monitoring

contraindications of central venous cath

Infected tricuspid-valve vegetations Renal cell carcinoma tumor because 1st place it metastisizes to is R atrium- extension into R atrium Ipsilateral CAE (same side carotid endarterectomy because gortex graft does not close back on it's own so pt will need sx if it is punctured) Anticoagulation SVC syndrome Infection at the site of insertion Newly inserted pacemaker wires Presence of carotid disease Contra lateral diaphragmatic dysfunction (paralyzed) Thyromegaly or prior neck surgery If you have a pneumo or paralyzed diaphram choose that side because the pt already has the injury

pulse ox placement, factors altering readings

Placement: Finger; ear; nose; toe; cheek; palm or forefoot in infants Factors that alter readings: Decr. Pulsatile blood flow (hypothermia; hypotension; hypovolemia; PVD); bright lighting; shivering; venous congestion; nail polish; methylene blue; MethHgb; carboxyHgb; motion/electrical interference; malpositioned probe

lead V

5th intercostal space ant. axillary line Most sensitive for ischemia. True lead V possible only with 5 leads Best for detecting anterior and lateral wall ischemia Can do modified lead V with 3-leads by: Place LA (left arm) lead in V5 position then select lead I on monitor

a line BP

Direct, beat to beat measurement Transducer pressure electronic signal display Aids in care of critically ill: Management; frequ. labs; hyper/hypotensive techniques; heparin (ACT/INR/TEG); Cardiac dx; vascular problems Avoid extremities with vascular problems Allen test: determines adequacy of ulnar collateral flow and integrity of radial artery <5-6 sec for return of pink color Tubing: < 4 ft, rigid, free of bubbles, minimal stop cocks

ventilation

Ensure adequate ventilation throughout anesthetic Auscultation, chest excursion, ETCO2- not exact but more adequate on intubated pt vs nasal cannula- always use, disconnect alarms (vent), volume monitoring/alarms (vent) (shunting, emboli, etc could cause inadequate ventilation)

CVP estimated by

Estimated by analyzing two factors: preload and the ability of the right ventricle to pump blood through the pulmonary circulation Factors affecting CVP: Vasodilatation, hypovolemia, hemorrhage, fluid infusion, alterations in local tissue metabolism, myocardial ischemia and changes in sympathetic stimulation

evoked potential

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 periphery to the brain Damaged pathway: Will 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

a line flush, zero pt, sites

Flush 3-5 cc/hr (.5-2 u heparin/cc) pressurized to ~300 torr we dont use heparin anymore bc people were getting HIT from heparin flushes. Saline only. Zero point R atrium: phlebostatic axis Mid ear: seated position (need to know cerebral pressure) zero a line to middle of ear and tells the pressure of the circle of willis in head and tells if they are perfusing their brain Sites: Radial, ulnar, brachial, axillary, femoral, dorsalis pedis, superficial temporal More peripheral

temp monitoring

Hypothalamus regulates temp Anesthetic effects inhibit ability of hypothalamus to regulate body temp Methods Temp strip Placed on skin, usually forehead Doesn't measure core temp., measures skin temp Esophageal stethoscope Most accurate reflection if placed in lower 1/3 of esophagus Swan Best reflection of core temp Rectal/bladder

monitor includes

Includes: Electrocardiography, blood pressure, pulse oximetry, temperature, capnography, heart/lung sounds, nerve stimulation, gas/agent monitors and continual presence of anesthetist

central venous catheters indications

Indications: Major operative procedures involving large fluid shifts and / or blood loss Intravascular volume assessment when urine output is not reliable or unavailable (i.e. renal failure, ureter and bladder surgery, major intraabdominal surgery) Major trauma- you need bigger line- cortus, introducer Surgical procedures with a high risk of air embolism, such as sitting position craniotomies (or any time your surgical site is above the level of the heart, or bladder, terous because exposure of multiple plexuses). In addition to monitoring, the central venous pressure (CVP) catheter may also be used to aspirate intracardiac air. Frequent venous blood sampling Venous access for vasoactive or irritating drugs Chronic drug administration Inadequate peripheral IV access( fat people, bilat mastectomy, bilat amputees, etc) Rapid infusion of IV fluids (using large cannulae) Special Uses: insertion of PA catheters, insertion of transvenous pacing wires, hemodialysis/plasmapheresis

body temp

To aid in the maintenance of appropriate body temperature during all anesthetics. when clinically significant changes in body temperature are intended, anticipated or suspected.

oxygenation

To ensure adequate oxygen concentration in the inspired gas and the blood during all anesthetics Inspired gas Oxygen analyzer On inspired limb of circuit Blood oxygenation Pulse oximeter Adequate visual inspection of pt FIO2 for intubated patients (fration of inspired gas) look at pt- are they pink? cap refill?

circulation

To ensure the adequacy of the patient's circulatory function during all anesthetics. EKG (continuous) Bp, Hr (q 5 minimum not a second later!) In addition: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound peripheral pulse monitoring, or pulse oximetry; visualization of pt

TEE uses

Trans esophageal echo Sends and receives ultrasound waves Depends on intensity of reflected waves all cardiac sx pts get one now Uses Diagnose myocardial ischemia, valve problems, wall motion abnormality, air emboli (looks like snow on the TEE), confirm the adequacy of valve reconstruction and other surgical repairs, determine the cause of hemodynamic disorders and other intraoperative complications Has reduced the need for reoperation, and has facilitated the prevention and early treatment of perioperative complications.

BIS uses

Uses: Decrease incidence of awareness Reduce costs Less drug Faster awakening Less total hospital time

swan ganz uses

Uses: Poor LV function Detect MI or complications of MI (IABP) Complicated valve lesions Shock of any cause Severe pulmonary disease Bleomycin toxicity- chemo drugs with cardiac and pulmonary complications Complicated surgical procedure Massive trauma Hepatic transplantation

monitor uses

Uses: Pre-operative period Intra-operative General, regional, MAC Post-anesthesia/recovery period

monitoring

Vigilance We are the "guardians" of the patients in the O.R. Multiple "monitoring devices" assist us in maintaining that vigilance However, WE are the most important monitor Purpose: Assist with data collection regarding patient's physiologic status & guide the administration of the anesthetic

EEG affected by:

Waveforms affected by Temperature, BP, pH (electrolyte/CO2 abnormalities) Anesthetics Cause a combination of slow frequencies and superimposed fast activity As depth of anesthesia incr. EEG becomes slower

CVP insertion 2 of 2

When flashback is seen, advance 1 mm, then advance catheter Once IV placement is established, end of catheter is capped with finger or syringe to avoid air embolism If blood is not aspirated freely: Catheter is probably through back wall Withdraw catheter until free flow of blood occurs Advance catheter slowly into vein- DO NOT EVER let go of guide wire until you are throwing it in the sharps because it can get sucked in and the pt will need surgery to remove Confirm IV placement (if arterial cannulation, remove catheter and hold pressure for at least 5 min.) Check for lack of pulsatile flow and hematoma formation Compare IJ and arterial blood samples, visually or by oximetry Pass flexible wire through catheter, ECG should be monitored because arrhythmias can result Make small slit with scalpel; advance dilator over wire Place central venous pressure catheter over wire and advance wire out through port of cvp, then advance catheter Check for blood return, flush, sterile drsg and follow with xray

central venous catheter correct placement

With proper placement tip of catheter lies just above the junction of the superior vena cava and R atrium. the tip of the catheter is in the right atrium.

ECG basics

ALL pt's must have No contraindications Electrodes with conductive gel placed on pt's body Conductive gel lowers skin's electrical resistance Lead selection will determine diagnostic sensitivity Picks up lethal arrythmias and most conduction defects Will detect: Arrythmias, MI, conduction abnormalities, pacemaker malfunction and electrolyte disturbances

diagnostic/monitor/filter modes ECG

Added due to interference in attempt to "clean up" the tracing Diagnostic mode: Least amount of filtering; best for assessing acute changes or pt's at risk for ischemia Monitor mode: More filtering, therefore less diagnostic Filter mode: Most filtering and acute changes can be missed

Waveforms

Alpha Eyes closed but awake Beta Normal, awake waveform Delta Sleep state (deep sleep-seen with sedation) Theta Sleep state

complications of central venous catheter

Arterial puncture with hematoma Pneumothorax/Hemothorax Nerve injury (Brachial plexus, Stellate ganglion (Horner's syndrome) Air emboli Catheter or wire shearing Complications of catheter presence Thrombosis, thromboembolism Infection, sepsis, endocarditis Arrhythmias hydrothorax (line in wrong place and fluid actually not going into vascular space

a line waveform

Arterial waveform provides information on patients hemodynamic status Slope of upstroke: myocardial contractility Respiratory variations: large variations may be indicative of hypovolemia Slope of downstroke: SVR Slurred/delayed stroke indicative of increased afterload Dicrotic notch: AV closure

arterial blood pressure monitoring

Arterial waveform provides information on patients hemodynamic status Slope of upstroke: myocardial contractility Respiratory variations: large variations may be indicative of hypovolemia Slope of downstroke: SVR Slurred/delayed stroke indicative of increased afterload Dicrotic notch: AV closure High incidence of interference Lacks specificity in regard to ST & T wave abnormality ST segment depression of >1mm or ST elevation with peaked T waves are a concern

pulse ox placement, theory

Based on Beer-Lamberts Law and principles of spectrophotometry relates the concentration of a solute to the intensity of light transmitted through a solution.

BIS normal values

Bispectral analysis of EEG data Calculates a single number that correlates with depth of anesthesia/hypnosis 100-85 Awake; memory intact 85-65 Sedation 65-40 General anesthesia; deep hypnosis <40 Cortical suppression

Normal wave tracing CVP

CVP parallels right atrial pressure which is influenced by right ventricular volume Normal waveform consists of three peaks (a,c,v waves) and two descents (x,y) A wave: R atrial contraction: occurs just after the P wave on the ECG. absent in afib; may be absent or exaggerated with junctional rhythms C wave: occurs due to isovolumic ventricular contraction(the ventricles have begun to contract but no volume has left the ventricle yet) forcing the tricuspid valve to bulge upward into the right atrium. V wave: reflects venous return against closed tricuspid valve: large v waves with tricuspid regurg.

about CVP monitoring

CVP refers 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 Measured by attaching catheter to fluid-filled pressure transducer Transducer converts pressure generated at distal end of catheter into an electrical signal that is displayed on screen MTP-massive transfusion protocol- triple lumen will not work need an introducter or cortus

CVP reflects, normal CVP

CVP reflects preload (RVEDV) for right ventricle; if patient healthy, may also reflect LVEDV; if patient has pulmonary HTN or ventricular failure, a PAP catheter may be warranted Normal values range from 1-15 mmHg Depends on patient's volume status, presence of PPV-(all mechanical ventilation, hand ventilation which increases CVP because of the increased pressure), cardiac function and chamber compliance

carboxyhemoglobin

Carboxyhemoglobin (COHb) Exists in varying degrees in smokers and urban pollution areas but may occur in very high concentrations with smoke inhalation COHb has an absorption spectrum similar to oxyhemoglobin (940 nm) so most pulse oximeters will over estimate the SpO2 in smoke inhalation patients, smokers etc. falsely high readings Toxicity: cherry-red appearance (late sign!) smoker comes in and has sat 99% it may not really be hgb with O2, it may have CO2 on it so their true sat is really lower. Also see this is smoke inhalation pts even if sat is 100% you know that pt needs O2 regardless to blow off some of that CO2

a line complications

Complications: Thrombosis, hematoma, bleeding, vasospasm, air embolism, necrosis/ischemia, nerve damage, infection, intra-arterial drug injection Vigilance, constant monitoring of perfusion, aseptic technique, decr attempt @ cannulation

noninvasive BP cuff size, location

Cuff size: Should be 20% greater than diameter of limb; cover 2/3 of upper arm or thigh Undersized cuff: Falsely high readings Oversized cuff: Falsely low readings Location: Upper arm (preferred); forearm; ankle; thigh Avoid bony prominences; joints; superficial nerves The more peripheral Higher systolic; lower diastolic, wider the pulse pressure (including a lines & cuffs) KNOW THIS Elevation of cuff site +/- 0.7 mm Hg for each cm off of horizontal plane of heart

EEG anesthesia related concerns

Decreased blood flow to the brain Loss of amplitude (volume is too low) Increase in slow wave activity Loss of fast activity

stethoscope

Detect changes in HR, onset of dysrhythmias, airway/ventilation problems, VAE (venous air embolism you'll hear a milvial murmur)

CVP insertion 1 of 2

Institute ECG monitoring Remove pillow, rotate head to left; use the bony landmarks of medial end of clavicle and mastoid process. Place patient in Trendelenberg position (distends IJ and reduces risk of air embolism) Perform careful sterile prep and drape (mandatory for central venous cannulation; full glove and gown should be used) Recheck landmarks, palpate for carotid, go immediately lateral to carotid. Local infiltration necessary if patient is conscious .skin wheel, and deeper infiltration with 1% Xylocaine.(withdraw on syringe before injection local anesthetic. Go b/t sternal head and clavicular head of sternocleidomastoid and insert finder needle aiming toward ipsilateral nipple as you aspirate Once vein has been located Leave finder needle in place Remove finder, remember direction Insert 18- gauge 1 ¾-in. catheter over needle unit into IJ (Constant aspiration is required to see flashback)

about BP

Invasive or non-invasive depending on complexity of case Blood draws, tight BP control or induced hypotension, pt. condition, blood loss, fluid/drug management (vasoactive drugs, special fluid management) CAD, surgical procedure hypotensive technique- hypotensive anesthesia Reflects organ perfusion and blood flow **an indicator NOT a measurement of end organ perfusion Non-invasive Avoid Vascular access sites, mastectomy, surgical sites, sites with injury/neuropathy Applied so one finger can be slipped underneath

swan contraindications

LBBB Tricuspid or pulmonary valvular stenosis Right atrial or right ventricular masses (tumor or thrombus) Tetralogy of fallot

lead II

Largest p wave voltage Better diagnosis of arrythmias Detection of inferior wall ischemia

leads for wall of heart

Leads II, III and aVF reveal disease in right coronary artery (inferior wall). Lead V1 to V6 represent left anterior descending and circumflex artery distribution; V1, V2 & V3 for anteroseptal wall V3, V4 & V5 for anteroapical wall V4, V5 & V6 for anterolateral wall. Lead V1 & aVL detect ischemia in posterior wall (reciprocal)

EEG

Monitors cerebral function and ischemia Carotid and Neurosurgery Measures electrical activity of the neurons in the cerebral cortex Detects risk of ischemia due to hypoperfusion

How pulse ox works, what it monitors

Non-invasive; simple Monitors % of Hgb saturated with oxygen Audible pulse flow should be audible; low limit alarms should be set Light emitting diodes with 2 wavelengths of light transmitted through tissue- if they arent facing each other it isn't working Infrared light (940nm) OxyHgb Red light (660 nm) DeoxyHgb MethHgb (~85%); CarboxyHgb (^) ***altered results

Methemoglobin

Normally occurs in < 1% in humans Oxidation product of hemoglobin that forms a reversible complex with oxygen and impairs unloading of oxygen to tissues Can be congenital or acquired Causes of acquired methemoglobinemia include: Local anesthetic- benzocaine, prilocaine nitrobenzene, dapsone Prilocaine: d/t metabolite o-toluidine, which oxidizes hemoglobin to methemoglobin Methemoglobin has the same absorption at both the red and infrared wavelengths, creating a 1:1 ratio The resulting 1:1 ratio corresponds to a saturation reading of 85% (algorithmically)

4 essential features of monitoring

Observation and vigilance Instrumentation Interpretation of data Initiation of corrective therapy if indicated

TEE complications

Pharyngeal and/or laryngeal trauma, dental injuries, esophageal trauma or bleeding, arrhythmias, respiratory distress, and hemodynamic effects

order

Pulse ox, BP, EKG Pulse ox ALWAYS on..... 1st on; last off...... BP Check and record a minimum of every 5 min. EKG Min. 3 lead; 5 lead if available If doing a general anesthetic: MUST have an oxygen analyzer with a low O2 alarm limit This measures the % of O2 being delivered to the pt Low limit is 30%, airway case 21% but can set alarm down to 19-20%, factory set to not let alarm go lower than 18% Exceptions: 25% if heli-ox or less (21%) if fire risk If using ventilator MUST have disconnect alarm, ETCO2 and stethoscope DO NOT ever turn this alarm off

S hemoglobin and fetal hemoglobin & pulse ox

S Hgb= sickle cell neither of these affect the pulse ox

methemoglobinemia

S/S: brownish-gray cyanosis, tachypnea, metabolic acidosis r/t tissue hypoxia LOC may occur in 50-60% of cases Healthy patients can tolerate this but patients with severe anemia or heart failure cannot tolerate the reduction in oxygen-carrying capacity Treatment: Spontaneous reversal without treatment can occur in 2-3 hours following last LA dose Immediate reversal: Methylene blue 1 mg/kg

precordial stethoscope

Small weighted disc Placed over suprasternal notch or point of max. impulse of heart Adult and pedi sizes Great tool for use during transporting pt's to and from O.R room and listening for breath sounds/ air movement intra-op and heart beat

methhemoglobinemia danelle points

So methemoglobinemia causes a falsely low SpO2 when saturation is actually greater than 85% and a falsely high SpO2 when saturation is actually lower than 85% hurricaine spray- throat spray has prilocaine in it which causes this what happens is the Fe in body becomes Fe3 instead of Fe2 which causes it unable to bind oxygen

esophageal stethoscope

Soft, thinned walled tube placed in the lower 1/3 of the esophagus Most accurate measure of temp (however best indicator of core temp is thermoster on swan, but not good for neck and chest open surgeries) Not to be used in pt's with varices Side attachment for temp monitoring and attaches at top to your ear piece for cont. heart and breath sounds must have for peds can use butt for temp also if you're in an airway surgery but at that point you are just monitoring temp only for pt under general anesthesia DOES NOT go in ett, it goes in ESOPHAGUS

A line supplies, technique

Supplies 18-22g catheter, armboard, ETOH, betadine, lidocaine/syringe (25g) remember not to do when pt already anesthetized, tape, dressing, sterile gloves, transducer set-up, face shield Technique Apply armboard; hyper-extend thumb Palpate radial artery Clean site/dry Skin wheel: TB syringe & 1-2% lidocaine Sterile gloves Insert angio @ 45 degree angle flashback flatten angle adv. Guide wire if avail- do not force itadv. cath over guide wire or needle occlude attach tubing suture suturing in a lines is controversial do what your facility tells you to do, just use steri strips

more about BP

Techniques: Palpation, doppler, auscultation, oscillations (auto cuffs measure oscillations) Deflation rate 2-3 mm Hg per heartbeat OR 3-5 mm Hg/sec Korotkoff sounds volatile blood flow, which cause vibrations against the artery walls. Automatic BP cuffs: Measure oscillations MAP: systolic+ 2 diastolic/3 MAP on auto cuff-point @ which oscillations maximal ulnar nerve (funny bone) can cause nerve damage from repeated BP most common nerve injury in anesthesia

indication from subclavian

if pt had neck sx bilaterally, carotids bilat

1st thing when pt gets in OR

look at ECG rhythm and start BP

pulse ox and a line

monitor pulse ox on a line side because it tells you they are perfusing their hand

RIF

rapid infuser, no longer using level 1 at some places cant give pt a ton of air MTP

swam complications

same as with CVP in addition to: Emboli (air, catheter insertion) Cardiac perforation Cardiac dysrhythmia/heart block Knotting

swan- types and techniques

types: VIP Paceport Oximetric Technique: Use seldinger technique as with CVP to insert introducer Sheath over swan (flushed/checked) and insert until get to approx. 20 cm Inflate balloon and advance until see RV waveform (30-35 cm) Cont. to advance to pulmonary artery (40-45 cm) At approx. 50cm balloon will wedge into PA Deflate balloon and it will float back into PA

methyline blue

use blue dye to see if surgeon nicked the uriter or to see if the anastomosis from gastic bypass is leaking or not