1 WITH METHEMOGLOBIN MEAN?
Sats will read 85%
So metHgb causes a falsely low saturation when SpO2 is greater than 85%, and a falsely high SpO2 sat when the actual sats are lower than 85%.
WHAT ARE THE SIGNS AND SYMPTOMS OF METHGB?
Brownish grey cyanosis, tachypnea, metabolic acidosis.
WHAT ARE THE S/S RELATED TO IN METHGB?
1) tissue hypoxia
--LOC may occur in 50-60% of cases
Healthy patients can tolerate but ***patients with severe anemia, or heart failure cannot tolerate the reduced oxygen carrying capacity.
WHAT IS THE TREATMENT FOR METHGB?
Spontaneous reversal can occur in about 2-3 hours following last dose of the offending drug.
Methylene blue 1mg/kg for immediate treatment.
WHAT HAPPENS WHEN YOU TREAT METHGB?
Fe3+ turns back to Fe2+
Ferric goes back to ferrous.
MAP IS WHAT?
an indicator of end organ perfusion NOT a measure of end organ perfusion.
WHAT SHOULD CUFF SIZE BE?
20% > than diameter of limb and cover 2/3 of upper arm or thigh
WHAT DO UNDERSIZED AND OVERSIZED CUFFS READ?
UNDERSIZED falsely high readings
OVERSIZED falsely low readings
WHAT IS TRUE ABOUT PULSE PRESSURE?
The more peripheral (away from the heart) the wider the pulse pressure.
WHAT IS PULSE PRESSURE?
It is the difference between systolic and diastolic blood pressure.
WHAT WILL HAPPEN IF THE BLOOD PRESSURE READING FROM EITHER THE A LINE OR CUFF IS ABOVE THE LEVEL OF THE HEART?
+/- 0.7 mmHg for each cm off the horizontal plane of the heart.
If arm is above the level of the heart you will get a low reading.
If below the level of the heart you will get a high reading.
WHAT IS THE DEFLATION RATE OF THE CUFF?
2-3 mmHg per heartbeat or 3-5 mmHg per sec
WHAT ARE KAROTKOFF SOUNDS?
volatile blood flow which causes vibrations against the arterial walls.
WHAT DO AUTOMATIC BP CUFFS MEASURE?
They measure oscillations,
WHAT IS MAP?
Mean arterial pressure.
Formula 2 x diastolic + systolic/ 3
MAP is the point at which there are maximal oscillations.
WHAT IS THE ALLENS TEST?
Determines the adequacy of ulnar collateral flow and the integrity of the radial artery.
Hold pressure on radial artery for 5-6 seconds have patient make fists, let go and observe for return of pink color to the hand.
If the hand does not quickly turn back pink it is considered a (+) allens test and do not put a radial a line in that hand.
WHAT HAPPENS WITH A READING THAT IS MORE PERIPHERAL FROM THE HEART?
the wider the pulse pressure and the higher the systole, and the lower the diastolic.
WHAT DO YOU NEED TO INSERT AN A-LINE?
1) 18-22 gauge catheter
2) armboard
3) alcohol or betadine
4) lidocaine syringe 25g
5) tape
6) dressing
7) sterile gloves
8) transducer setup
9) face shield
WHAT ARE THE STEPS FOR THE TECHNIQUE OF INSERTING AN A-LINE?
Apply armboard, hyperextend the thumb
Palpate the radial artery
Clean the site
skin wheel with TB syringe of 1-2% lidocaine
Sterile gloves
Insert angio at 45 degree angle until you get flashback, flatten the angle and advance, guide wire if available thread over wire, occlude attach tubing, suture.
WHAT INFORMATION DOES A-LINE MONITORING GIVE YOU?
-slope of upstroke- myocardial contractility
- resp variations- large variations may be indicative of hypovolemia
- slope of downstroke- SVR (slurred delayed downstroke indicative of increased afterload
- Dicrotic notch- AV closure
WHAT IS GOOD ABOUT LEAD II?
Easiest to see the p wave, better diagnosis of arrhythmias, and will show inferior ischemia.
WHAT DO LEADS II, III, AND aVF SEE?
disease in the inferior side of the heart. RCA
WHAT DO LEADS V1-V6 SEE?
left anterior descending and circumflex artery distribution
LEADS V1, V2, V3
anteroseptal wall
LEADS V3, V4, V5
anteroapical wall
LEADS V4, V5, V6
anterolateral wall
LEADS V1, AND aVL?
posterior wall of the heart (reciprocal)
DIAGNOSTIC MODE OF MONITOR FOR EKG?
least amount of filtering, best for assessing acute changes or pt's risk for ischemia
MONITOR MODE FOR EKG?
more filtering therefore less diagnostic
FILTER MODE FOR EKG?
most filtering so changes can be missed
WHAT DOES CVP MEASURE REFER TO?
hydrostatic pressure generated by the blood within either the right atrium, or the great veins of the thorax at a point adjacent to the right atrium
WHAT DOES CVP ESTIMATE?
estimated by analyzing two factors, preload and the ability of the right ventricle to pump blood through the pulmonary circulation
WHAT CAN YOU TELL FROM THE CVP NUMBER?
vasodilation, myocardial ischemia, hypvolemia, hemmorhage, fluid infusion, alterations in local tissue metabolism, changes is sympathetic stimulation
WHAT ELSE DOES CVP REFLECT?
RVEDP which is preload for the right ventricle
*** if the patient is healthy, may also reflect LVEDP
*** if patient has pulm HTN, or ventricular failure a PAP may be warranted
WHAT ARE THE NORMAL VALUES FOR CVP? AND WHAT DO THEY REFLECT
1-15 mmHg
depends on patients volume status,
presence of PPV
cardiac function and chamber compliance
WHAT ARE THE CONTRAINDICATIONS OF INSERTING A CVP?
infected Tricuspid valve vegetations, renal cell tumor extension into right atrium, ipsilateral CEA, anticoagulation, SVC syndrome (obstruction of the SVC), infection at the site of insertion, newly inserted pacing wires, presence of carotid disease, CONTRA LATERAL DIAPHRAGMATIC DYSFUNCTION, thyromegaly or prior neck surgery
WHAT ARE THE CVP WAVEFORMS?
three peaks a, c, and v waves
two descents x, y
WHAT IS THE A WAVE?
R atrial contraction, occurs just after the p wave
(absent in a-fib, may be exaggerated in junctional rhythms)
WHAT IS THE C WAVE?
occurs due to isovolumic ventricular contraction, forcing the tricuspid valve to bulge upward into the right atrium
WHAT IS THE V WAVE?
reflects venous return against closed tricuspid valve
(LARGE v waves with tricuspid regurgitation
CVP INSERTION TECHNIQUE
1) Put on monitors 2) Remove pillow and rotate the head to the left 3) Use the bony landmarks of medial end of clavical and mastoid process 4) Place pt in trendelenburg (to distend IJ and reduce risk of air emboli) 5) Full glove and gown sterile prep 6) Recheck landmarks, palpate carotid and immediately lateral 7) If pt awake skin wheel 1% Xylocaine (withdraw on syringe before injecting) 8) using finder needle go b/t sternal head and clavicular head of sternocleidomastoid and insert finder needle aiming toward ipsilateral nipple as you aspirate 9) Once vein has been located leave the finder needle in place 10) Remove finder remember direction 11) Insert 18g 1 3/4 in catheter over needle unit into IJ (constant aspiration is required to see flashback) 12) when flashback is seen advance 1 mm then advance catheter- once iv placement established place finger or syringe over cap to prevent air - withdraw catheter until free blood flow - check for lack of pulsatile flow - compare IJ and arterial blood - pass flexible wire through the catheter (watch ECG monitor for arrythmias) - make small slit with scapel and advance dilator over the wire - advance catheter - check for blood return and flush all ports
WHAT IS THE MOST COMMONE REASON TO USE A SWAN? OTHER REASONS?
Shock (most common) - poor LV function - detect MI or IABP - complicated valve lesions - severe pulm disease - Bleomycin toxicity - complicated surgical proc - massive trauma - hepatic transplantation
TECHNIQUE OF INSERTION OF SWANS
Seldinger tech (same as CVP) - sheat over swan (flushed and checked) - insert until you get ~20cm - Inflate balloon and advance until you see RV waveform ~ 30-35cm - Cont to advance to PA ~40-45cm - at ~50cm balloon will wedge into PA - deflate balloon and it will float back into the PA *****know these numbers
WHAT ARE THE CONTRAINDICATIONS OF INSERTING SWANS
LBBB - tricuspid or pulmonary valve stenosis - right atrial or right ventricular masses - tetralogy of falot - all others same as with CVP
WHAT IS THE TEE USED FOR?
diagnose myocardial ischemia - valve problems - wall motion abnormalities - air emboli - confirm the adequacy of valve reconstruction - determine the cause of intraop complications or hemodynamic disorders
WHAT DOES THE EEG MONITOR?
- monitors cerebral function and ischemia - used in carotid and neurosurgery - measures electrical activity of the neurons in the cerebral cortex - detects risk of ischemia due to hypoperfusion
ALPHA WAVEFORM ON EEG?
eyes closed but awake
BETA ON THE EEG?
normal, awake waveform
DELTA ON EEG?
sleep state (deep sleep)
THETA ON EEG?
sleep state
WHAT ARE YOU CONCERNED WITH ON THE EEG?
-decreased blood flow to the brain - loss of amplitude - increase in slow wave activity - loss of fast activity
WHAT ARE THE WAVEFORMS AFFECTED BY?
temp - bp - pH - (electrolyte/CO2 abnormalities) - anesthetics
WHAT DO ANESTHETICS DO ON THE EEG ?
cause a combo of slow frequencies and superimposed fast activity
**as depth of anesthesia gets deeper the EEG becomes slower
WHAT DOES BIS MONITORING DO?
Calculates a single number that correlates with depth of anesthesia and hypnosis
WHAT DO THE NUMBERS IN BIS MONITORING MEAN?
85-100 - awake, memory intact
65-84 - sedation
40-64 - general anesthesia, deep hypnosis
< 40 - cortical suppression
WHAT ARE EVOKED POTENTIALS AND WHAT DO THEY DO?
evaluate integrity of neural pathways by monitoring response to stimulus - electrical potentials are generated in response to stimulation of a peripheral or cranial nerve - potentials are recorded as they travel from the periphery to the brain -
WHAT DOES A DAMAGED PATHWAY SHOW?
decrease in amplitude of waveform and prolonged latency
AMPLITUDE - intensity of response
LATENCY - length of time from stimulation to time it reaches the brain
WHAT ARE SSEP'S?
somatosensory evoked potentials (dorsal)
- stimulate peripheral nerve
- record evoked potential over spinal cord or brain
- used in TAA'S, A/P spinal fusions, harrington rods, complex back surgeries
(SSEP'S are sensing (afferent) effector (efferent) motor coming down from the brain)
WHAT ARE BAEP'S OR BAER'S?
brainstem auditory ep's
reflect impulses along auditory pathways
MOST RESISTANT TO EFFECTS OF ANESTHESIA
Posterior fossa crani's, acoustic neuromas, CN VIII
WHAT ARE VEP'S?
Visual EP's
measure cerebral response to flashing light
surgery near optic nerve, pituitary tumor resections
WHAT ARE MEP'S?
Motor evoked potentials.
(ventral)
Detect motor function of the spinal cord.
MOST SENSITIVE TO EFFECTS OF ANESTHESIA
TAA'S and spinal surgeries
WHAT DOES CAPNOGRAPHY MEASURE?
ETCO2, gold standard of ET placement and verification
- Continuous monitoring of alveolar ventilation
(PaCO2 <> on avg are 4-6 mmHg > than ETCO2 due to V/Q mismatching (alveolar dead space, alveoli that are ventilated but not perfused)
WHAT DOES CAPNOGRAPHY HELP YOU EVALUATE?
-evaluates co2, pulm and metabolic status of the patient,
WHAT IS CAPNOMETRY?
the measure of CO2
WHAT IS A CAPNOGRAM?
plotting of CO2 over time
WHAT IS A CAPNOMETER?
instrument used to measure CO2
IF NO CO2 DETECTED?
ASSUME FAILURE TO VENTILATE--> then check equipment failure, apnea, disconnect, accidental extubation, esophageal intubation, no perfusion state
WHAT WILL HAPPEN IN A NO PERFUSION STATE?
your CO2 will be low
HOW DO YOU ANALYZE A CO2 WAVEFORM?
HEIGHT - higher (increasing CO2)
FREQUENCY - more frequent increasing RR
RHYTHM -
BASELINE - should return each time to zero
WHAT DO YOU DO IF THE CO2 WAVEFORM DOES NOT RETURN TO ZERO?
Recalibrate, could be rebreathing CO2, or retaining CO2.
Check the soda lime, change it and check the expiratory valve
WHAT ARE THE FOUR PHASES OF ETCO2 MONITOR MEAN?
4 PHASES
I - inspiration (no CO2, breathing in O2)
II - expiratory upstroke (beginning to exhale)
III - expiratory plateau, (static period, no air movement)
IV - inspiratory downstroke, (fresh gas entrained, CO2 washed away)
WHAT IS GOING ON IF YOU HAVE A LEANED OVER CO2 WAVEFORM?
the patient is having trouble exhaling
- COPD, kink, foreign body obstruction, emphysema
STAIR STEPPING FORM ON CO2 WAVEFORM?
cardiac oscillations (normal)
V FORM IN THE MIDDLE OF THE CO2 WAVE?
curare cleft ( patient is attempting to breathe)
WHAT'S PROB HAPPENING WITH A GRADUAL DOWNSTROKE?
inspiratory problem probably kink in tube
WHAT DOES ESOPHAGEAL INTUBATION LOOK LIKE?
waveform small and gradually decreased to zero
WHAT MAY A LOW ETCO2 WITH A GOOD ALVEOLAR PLATEAU SHOW?
hyperventilation or an increase in dead space ventilation
***comparison of PetCO2 with PaCO2 is necessary to distinguish these two conditions
**you can also slow their breathing and see what happens
ELEVATED ETCO2 WAVEFORM WITH GOOD ALVEOLAR PLATEAU?
may be hypoventilation or increased CO2 delivery to the lungs
**could be not fast enough or deep enough breathing, MH, hyperthermia, could also be the belly inflated with CO2
CURARE CLEFT?
looks like a M
occurs during spontaneous breathing, the cleft is in the last plateau, and is caused by a lack of synchronous action between the intercostal muscles and the diaphragm, most commonly caused by inadequate muscle relaxant reversal.
**the depth of the cleft is proportional to the degree of muscle paralysis
**the notch is also seen in patients with cervical transverse lesions, flail chest, hiccups, and pneumothorax when a patient tries to breathe during mechanical ventilation.
SPONTANEOUS RESPIRATIONS DURING MECHANICAL VENTILATION?
causes include maladjusted ventilator (hypoventilation), inadequate muscle paralysis, severe hypoxia, or the patient waking up
CARDIAC OSCILLATIONS?
believed to represent the effects of the contractions and relaxations of the heart and intrathoracic great vessels of the lungs, forcing air in and out.
***many things contribute - presence of negative intrathoracic pressure, a low RR, dimunition in the VC: heart size ratio, low inspiratory : expiratory ratio, low tidal volumes, and muscular relaxation
**rule rather than the exception in pediatric patients
OBSTRUCTIVE ETCO2 WAVEFORM?
slanting and prolongation of the expiratory upstroke, indicative of tube obstruction, or obstruction in patient's airway, (chronic obstructive lung disease, bronchospasm, asthma, or upper airway obstruction)
PROBLEM WITH ETCO2 BASELINE?
incompetent expiratory valve, (normal waveform just not going to baseline)
**could also be exhauseted absorbent in the circle system, insufficient gas flow in mapleson system, problems with the inner tube of the Bain system, deliberate addition of CO2 to the fresh gas,
**might also be a spontaneously breathing patient under the drapes that is not intubated
INCOMPETENT INSPIRATORY UNIDIRECTIONAL VALVE?
prolonged CO2 plateau and an inspiratory downstroke that is less steep
***may be seen with suction on a chest tube
REINSTATING SPONTANEOUS BREATHING?
In the beginning first breath is typically of small volume,
WHAT COULD CAUSE A SUDDEN DECREASE IN ETCO2 READING FROM NORMAL TO ZERO?
PE, esophageal intubation, ventilator disconnection or defect in ventilator, defect in CO2 analyzer, kinked ET tube
SUDDEN DECREASE OF ETCO2 BUT NOT TO 0?
leak in ventilator system, partial disconnect, partial airway secretions, (secretions)
EXPONENTIAL DECREASE IN ETCO2?
PE, cardiac arrest, hypotension (sudden), severe hyperventilation
CHANGE IN CO2 BASELINE?
CO2 absorber saturation (anesthesia), calibration error, water droplet in analyzer, mechanical failure (ventilator),
SUDDEN INCREASE IN ETCO2?
Accessing an area of lung previously obstructed, release of tourniquet, sudden increase in bp
GRADUAL LOWERING OF ETCO2?
hypovolemia, decreasing CO, decreasing body temp, hypothermia, drop in metabolism
GRADUAL INCREASE IN ETCO2?
rising body temp, hypoventialtion, CO2 absorption, partial airway obstruction (foreign body) reactive airway disease.
WHAT DO SPIROMETERS MEASURE?
RR, MV, AND TV (manual or electric)
INFRARED ANALYSIS?
Absorption of energy yields measurement, (gas drawn out of circuit, exposed to infrared energy, --> CO2, ISO
MASS SPECTROMETRY OF ETCO2?
sample ionized in electron beam, fragments form and are weighed, <> of agents are determined.