clinical monitoring in anesthesia

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clinical monitoring in anesthesia
2013-11-09 20:32:28
principles anesthesia

principles of anesthesia
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  1. Standards for monitoring were first introduced by who in what year
    The AANA in 1974

    This is an expected standard of care required by JCAHO
  2. Monitors were encouraged by anesthesiology staff at what medical school in what year
    Harvard medical school in 1986

    * Quickly adopted by ANA, this act raised awareness amount the medical community and was help as a legal precendence
  3. What year were monitors required to be used
  4. Part 1 standard V of AANA professional practice manual states
    monitor, evaluate, and document patients physiologic condition as appropriate for the type of anesthesia and specific patient needs. When any physiologic monitoring devise is used, variable pitch and threshold alarms shall be turned on and audible
  5. AANA standard for monitoring include
    • ventilation
    • oxygenation
    • circulation
    • thermoregulation
    • NM functioning
    • Positioning
    • ETCO2
    • *ANA standards address first four and are very similar to the AANA standards.
  6. CO2 monitoring should be done how often?
    continuously through capnography
  7. All alarms must be
  8. during moderate or deep sedation continuously monitor what
  9. Pulse oximetry is used when
    during all anesthetics, tone should be audible
  10. ECG monitoring should be used when
    continuously from beginning to end of procedure
  11. How often should you record BP and Heart rate for:

    monitored IV sedation

    General anesthetic
    atleast every five minutes for monitored IV sedation

    every 3 minutes for general anesthetic
  12. Who should continuous monitoring of temperature be done on
    all pediatric patients

    -other patients if changes in body temp are anticipated, intended, or suspected
  13. When is continuous monitoring of NM function needed

    What is used to assess this
    when NM agents are used

    Use a peripheral nerve stimulator to monitor effects of NM drugs
  14. Most common site for arterial line
    radial artery
  15. CVP monitors do what
    monitors intravascular volume status ,and helps measure left ventricular filling, atrial dysrhythmia, and right sided valve dysfunction
  16. PA catheter measures what
    CO, mixed venous oxygen tension, pulmonary arterial and right arterial pressure and LVEDP (left ventricular end diastolic pressure)
  17. What is the primary method to confirm bilateral lung ventilation
    chest auscultation

    ETCO2 monitor is primary mechanism to exclude esophageal intubation
  18. precordial stethoscope what is it and what does it detect
    metal chest piece that seals to patients skin with hollow tubing ear piece

    • -easily detects changes in breath and heart sounds  
    • ---- airway or circuit disconnect
    • ---- endobronchial intubation
    • ---- Anesthetic depth
  19. Where do you place precordial stethoscope in children
    • over left chest or supraclavicular notch to monitor for right main stem intubation
    • ie- no breath sounds on left side would indicated right main stem
  20. Esophageal stethoscope is what and what does it do
    • small soft plastic catheter
    • balloon covered distal opening with temp probe

    • Excellent for quality of breath and heart sounds
    • accurate for core body temp
    • ***limited to intubated patients
  21. Where do you place esophageal stethoscope
    distal 1/3 of esophagus in anesthetized patients
  22. What will you see in esophageal intubation
    ETCO2 will be normal at first, but then will begin to drop off.

    After patient is masked there is CO2 in stomach for a few minutes that is why you will get a reading for a few seconds
  23. CO2=0 what does this indicate
  24. What should CO2 be during inspiration
    • 0
    • if your baseline is not zero you have a problem
  25. Capnometry is what and measures what
    an invaluable tool for monitoring adequacy of ventilation

    Measures CO2 concentration during respiratory cycle

    Measurement and display of carbon dioxide on a digital or analogue monitor. Maximum inspiratory and expiratory CO2 concentrations during respiratory cycle are displayed
  26. Increased metabolism= ____ CO2
  27. Decreased metabolism = ____ CO2
  28. CO2 is  ___ with MH
  29. CO2 is ____ with hypothermia
    decreased b/c hypometabolic state
  30. CO2 is ____ with embolism
  31. IF CO2 drops what do you want to check related to circulation
    BP, it could be sign of bleed
  32. PaCO2 and ETCO2 should be what
    equal or close within 1-6 mmHg, if patient has bad lungs the number may be different
  33. Normal PaCO2

    What do you want ETCO2 to be?

    want end tidal to be 35 so patient wont try to breath on own
  34. PaCO2 greater than 45=
    PaCO2 less than 35 =
    greater than 45= hypoventilation

    less than 35= hyperventilation
  35. PACo2 reflects what
    the adequacy of ventilation for removing CO2 from the blood
  36. Capnography is a breath by breath analysis and clinical data is based on
    • shape of curve
    • height
    • rate
    • baseline examination
  37. Phase I of  wave form

    What should CO2 be
    • represents the first portion of expired air (Dead space)
    • corresponds with dead space ventilation

    fresh gas moves over sampling site

    CO2 should be zero unless rebreathing occurs
  38. Baseline elevation of wave form could indicate
    • CO2 absorbent exhaused
    • Incompetent expiratory and inspiratory valve
    • Bain circuit flows to low (b/c need really high FGF)
  39. Phase II of waveform
    • early exhalation/ steep upstroke
    • quick mixing of dead space and alveolar gas
  40. prolonged upstroke could indicate

    How much CO2 does this contain
    • mechanical obstruction (kinking of tubing)
    • slow emptying of lungs
    • -COPD
    • -bronchospasm

    5% CO2
  41. Phase III of wave form
    • CO2 rich alveolar air
    • Horizontal with mild upslope
    • Represents maximum CO2 at end of phase
  42. Steepness of phase 3 indicates
    ** it should be horizontal with baseline
    • COPD and bronchospasm
    • (same as phase 2, prolonged upstroke)

    Could also be right main stem if it is a healthy patient with no underlying disease
  43. What part of wave form do you measure end tidal co2

    end of phase III
  44. Phase IV of waveform (downward slope)
    inspiration phase of pure fresh gas
  45. prolonged downstroke of phase IV could indicate
    • restrictive lung disease
    • patient trying to breath with elephant on chest can not breath in very well
    • ie- broken ribs, NM disease of chest wall
  46. ETCO2 wave form either labeled 1,2,3,4 or P,Q,R,S
    • P= dead space ventilation
    • P-Q= mixed alveolar/ dead space ventilation
    • Q-R= Alveolar ventilation
    • R= Max CO2/ETCO2
    • R-S= inhalation (pure fresh gas)
  47. Exponential decrease (CO2 decreasing about half with each breath)  in CO2 on wave form indicated
    • pulmonary embolism
    • hyperventilation- blowing off CO2
    • hypotension- decreased metabolism=decreased CO2
  48. Rapid fall in CO2 to zero in wave form indicates
    • ventilator defect
    • tube disconnect or kink
    • extubation

    **if co2 goes all the way to zero patient could be dead
  49. Rapid decrease in CO2 and cardiac output
    could be from surgeon hitting an artery
  50. what is CO2 embolism  caused from

    what will it show on wave form
    • when surgeon puts in berris needle before placing trochar, CO2 is hooked up to this to inflate abdomen (if in right place the patient will reabsorb CO2)
    • -If needle not in right place and in vessel pt will get CO2 embolism so CO2 will go way up, then rapidly decrease
  51. If berris needle placed in vein what will be heard with stethoscope or ear piece
    mill wheel murmur
  52. CO2 embolism leads to
    cardiovascular collapse
  53. Rapid fall in Co2 on waveform but not to zero could be cause by
    • leak in system
    • progressive obstruction of airway (mucous plug)
  54. Sudden upward shift of baseline and topline on waveform cause by
    contamination of CO2 monitor (moisture)

    * you will have a reading but not an accurate reading
  55. what will hyperventilation show on waveform

    Do what if pt is hyperventilating
    gradual decrease in height of the capnoram, base line remaining at zero

    ***slow patient rate if CO2 is getting to low (they are blowing to much off)
  56. What do you do if Co2 absorber becomes exhausted during case
    Increase FGF
  57. Slow upward shift of baseline and topline
    • 1. miscalibrated unit
    • 2. exhausted CO2 absorber
    • 3. Rebreathing
  58. What does curare cleft at end of phase III indicate
    that patient is starting to breath on their own because NM agent is wearing off.

  59. What was curare used for
    • it was a pigme poison they put it on the end of their darts to kill enemies
    • -used as an anesthetic and could cause NM blockade
    • -it is not used anymore
  60. hypoventilation shows what on waveform
    gradual elevation of the height of capnogram, baseline remains at 0
  61. What does sticking inspiratory valve look like on capnogram
    Kind of looks like curare cleft but will also have an elevation of baseline.

    ***Asses your patient
  62. Elevated baseline of waveform can indicate (3)
    • Rebreathing
    • Exhausted soda lime
    • Inspiratory or Expiratory valve stuck open
  63. What are cardiogenic oscillations
    ripple effect, superimposed on the plateau and the descending limb, resulting form small gas movements produced by pulsations of the aorta and heart
  64. What does patient fighting ventilator look like on wave form

    What do you do if happens in middle of case?
    End of case?
    irregular, clefts seen at beginning or end of phase III, humps in between

    • If middle of case redoes muscle relaxer
    • If end of case may want patient to be waking up.
  65. Progressive slow downslope of waveform
    restrictive lung disease
  66. Progressive slow upstoke
    obstructive lung disease

  67. O2 analyzer
    • routine MANDATORY monitor
    • Measures FIO2
    • Calibrates to room air and 100%
    • Inspiratory limb of breathing circuit
  68. Pulse Ox sensor contains what
    two light emitting diodes- measures 2 lights and then comes up with number
  69. Lambert-Beer law of spectrophometry
    two different wave lengths of light passed through vascular beds differentiate oxygen/deoxyhemoglobin
  70. Oxyhemoglobin absorbs more _____ light, while deoxyhemoglobin absorbs more ____ light?

  71. Carboxyhemoglobin absorbs light identical to _________, thus giving a _____ high reading
    oxyhemoglobin, false
  72. O2 saturation is directly proportional to the amount of what
    oxygen dissolved in the plasma
  73. Pulse ox accuracy correlates well with what 2 things
    arterial samples (PaO2) and the oxyhemoglobin dissociation curve
  74. PO2 30 = SaO2 ___
  75. PO2 60= SaO2 ___
  76. PO2 40= SaO2 ____
  77. Large changes in O2 saturation (SaO2) do not occur until PO2 less than
    60  you have used up reserve at this point

    **PO2 60= 90% sat
  78. Each Hgb molecule holds how many O2 molecules
    4, once the first one leaves the Hgb it makes it easier for others to leave. this results in reduction of O2 saturation
  79. O2 reserve ends at PO2 of

    **this is sat of 90%
  80. Shifts of oxyhemoglobin dissociation curve to right mean, what factors influence this?
    more ready release of O2 from Hgb at the tissue level

    • -Elevated CO2
    • -Elevated temperature
    • -Elevated levels of 2, 3-DPG
    • -Decreased pH, acidosis (elevated H+ ions)
  81. Shifts of oxyhemoglobin dissociation curve to left mean, what factors influence this?
    greater attachment of O2 to Hgb, thereby decreasing release to tissues

    • -decreased CO2
    • -decreased temperature
    • -decreased levels of 2, 3-DPG
    • -increase pH, alkalosis (decreased H+ ions)
  82. Lead II (limb lead)
    • most commonly used- largest voltage projection is onto this lead
    •  (reads between right arm lead and left lower lead)

    • -yields maximum p wave
    • -detects arrythmias
    • -shows inferior wall/ST depression
  83. V5 (brown lead)
    where is it placed

    5th ICS/ left axillary line

    detects anterior and lateral wall ischemia
  84. BP cuff to small=
    false high reading
  85. BP cuff to big=
    false low reading
  86. correct size of bp cuff
    20-50 % greater than the diameter of the patient extremity
  87. hypothermia is < _____ degree Celsius

    significant morbidity < ______degree C

    Fibrillatory threshold <_____ degree C

    In state of KY patient has to be what degree to be declared dead?
    • < 36 hypothermia
    • < 34 significant morbidity
    • <32 Fibrillatory threshold

    95 degrees F in KY, may have to warm them up in order for them to be pronounced dead
  88. During surgery patients loose heat how fast
    0.5 to 1 degree Celsius/hour
  89. Radiation accounts for what percent of heat loss

    what is radiation
    60 %

    Loss of heat from warmer to cooler, vasodilation
  90. Evaporation accounts for what percent of heat loss?

    what is evaporation

    Insensible water/heat loss, ventilation (HME)
  91. Convection accounts for what % of heat loss?

    what is convection
    12 %

    Air movement or ventilation, when things blow across patient
  92. Conduction accounts for what % of heat loss?

    What is conduction
    3 %

    Direct contact, loss of heat from OR table
  93. Contributing factors to hypothermia
    • patient type
    • -ambient room temperature (MAJOR)- this is best way to change patient temp
    • -type/length of surgery
    • -hypothalamic depression
    • -intraoperative fluid replacement
    • -Lack of VIGILANCE

    ***once patient is cold, is much harder to warm them back up
  94. If patient is cold what occurs more
  95. arrhythmias, and make patient bleed more easily
  96. Liquid crystal temp monitoring
    • mylar strips of liquid crystal, good for short cases and peds
    • -use for regional/MAC cases

    • Disadvantages
    • -inaccurate
    • -temp varies with application site
    • -does not approximate core body temp
  97. Probes for temp monitoring:




    Pulmonary artery catheter
    tympanic- reflect brain temp, risk for membrane perf

    rectal- slow response to change in core temp

    • nasal-pharyngeal- accurate core temp if placed next to mucosa
    • -be careful not to cause nose bleed

    -pulm art cath- accurate core body temp
  98. How often are recalls reported
    How many cases annually in US
    1-2 per 1000 cases receiving General Anesthesia


    JCAHO- issued sentinel event alert on preventing and managing the impact of anesthesia awareness
  99. BIS

    reading of 100=

    reading of 0=
    processes EEG info and calculates a number between 0-100

    100= patient fully awake

    0= absence of brain activity
  100. General anesthesia BIS goal is
    between 40-60
  101. 4 patients that are at risk for recall
    • 1. trauma b/c low bp
    • 2. mother- stat c-section
    • 3. people on bypass, bypass eats up drugs
    • 4. people on lots of meds
  102. BIS does NOT determine
    • whether patient will move or not
    • whether patient is in pain

    does not take place of standard monitors and observations of the patient
  103. Invasive Art BP best measured by
    • stiff catheter
    • stiff tubing
    • minimal fluid mass
    • lowest # of stopcocks
    • least connective tubing
  104. risk of femoral art line placement
    hemorrhage because of a lot of movement

    ** Does have Easy access, and good central pressures
  105. Increased risk of complications from art line with patients with
    • -arthrosclerosis (thrombosis)
    • -diabetes
    • -low cardiac output
    • -intense peripheral vasoconstriction
  106. Complication of ART line cannulation
    • Hematoma
    • Thrombosis
    • Damage to adjacent nerves
  107. 2013 updated standards of care (3)
    • 1. a stronger emphasis on the importance of care documentation
    • 2. updates to several monitoring standards, most significantly the requirement to continuously monitor for the presence of expired CO@ during moderate and deep sedation
    • 3. continued emphasis on the importance of CRNA professional judgment and patient advocacy