1
Q
Scope and Standards for Nurse Anesthesia Practice
A
Standard V
2
Q
Standard V
A
Monitor the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs
3
Q
Requirements/Monitoring Parameters
A
VOTC -Ventilation -Oxygenation -Temperature -Circulation Neuromuscular Patient Positioning
4
Q
Ventilation
A
- Verify intubation by auscultation, chest rise, EtCo2
- Continuously monitor EtCO2
- Use spirometry and pressure monitors as indicated
- Inspired anesthesia gases
5
Q
Oxygenation
A
- Clinical observation
- Pulse ox
- ABGs
- Inspired O2
6
Q
Temperature
A
- Continuously on all pediatric patients under GA
- When indicated on adult pts
7
Q
Circulation
A
- ECG and heart sounds
- HR
- BP every 5 minutes
8
Q
Neuromuscular
A
when neuromuscular blockade agents are used
9
Q
Patient positioning
A
Assess and institute protective measures
10
Q
Cardiac surgery monitors
A
invasive BP CVP TEE UOP ABGs cerebral oximetry
11
Q
Preload definition
A
Tension on LV after diastole
End diastolic volume
12
Q
Increased preload = ?
A
Increased SV
13
Q
Components of preload
A
Volume (intravascular, extravascular, total body sodium)
Venous tone
Compliance
14
Q
End Systolic Volume
A
Contractility
Afterload
15
Q
Contractility
A
Heart’s ability to generate force
16
Q
Afterload
A
Tension on LV when aortic valve opens
-Indirectly measure by SVR
17
Q
Increased afterload = ?
A
Decreased SV
18
Q
CO
A
HR x SV
19
Q
Arterial Pressure Monitoring
A
Radial most common
- easy, superficial
- ulnar nerves supply 90% of flow
- Allen’s test
20
Q
Optimally damped art line
A
Baseline is re-established after 1 oscillation
21
Q
Under-damped art line
A
Baseline is re-established after several oscillations (SBP is overestimated, DBP is underestimated, and MAP is accurate)
22
Q
Over-damped art line
A
Baseline is re-established with no oscillations (SBP is underestimated, DBP is overestimated, and MAP is accurate). Causes include an air bubble or clot in the pressure tubing or low flush bag pressure
23
Q
Invasive BP measures BP where?
A
At level of transducer. Should be at RA
24
Q
Reasons to have art line
A
Major surgery with blood loss or fluid shifts CPB Aortic surgery Need for frequent ABGs Recent MI, unstable angina, severe CAD Shock Permissive hypotension Hypothermic procedures Trauma COPD, PHTN, PE Inotropic support needed Inability to measure noninvasively Asymptomatic AS, MS, AR, MR
25
Reasons NOT to have art line
Local infection
Coagulopathy
Vaso-occlusive or spastic disease (Raynaud's)
Interferes with surgical field
26
Complications from art line
```
Infection
Hemorrhage
Hematoma
Arterial spasm
Thrombosis
Embolization
Miscalibration
Injury to adjacent vessels
Ischemia
Blood loss
```
27
Arterial BP Waveform
| PEAK OF WAVEFORM
Systolic BP (contractility is the upstroke of the peak)
28
Arterial BP Waveform
| TROUGH OF WAVFORM
Diastolic BP
29
Arterial BP Waveform
| PULSE PRESSURE
Peak - Trough
30
Arterial BP Waveform
| CONTRACTILITY
Upstroke
31
Arterial BP Waveform
| STROKE VOLUME
Picture entire area under the "hill" shaded
32
Arterial BP Waveform
| DICROTIC NOTCH
Closure of AV
33
CVP/RA Waveforms
Waves - a,c,v
| Descents - X, X1, Y
34
A waveform
- 1st wave
- Produced by contraction of the RA
- Just after P wave (atrial depolarization)
35
C waveform
- 2nd wave
- Produced from closure of the triCuspid valve
- Right ventricular contraction
- Just after QRS (ventricular depolarization)
36
V waveform
- 3rd wave
- Produced from passiVe filling of RA (encompasses portion of RV systole)
- Just after T wave begins (ventricular repolarization)
37
X descent
start of atrial diastole (btwn a and c waves)
38
X1 descent
Produced by downward pulling of the septum during ventricular systole (btwn c and v waves)
- RA relaxation
- ST segment
39
Y descent
opening of the tricuspid valve (after v wave)
| Just after T wave ends
40
RA/CVP
5 mmHg
41
Elevations of CVP due to:
```
RV disease
PHTN
Pulmonic stenosis
L-R shunts
TV disease
Tamponade
Constrictive pericardial disease
Restrictive cardiomyopathies
Systolic HF
Hypervolemia
```
42
High RA and High PA =
PHTN
43
High RA and Normal PA =
Pulmonic stenosis
44
Insertion sites for CVP
```
IJ
EJ
SC
Basilic/cephalic
Femoral
```
45
IJ
short, straight course and accessible at HOB
- just under medial border of SCM (carotid deeper and more medial to IJ)
- Now mandate to use US guidance
- Right better than left bc it is straighter, the right lung apex is lower, and larger vessel
46
EJ
must go through valves
more difficult
neck maneuvering
47
SC
increased risk of pneumothorax
non-compressible site
Can cause aortic injury, cardiac tamponade, hemothorax, mediastinal hematoma
48
Basilic/cephalic
easy to access
difficult to stay in RA
migrates with arm movement
49
Femoral
Higher infection rates
easiest
no US guidance needed
50
Reasons to have CVP
```
Major surgery with blood loss or fluid shifts
Procedures with high risk of VAE
Chronic drug or TPN
Poor peripheral IV access
Rapid infusion of fluids
Trauma
Inotropic support needed
```
51
Reasons NOT to have CVP
Superior vena cava syndrome
Coagulopathy
New pacemaker or AICD within 2 months
Surgical site access
52
Complications from CVP
```
Infection
Hemorrhage
Thrombosis
Embolization
Chylothorax, hemothorax, pneumothorax
Major nerve injury
Pericardial effusion/tamponade
Arrhythmias
PFO
Puncture of thoracic duct
```
53
PAC Contraindications
```
Severe tricuspid or pulmonic disease
RA or RV mass
Tetralogy of Fallot
Severe arrhythmias
LBBB
New PM
Severe coagulopathy
```
54
PAC Complications
```
Complete HB
Endobronchial hemorrhage
Pulmonary infarct
Catheter knotting
Valve damage
Thrombocytopenia
Thrombus formation
```
55
CI
CO/BSA
| 2.6-4.2 L/min
56
SV
CO * 1000/HR
| 50-110 mL per beat
57
Stroke Index
SV/CI
| 30-65 mL per beat
58
SVR
(MAP-CVP)*80/CO
| 900-1400
59
SVRI
(MAP-CVP)*80/CI
| 1500-2400
60
Pulmonary vascular resistance
(MPAP-Wedge)*80/CO
| 150-250
61
Pulmonary vascular resistance index
(MPAP-Wedge)*80/CI
62
SVR
estimate of LV afterload
increased SVR = LV wall stress (shock states)
determinant of O2 consumption
63
PVR
estimate of RV afterload
limited d/t pulmonary vasculature
elevated in PHTN
64
CO determination
thermodilution
continuous
dyes
65
PAC Placement
| Subclavian to RA
10 cm
66
RIJ to Vena cava
15 cm
67
LIJ to Vena cava
20 cm
68
Femoral to Vena cava
40 cm
69
Right median basilic to Vena cava
40 cm
70
Left median basilic to Vena cava
50 cm
71
Distance from RIJ to RA
25-35 cm
72
Distance from RIJ to RV
35-45 cm
73
Distance from RIJ to PA
45-55 cm
74
Distance from RIJ to PA wedge
50-60 cm
75
Goal of PAC placement
West Zone III
- bulk of pulmonary blood flow
- continuous column of blood btwn tip of PAC and LV
- provides most accurate estimate of LVEDP
76
Zone III
arterial pressure > venous pressure > alveolus pressure
77
Where is Zone III
```
Dependent region of lung
physiologically not anatomically defined
Base when sitting
towards back when supine
Towards chest when prone
towards dependent lung in lateral position
```
78
What contributes to state of Zone III?
PEEP
diuresis
hemorrhage
change in position
79
PAC in Zone I or II will produce?
marked variations in PAOP
a & v waves lost
PAOP > PADP
80
RA mean/range
```
Mean = 5
Range = 1-10 mm Hg
```
81
RV mean/range
```
Mean = 25/5
Range = 15-30/0-8 mmHg
```
82
PA mean/range
```
Mean = 23/9
Range = 15-30/5-15 mmHg
```
83
PAOP mean/range
```
Mean = 10
Range = 65-15 mmHg
```
84
LA mean/range
Mean = 8
| Range 4-12
85
LVEDP mean/range
```
Mean = 8
Range = 4-12
```
86
No a waves or only v waves
A-fib
| V- pacing in asystole
87
Giant a-waves or "Cannon" waves
```
Junctional rhythms
Complete HB
PVCs
V-pacing
Tricuspid or mitral stenosis
Diastolic dysfunction
MI
Ventricular hypertrophy
```
88
Large V-waves
Tricuspid or mitral regurgitation
| Acute increase in volume
89
Cause of elevated CVP
```
RV failure
TS or TR
Cardiac tamponade
Constrictive pericarditis
Volume overload
PHTN
Chronic LV failure
```
90
Causes of elevated RV
```
Systolic elevation
-PHTN
-Pulmonary stenosis
-PE
Diastolic elevation
-Cardiomyopathy
-RV ischemia/infarct
-Tamponade
-RV failure
```
91
Causes of elevated PAP
```
LV failure
MS or MR
L-R shunt
ASD or VSD
Volume overload
PHTN
Catheter whip
PE
COPD
```
92
Causes of elevated PAOP
```
LV failure
MS or MR
Tamponade
Pericarditis
Volume overload
Ischemia
AV disease
Hypertrophy cardiomyopathies
R-L shunts
```
93
Causes of Low PAOP
low volume
PE
Pulmonary veno-occlusive disease
94
Where is the correct area on the PAOP to determine preload (LVEDP)
Just before upstroke of v-wave
| End expiration
95
Data obtained from PAC allows for direct or indirect assessment of CF function?
indirect
96
When PAC is not indirect measure:
| PADP approximates PAOP
PADP does not equal PAOP with PHTN, MR or AR, lung zone I/II, tachycardia , ARDS, RBBB
97
When PAC is not indirect measure:
| PAOP approximates LAP
PAOP does not equal LAP with PEEP, lung zone I/II, mediastinal fibrosis, RBBB
98
When PAC is not indirect measure:
| LAP approximates LVEDP
LAP does not equal LVEDP with PEEP, MV disease, change in LV compliance, zone I/II, pulmonary disease
99
When PAC is not indirect measure:
| LVEDP approximates LVEDV
LVEDP does not equal LVEDV with PEEP, ventricular interdependence, and change in LV compliance (ischemia)
100
When PAC is not indirect measure:
| CVP approximates PADP
CVP does not equal PADP with change in RV compliance or Tricuspid disease
101
CVP low
PADP low
PAOP Low
Hypovolemia, transducer not at phlebostatic axis
102
CVP normal/high
PADP High
PAOP high
LV failure
103
CVP high
PADP Normal/low
PAOP Normal/low
RV failure, TR, or TS
104
CVP High
PADP High
PAOP Normal/low
PE
105
CVP high
PADP high
PAOP Normal
PHTN
106
CVP High
PADP high
PAOP high
Cardiac tamponade, transducer not at phlebostatic axis
107
CV Normal
PADP normal or high
PAOP High
LV myocardial ischemia or MR
108
CVP Low
PADP high
PAOP normal
ARDS
109
How does pulse-ox work?
Based on Beer-Lambert law which relates the intensity of light transmitted through a solution and the concentration of the solute within the solution. For us, the solution is blood and the solute is hemoglobin.
Oxygen saturation determines color of blood. We compare the ratio of light absorption in arterial and venous blood.
Pulse ox emits 2 wavelengths of light
- Red light is absorbed by deoxyhemoglobin (venous blood)
- Near infrared light is absorbed by oxyhemoglobin (arterial blood)
110
At PaO2 <100 mmHg =
SpO2 starts to decline
111
At PAO2 < 60 mmHg =
sharper/faster decline in SpO2
112
OHDC
Right is RIGHT for the patient (O2 offloading
| Left LOVES to hold on (greater attachment of O2)
113
SvO2
Normal 65-75% and decreases when decreases O2 delivery or increased consumption
114
Coronary perfusion pressure
DAP-LVEDP
Most prominent with diastole
-Increase in LVEDP or decrease in DAP = subendocardial tissues at risk
115
CPP
MAP-ICP
| CVP can be substituted for ICP
116
ECG monitoring
Became standard in 1980s
| Einthoven created LA/LL/RA leads (bipolar, RL as ground)
117
Ventricular depolarization proceeds from ?
endocardium to epicardium (reverse for repolarization)
118
Inferior STEMI leads
II, III, aVF
119
Inferior STEMI artery
RCA
120
Posterior STEMI leads
V1-V4 ST DEPRESSION
121
Posterior STEMI artery
Left circumflex
122
Lateral STEMI leads
I, aVL (High)
| V5, V6 (Low)
123
Lateral STEMI artery
Left circumflex
124
Anterior STEMI leads
V3-V4
125
Anterior STEMI artery
LAD
126
Anteroseptal leads
V1-V4
127
Anteroseptal artery
LAD
128
Which lead selection is not as specific as other 2 lead combinations?
II and V5
129
EEG monitoring
post-synaptic action potentials of cortical neurons
130
3 Laws of EEG
1. EEG amplitude and frequency are inversely related
2. Simultaneous decrease indicates hypothermia, ischemia, anoxia, or excessive hypnosis
3. Simultaneous increase indicates seizure or artifact
131
Beta waves
Awake
132
Alpha waves
Moderate sedation
133
Theta waves
General anesthesia
134
Delta waves
Deep anesthesia
135
BIS 40-60
anesthesia
| reduced recall/awareness
136
BIS <40
increased post op M/M
137
BIS >60
increased risk of awareness
138
What surgery has higher rates of intra-op awareness
cardiac
| 10x higher
139
Transcranial doppler
US waves transmitted through temporal bone
| -notice changes in flow = air and calcifications become more noticeable than erythrocytes
140
Jugular Bulb Oximetry
```
Measures cerebral venous O2 sats via a catheter
-Placed in IJa nd migrated upwards
-Kinking can occur
-55-70% normal
Global measurement
```
141
Cerebral Oximetry
- Noninvasive
- Transducers emit infrared light
- Normal is < 20% of baseline
- Trends more important
- Decline > 20% indicative of focal ischemia
- INVOS at VA = normal is 71% +/- 6% for adults
- Looks at ACA, MCA, and PCA (watershed zone)
142
Coagulation Monitoring
Required in bypass
CPB produces a massive inflammatory response and clotting cascade
Lethal if no anticoagulants are used = unfractionated heparin is choice
Heparin reversed with protamine ( 1 mg Protamine for every 100 units of Heparin)
Protamine can cause anaphylaxis = hypotension, R HF, pulm edema
143
ACT
normal 80-120
| Desired value during DBP is 300-400
144
Heparin resistance
inability to increase ACT with heparin doses
145
Competitive antagonism
needs higher disease to overcome (tachyphylaxis)
146
HIIT
5% get after 5-14 days of heparin therapy
147
aPTT
intrinsic and final common pathways> sensitivity than ACT with lower levels of heparin
Normal is 28-32 seconds
148
PT
```
extrinsic and final common pathways
12-14 seconds is normal
Used to guide warfarin therapy
increases with vitamin K deficiency
used with INR
```
149
TEG
highly variable
looks at integrity of platelets and the clotting cascade
evaluates clot strength and ability to maintain hemostasis through breakdown
150
TEG
| R time
time to start forming clot
Normal is 5-10 minutes
Indicates problem with coag factors
treatment = FFP
151
TEG
| K Time
Time until clot reaches a fixed strength
Normal is 1-3 minutes
indicates problem with fibrinogen
treatment = Cryoprecipitate
152
TEG
| Alpha angle
Speed of fibrin accumulation
normal is 53-72 degrees
Indicates problem with fibrinogen
treatment = cryoprecipitate
153
```
TEG
Max Amplitude (MA)
```
Highest vertical amplitude of TEG
Normal is 50-70 mm
Indicates problem with platelets
Treatment = platelets and or DDAVP
154
TEG
| Lysis at 30 minutes
% of amplitude reduction 30 min after MA
Normal is 0-8%
Indicates problem with Excess fibrinolysis
Treatment = TXA or aminocaproic acid
6902
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