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APA I > Foundations I-Clinical Monitoring Quiz 2 > Flashcards

Foundations I-Clinical Monitoring Quiz 2 Flashcards

1
Q

What is Standard V from AANA?

A

Monitor the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs

*omission of any monitory standards shall be documented and the reason stated on the patients anesthesia record.

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2
Q

What are we required to monitor and document?

A
  • ventilation
  • oxygenation
  • cardiovascular status
  • body temperature
  • neuromuscular functional and status
  • patient positioning
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3
Q

What are some aspects of ventilation that you should monitor?

A
  • verify intubation of trachea
  • auscultation B/L breath sounds
  • observe end-tidal CO2
  • use spirometry and ventilatory pressure monitors as indicated
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4
Q

When are precordial and esophageal stethoscopes indicated?

A
  • provides continuous assurance that ventilation is occurring, quality of breath sounds, regularity of heart rate and quality of heart tones
  • is useful in detecting changes in breath sounds
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5
Q

When is a precocial or esophageal stethoscope contraindicated?

What are potential complication of precocial stethoscopes?

What are complication of esophageal stethoscopes?

A

-esophagus should be avoided if history of esophageal varices, strictures, bariatric surgery, etc

Precodial
-generally unlikely, but local allergic reactions, skin abrasions/burns, and pain when adhesive is removed can occur

Esophageal

  • mucosal irritation or bleeding
  • if slides into the trachea vs the esophagus a gas leak will occur around the ETT
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6
Q

What is pulse oximetry?

A
  • continuous noninvasive monitory of peripheral arterial hemoglobin O2 saturation
  • provides early warning of arterial hypoxemia that may not be appreciated by subjective observations
  • no contraindications
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7
Q

What are the 2 wavelengths used in pulse oximetry?

A

2 waves of light

  • 660mm (red): absorbed by deoxyhemoglobin
  • 940mm (infrared): absorbed by oxyhemoglobin
  • passes through arterial bed
  • wavelengths received and analyzed based on light reaching photo detector
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8
Q

What is Beer Lambert’s Law?

A
  • relates the absorption of light by a solute to its concentration and optical properties at a given wavelength
  • depends on the absorbable characteristic of hemoglobin in the red and infrared range
  • in the red region, oxyhemoglobin absorbs less light than deoxyhemoglobin and vice verse in infrared region
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9
Q

What are some reasons for inaccurate pulse-ox measurements?

A 
Physiologic states of hypoperfusion
-vasoconstriction
-hypothermia
-hypotension
Motion artifact
Methylene blue (interferes with absorption of light in sensor)
Anemia
-hemoglobin <5g/dL
Cautery interference
Abnormal Hgb
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10
Q

What is end-tidal CO2 monitoring

A

Capnometry

  • continuous measurement of a patient’s inhaled and exhaled concentration of CO2
  • provides info about adequacy of ventilation
  • confirms placement of ETT

end-tidal from ETT and LMA are accurate. Nasal cannula not accurate

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11
Q

What does the absence of and end-tidal CO2 waveform indicate?

A
  • esophageal intubation
  • accidental disconnect from breathing system
  • cardiac arrest
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12
Q

Is end-tidal CO2 higher or lower than PaCO2?

A

End-tidal CO2 is 2-5 Torr (?) lower than arterial PaCO2

-gap will widen if pt smokes

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13
Q

What are the different points along an end-tidal CO2 waveform?

A

4 Phases
A-B: inhalation. Baseline Should be 0
B-C: expiratory upstroke mix of dead space and alveolar gas
C-D: expiratory plateau. Alveolar emptying of CO2
D: represents where end-tidal measurement is taken
D-E: descent to baseline, pt beginning to inhale

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14
Q

What will the end-tidal CO2 waveform look like in a pt with COPD or asthma?

A
  • will look like a “shark-fin”.

- takes longer to breath out, has a slow upstroke.

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15
Q

What are multiple gas analyzers?

A
  • continual analysis of inhaled and exhaled concentrations of respiratory and anesthetic gases.
  • no contraindications
  • There are different types
    • mass spectrometry
    • infrared spectrometry
      • monochromatic infrared spectrometry
      • polychromatic infrared spectrometry
    • Raman spectroscopy
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16
Q

What is mass spectrometry?

A

Complex system that could connect up to 32 rooms. A computer directed all operations of the system and data that was collected was delivered to the individual room for the anesthesiologist to use
-no longer being manufactured

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17
Q

What is monochromatic infrared spectrometry?

A
  • Infrared beam of light with a wavelength of 3.3um is passed through the anesthetic gas sample
  • absorption spectrum of halogenated agents is similar at this wavelength of light
  • the monitor must be programmed with the agent selected
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18
Q

What is polychromatic infrared spectrometry?

A
  • infrared beam of light with a wavelength 7-13um is passed through the anesthesia gas sample
  • absorption spectrum of halogenated agents is different at this wavelength
  • the monitor can describe the concentration of the gas being delivered
  • should the SRNA change from one agent to another, the monitor can measure the concentration of both drugs simultaneously
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19
Q

What is Raman spectroscopy?

A

-measures composition and concentration of gasses present in a pts airway by measurement of the spectrum of “Raman scattered light” from these gases

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20
Q

What is a respirometer/ventimeter?

A

Old machines:

  • gauge located on the exhalation limb of the anesthetic breathing system
  • measured tidal volume and minute ventilation

New machines:
-now digital information is incorporated into the anesthesia display panel

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21
Q

What is the peak inspiratory pressure gauge used for?

A

-measures positive pressure created by mechanical ventilation of the lungs

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22
Q

What does the low pressure disconnect alarm indicate?

A
  • the minimum inspiratory pressure did not achieve predetermined level
  • disconnect in the patient breathing system
  • leak in patient breathing system
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23
Q

What does the high peak inspiratory pressure alarm indicate?

A
  • alarm indicating the positive airway pressure exceeded a predetermined value
  • excessive airway pressure may indicate low pulmonary compliance
  • check for obstruction in the breathing system
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24
Q

What level is the high peak pressure alarm usually set at?

A

-40cm H2O

25
Q

What are examples of vigilant “real-time” assessments that SRNAs should monitor?

A
  • hand on reservoir bag
  • observation of chest movement
  • auscultation with precodial stethoscope
    • respiratory rate
    • regularity of effort
    • depth of tidal volume
  • ongoing assessments are used to evaluate
    • adequacy of pt airway
    • depth of anesthesia
    • titration anesthetic agents to effect
26
Q

How often should we record blood pressure and heart rate?

A

At least every 5 minutes

27
Q

What is used to proved a recording of electrical potentials generated by myocardial cells?

A

ECG

Electrocardiography

28
Q

Does and ECG measure heart function?

A

NO

You may have normal ECG complexes on the monitor with no effective cardiac output

29
Q

What may predict or prevent adverse cardiac outcomes in some pts?

A

ST segment analysis

  • continuously analyzes ST segments for early detection of myocardial ischemia
  • *standardized 1mVB signal changed indicates a deflection of 10mm on a paper strip**
30
Q

Routine intra-op use of ECG allows for detection of what?

A
  • arrhythmia
  • myocardial ischemia
  • conduction abnormalities
  • electrolyte disturbances
31
Q

How should the sound on your ECG monitor be set?

A

The audible beep for each QRS complex should be set loud enough to detect rate and rhythm changes when visual attention is directed to other clinical tasks

32
Q

Why are the images provided from a TEE so good?

A

Bc the transducer lies in the lower esophagus in close direct fluid contact with the posterior of the heart, the images are superb since there is no interference by lung tissue

33
Q

T/F: With the use of topical mouth anesthesia, most pts are able to swallow the TEE probe easily.

A

True

34
Q

CVP = what pressure?

A

Right atrial pressure

35
Q

What is a major determinant of right ventricular end-diastolic volume?

A

Right atrial pressure

*in healthy hearts, right and left ventricular performance is parallel, so left ventricular filling can also be assessed by CVP measurement

36
Q

What provides a more accurate hemodynamic assessments in the critically ill patient that clinical assessment alone?

A

Pulmonary artery catheter

37
Q

Why is the use of PAC controversial?

A
  • Recent study found there was no difference in pt mortality of in ICU or hospital length of stay when PACs were used
  • while some pts may have improved outcomes with PACs, many pts with lower severity of illness may have increased mortality
38
Q

When should you continuously monitor body temperature?

A

-on all pediatric patients

And when indicated on all other pts

39
Q

Why is it important to continuously monitor pt temp?

A
  • during GA the body cannot compensate for hypothermia
    • inhibits central thermoregulation by interfering with hypothalamic function
  • during spinal/epidural anesthesia hypothermia occurs secondary to natural redistribution of heat
    • sympathetic blockade causes vasodilation with peripheral pooling of blood

-regional blockade also imparts thermoregulation process

40
Q

When do you monitor neuromuscular function?

A

Whenever neuromuscular blocking agents are administered

-no contraindications

41
Q

What are the 2 sites used to monitor neuromuscular function?

A
  • Adduction pollicis muscle (stimulated by ulnar nerve)
  • Orbicularis oculi contraction (stimulated by facial nerve)
  • the orbicularis oculi recovers from neuromuscular blockade before the adduction pollicis
  • flow gos from positive to negative
42
Q

What is “fade” when monitoring neuromuscular function?

A

When twitches become progressively weaker

43
Q

What percentage of receptors are blocked when a pt starts to lose twitches?

A

70%

44
Q

Will you see fade in depolarizing or non-depolarizing neuromuscular blockers?

A

Non-depolarizing: will see fade

Depolarizing: no fade. Twitches all the same

45
Q

Which neuromuscular blockers will pts have vessiculations? (Sp?)

A

Depolarizing neuromuscular blockers will cause pts to move.

Non-depolarizing, pts won’t move

46
Q

When might a foley be indicated to monitor renal function?

A
  • CHF
  • renal failure
  • shock
  • procedure where large fluid shifts are expected
  • intraoperative diuretics
47
Q

How does a foley monitor renal function?

A
  • provides a reliable measure of urinary output
  • reflection of kidney perfusion and function
  • indicator of renal, cardiovascular, and fluid volume status
48
Q

Oliguria is defined as what?

A

Urine output <0.5mL/kg/hr

49
Q

What are uses of EEG monitoring?

A
  • monitor cerebral function
  • provides early evidence of cerebral ischemia
    • carotid endarterectomy
    • cardiopulmonary bypass
  • has been advocated as a monitor of depth of anesthesia
    • EEG activity generally decreases in amplitude and frequency while pt is under GA
  • complexity of interpretation detracts from frequent use
50
Q

What are evoked potentials?

A
  • an electrical manifestation of the brain’s response to an external stimulus
  • most EPS cannot be seen in routine electroencephalographic recordings bc of their low amplitudes (0.1-20uV) and their admixture with background brain-wave actively and artifacts
51
Q

When are intra-op evoked potentials used?

A
  • when a surgical procedure is associated with potential for neurological injury
    • spinal fusion
    • craniotomy
52
Q

What are the non-invasive uses of evoked potentials?

A

-assess neural function by measuring electrophysiology capacity responses to sensory stimuli

  • visual evoked potentials (VEP)
  • Auditory evoked potentials (AEP)
  • Somatosensory evoked potentials (SSEP)
  • motor evoked potentials (MEP)

*general anesthesia can alter these

53
Q

What is bispectral index monitoring?

A

BIS monitoring

  • processes EEG that reflects sedative and hypnotic effects of anesthetic drugs on CNS
  • 0-100
  • <60 = high probability of unresponsive ness during surgery and a low probability of intraoperative awareness
  • goal is to titration anesthesia to maintain BIS near 60

-supposed to decrease total drug use and more rapid emergence and recovery

54
Q

What is cerebral oximetry monitoring>

A
  • noninvasive, safe and effective oxygen monitor for adults, children, infants and neonates
  • can use if believe pts at risk for oxygenation problems
  • use pt’s baseline and don’t want to drop below that
  • uses optical spectroscopy to proved real-time monitoring of changes of regional oxygen saturation (rSO2) of blood in the brain or other body tissues beneath sensor
55
Q

Hypothermia is defined as:

A

Temperature less than 36 degrees C

Normal temp is between 36.7-37.1

56
Q

What are the 4 ways of heat loss and their percentages?

A
  1. Radiation: Infrared (60%)
    - the #1 source of heat loss
    - most heat is lost through the skin
    - covering the pt reduces radiant heat loss
  2. Convection: Air (15-30%)
    - #2 source of heat loss
    - the transfer of heat by the movement of matter
    - think of as “wind chill”. Air movement over body whisks away heat that has been radiated from body
    - laminar flow increases the amount of heat loss to convection
  3. Evaporation: Water loss (20%)
    - it takes a sig amount of energy to vaporize water
    - can be lost through evaporation from respiration, wounds, and posture of internal organs during surgery
  4. Conduction: Contact (<5%)
    - heat loss when pt comes in contact with cooler object
57
Q

What are 3 phases of intra-op heat transfer?

A
  1. Heat redistribution from core to periphery
  2. Heat transfer > heat production
  3. Heat transfer similar to heat production
58
Q

At what position should esophageal temp probe be placed?

A

-distal 1/3 - 1/4 of esophagus (38-42cm past incisors)

  • in stomach temp will be increased due to heat created by liver metabolism
  • proximal esophagus temp will be decreased due to cool inspiratory gas

APA I (9 decks)

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