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Confirming placement of CVL
Transduce CVP, Compare color or PaO2 to arterial sample
Relative contraindications to PAC
Complete LBBB, Wolf-Parkinson-White syndrome, Ebstein's malformation
Factors for accurate CO measurement
Rapid and smooth injection, precise injectate volume and temp, correct entry of calibration factors, avoid measurement during electrocautery
Confirmation of airway with capnography
Rapid and reliable for detection of esophageal intubation, does not detect bronchial intubation
Which EEG changes accompany ischemia?
High-frequency activity
What conditions can mimic ischemic EEG changes?
Hypothermia, anesthesia, electrolyte disturbances, marked hypocapnia
What causes the initial decrease in temperature during an anesthetic?
Redistribution of heat from central compartments to peripheral tissues from vasodilation (actual loss is more minor)
What mediates central thermoregulation? (Inhibited by anesthesia)
The hypothalamus
Minimal monitoring standards for all anesthetics
Qualified anesthesia personnel, oxygenation, ventilation, circulation, body temperature
How is oxygenation measured?
Inspired gas (O2 analyzer with low concentration limit alarm), Blood oxygenation (pulse oximeter, exposure and illumination)
How is ventilation monitored?
Chest excursion, observation of reservoir bag, auscultation, presence of ETCO2 (capnography,capnometry, or mass spectroscopy), expired gas volume, audible disconnect alarm
How is circulation monitored?
ECG, Q 5 minute BP and HR measurement, and at least one other measure: palpation of pulse, auscultation of heart sounds, intraarterial tracing, U/S pulse monitoring, pulse plethysmography or oximetry
What is the formula for mean arterial pressure (MAP)?
1(SBP) + 2(DBP) ÷ 3
How does the arterial waveform change as a pulse moves peripherally?
SBP and pulse pressures are exaggerated
When a discrepancy exists between BP measurements, which should be recorded?
The higher pressure
How much does SBP decrease for each 1 cm increase above heart level?
0.74 mm Hg
Which component of BP can be measured with Doppler?
Systolic
Which component of blood pressure can be measured with a piezoelectric crystal?
Systolic AND diastolic
Who should oscillometric BP monitors NOT be used on?
Patients on cardiopulmonary bypass
Define flow
Pressure/Resistance
Which incorrectly sized BP cuff will produce the greatest error?
A cuff which is too narrow
How much greater than the diameter of the arm should the width of a BP cuff be?
20-50%
When is an A-line indicated?
Unstable trauma, intraabdominal pathology, cardiac, vascular, chest, spine, and brain surgeries, need for frequent blood sampling, induced hypotension, wide BP swings, end-organ disease
When is a CVC indicated?
Significant blood or fluid loss experienced, rapid infusion, administration of caustic medications, TPN, insertion of pacing leads, gaining access when peripheral veins are poor
When is an A-line contraindicated?
Lack of collateral flow, Raynaud's phenomenon
How is an Allen's test interpreted?
Time to thumb flush after ulnar pressure released:
5 seconds - adequate
5-10 seconds - delayed, unequivocal
> 10 seconds - insufficient
What are the main complications of femoral artery cannulation?
Infection, thrombosis, asceptic necrosis of the femur head (children)
What is a risk with left axillary artery cannulation?
Aside from nerve damage, air or thrombi can quickly gain access to the cerebral circulation during retrograde flushing
What is the heparin concentration of arterial flush solutions?
0.5-2.0 U/mL (infused at 2-3 mL/hr)
Factors associated with increased complications from arterial cannulation
Prolonged cannulation, hyperlipidemia, repeated insertion attempts, female gender, extracorporeal circulation, use of vasopressors
How is an arterial pulse wave used to calculate BP?
Summation of sine and cosine waves (Fourier analysis). A pressure-distorted diaphragm measures mechanical energy which is then converted to electrical energy. Resistance type (strain gage), Wheatstone bridge
What is the natural frequency of the arterial pulse?
16-24 Hz
What decreases measuring system frequency and what is the result?
Tubing, stopcocks, and air in the line; overdamping, underestimation of SBP
What is the optimal damping coefficient of a pressure measuring system?
0.6-0.7 (beta)
How can overdamping be avoided?
Using a smaller catheter
Where is the transducer leveled in the supine patient?
At the midaxillary line (approximates left ventricle)
Where is the transducer leveled in the sitting patient?
At the ear (approximates Circle of Willis)
What does the arterial waveform rate of upstroke indicate?
Contractility
What does the arterial waveform rate of downstroke indicate?
Peripheral vascular resistance
How is hypovolemia indicated by an arterial waveform?
Exaggerated variations in size during the respiratory cycle
What is Lead II most sensitive to?
Arrhythmias, inferior wall ischemia
Where is Lead V5 placed?
5th intercostal space, anterior axillary line
What does Lead V5 detect?
Anterior and lateral wall ischemia
How should the ECG be calibrated to accurately detect ST changes?
A 1-mV signal should result in a deflection of 10 mm
What are criteria for diagnosing myocardial ischemia?
A flat or downsloping ST-segment depression exceeding 1 mm, 60 or 80 ms after the J point (end of the QRS complex), particularly in conjuction with T wave inversion.  May also be represented by ST-segment elevation with peaked T waves.
When is ST segment information unhelpful?
WPW syndrome, bundle branch blocks, extrinsic pacemaker activity, digoxin therapy
When are CVC's contraindicated?
Renal cell tumor extension into the RA or fungating tricuspid valve vegetations.  IJ site contraindicated s/p ipsilateral carotid endarterectomy
What is the easiest CV site to cannulate?
Basilic
Which CV site is the best for long-term use?
Subclavian
Which CV site has the highest success rate (PAC placement)?
Internal jugular
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