1
Q
2 Basic Modes of US for vascular access
A
Doppler and B-mode
2
Q
Doppler US
A
audible sound
- arteries and veins sound different
3
Q
B-Mode US
A
2D mode
Generates a 2D picture in a gray scale that is applied based on the amplitude of the signal
- B stands for brightness
4
Q
B-Mode US appearance
A
fluid filled = black or dark grey
soft tissue (muscle) = gray
Solid structures
5
Q
Technical Tricks for IV access
A
T-berg and valsalva manuever
6
Q
Controls to know on US machine
A
- gain adjust
- depth
- freeze
- contrast/brightness
7
Q
4 manuevers for a good US image
A
- pressure
- alignment
- rotation
- tilting
8
Q
Color Doppler
A
represent the direction of low relative to transducer
- Red: flow towards transducer
- Red does not always mean artery
9
Q
When is a provider considered competent in CVC placement
A
after 50 times
10
Q
US guidance for regional usually uses what probes?
A
linear probes and dynamic (B-mode) setting
11
Q
Different frequencies for regional anesthesia
A
Higher frequency for superficial (upper extremity) blocks
Lower frequency needed for deeper blocks (infraclavicular, femoral)
12
Q
CFNB
A
continuous femoral nerve block
13
Q
US vs. nerve stimulator
A
US has decreased time to placement and no conversion to general anesthesia
14
Q
What does an implantable pacemaker treat?
A
bradycardia and conduction abnormalities
15
Q
What does AICD treat?
A
SVT and fibrillation
16
Q
What battery is commonly used in a pacemaker?
A
lithium-iodide
17
Q
How long does a pacemaker/AICD usually last?
A
5-8 years
- output voltage decreases gradually
- sudden battery failure unlikely
18
Q
Pacemaker lead system
A
- endocardial leads placed via central access
- fix on the endocardium
19
Q
Endocardial Leads
A
active fixation: metal scews
passive fixation: rubber fins or tines
20
Q
Epicardial Leads
A
screw-in or sew-on
21
Q
Polarity of pacing leads
A
unipolar - highest reliability
bipolar - improved rejection for better sensing
multipolar - special purpose leads
22
Q
Types of lead tip of pacing leads
A
- steroid eluting
- non-steroid eluting
- carbon
23
Q
Synchronous Pacemaker (basics)
A
- Demand mode
- Sensing circuit searches for intrinsic depolarization potential
- If absent, a pacing response is generated
- Can mimic intrinsic electrical activity pattern of the heart
24
Q
Anti-tachycardic functions are only used in which type of pacer?
A
AICDs
25
1 in pacemaker classification
What does it pace?
V – Ventricle
A – Atrial
D – Both
0 – None
26
2 in pacemaker classification
What does it sense?
V– Ventricle
A – Atrial
D – Both
0 – None
27
3 in pacemaker classification
How does it respond?
I – Inhibited
T – Triggered
D – Inhibited & Triggered
0 – None
28
Inherent rate of SA node
60-100 bpm
29
inherent rate of AV node
40-60 bpm
30
Inherent rate of His and Purkinje
20-40 bpm
31
(6) Absolute indications for a Pacemaker
- sick sinus syndrome
- symptomatic sinus bradycardia
- tachy-brady syndrome
- a-fib with slow ventricular response
- 3rd degree heart block
- chronotropic incompetence
32
Chronotropic incompetence
inability to increase heart rate to match exercise
33
Programability Function "R"
rate responsive
device is capable of a rate responsive function
34
Programability Function "C"
Communicating
capable of transmitting or receiving data
35
Programability Function "M"
multi-programmable
| device can be programmed in more than 3 parameters
rate, sensing, output, refractory periods, mode hysteresis
36
Programability Function "P"
simple programmable
limited to 3 or fewer programmable parameters
37
Programability Function "O"
None
not programmable
38
Most bradycardia devices are ____
O
39
Most AICDs are ____
D
40
AOO
fixed atrial pacing
41
VOO
fixed ventricular pacing
42
DOO
fixed AV sequential pacing
43
Asynchronous Modes
during application of a magnet
- does not mean you are turning off pacemaker
- AOO, VOO, DOO
44
VVI
single chamber pacing
- if native activity is sensed, pacemaker will not fire (inhibit)
- Also has a clock to prevent firing during refractory period
45
DDD
paces atria and ventricle
- senses atria and ventricle
- atrial triggered and ventricular inhibited
- EKG shows 2 spikes
46
what does AICD stand for?
Automatic Implantable Cardio-Defibrillator
47
What can and AICD do?
- antitachycardia pacing
- cardioversion
- defibrillation
- bradycardia pacing
48
Joules applied to biphasic vs. monophasic
biphasic - 150J
| monophasic - 300J
49
Anti-Tachycardia Pacing (ATP)
overdrive pacing in an attempt to terminate ventricular tachycardias
- fires during refractory period
50
Magnets and pacemakers
closes an internal reed switch
- causes sensing to be inhibited
- asynchronous mode
51
Anesthesia for Patient with Pacemaker
- know what type and what the magnet does
- set to fixed rate pacing unless bipolar
- continuous ECG and peripheral pulse
- pulse ox with plethysmography to see mechanical heart output
- defibrillator and crash cart available
- external pacer available
- external converter magnet available
52
Essential information to ask CIED team
- indication for device placement
- current programming
- is the patient pacemaker-dependent?
- device response to magnet
- perioperative recommendation/prescription
53
How do you know if a magnet is working on a pacer?
if it goes to 60bpm and stays there
54
Bipolar vs Electrocautery and pacemakers
Bipolar - OK
Electrocautery may interfere with pacer
55
Cardiac arrest with AICD
start CPR and defibrillate immediately
56
IABP
Intra-Aortic Balloon Counterpulsation
57
Intra-Aortic Balloon Counterpulsation
used to reduce left ventricular systolic work, LVED pressure, and wall tension
58
Benefits of IABP
- decreases O2 consumption
- increases CO, perfusion
- increases pressure to coronary arteries
59
Where is an IABP placed through and position?
placed through femoral artery into the descending aorta
tip should be 1-2cm below the origin of the left subclavian artery and above the renal arteries
60
Balloon volume in IABP
30 - 50 mL
61
Drive gas in IABP
helium or carbon dioxide
62
Hemodynamic affects of IABP
```
- increase coronary perfusion
+ increase diastolic BP
+ decrease atrial pressure
- decrease afterload on left ventricle
+ decrease aortic systolic pressure
- decreases LVEDV and LVEDP
```
63
IABP balloon inflation
triggered to inflate immediately after aortic valve closure
- augments diastolic coronary perfusion pressure
64
IABP balloon deflation
triggered to deflate with opening of the aortic valve
- reduce left ventricular work
- creates a "potential space" in the aorta
+ reduces aortic volume and pressure
65
Indications for IABP
- cardiac failure after surgery
- refractory angina
- cardiogenic shock
- mitral regurgitation
- perioperative treatment of complications due to MI
- failed PTCA
- bridge to cardiac transplantation
66
Contraindications for IABP
- severe aortic insufficiency
- aortic aneurysm
- aortic dissection
- limb ischemia
- thromboembolism
67
CPB
cardio pulmonary bypass
68
(3) Functions of CPB
- oxygenation of venous blood
- elimination of CO2
- maintenance of system perfusion
69
main components of CPB
- blood reservoir
- oxygenators and gas exchangers
- pumps
- heat exchangers
- filters
- cardioplegia system
70
3 processes in urine formation
- glomerular filtration
- tubular reabsorption
- tubular secretion
71
Normal urine output
> 1 mL/kg/hr
- daily output of 400-500 is required to excrete nitrogenous wastes
72
most likely cause of oliguria
decreased renal perfusion
- hypotension
- hypovolemia
- decreased CO
73
red urine
hemoglobinuria, myoglobinuria, hematuria, beets, rifampin
74
orange urine
bilirubin or pyridium
75
brown urine
bilirubin or methemoglobin
76
black urine
melanin, hemoglobinuria, and homogentistic acid
77
Blue urine
amitriptyline and methylene blue
78
white urine
chyluria
79
magnetic strength of MRI
1.5 to 4 Tesla
| 60,000x Earth's field
80
How are MRI magnets cooled
liquid helium and nitrogen
81
ferromagnetic
materials that form permanent magnets or are attracted to magnets
82
Paramagnetic
only attracted when in the presence of an externally applied magnetic field
83
diamagnetic
materials repelled by magnetic fields
84
Gauss Line
5 gauss
- 'safe' level of magnetic exposure
85
Magnetic Force in MRI
Attractive Force = M * (1/D)^2
```
M = mass
D = distance
```
86
Quench
(emergency stop)
destruction of superconducting state and a change to increased magnet resistance
87
Where is the superimposed potential greatest in ECG?
ST-segment and the T waves of leads I, II, V1, and V2
88
which vectors maximize QRS and minimize artifact in an ECG
V5 and V6
89
temperature monitoring in MRI
liquid crystal strips
90
Medication patches that need to be removed for MRI
- Androderm
- transderm-Nitro and Deponit
- Habitrol, Nicoderm, and Nicotrol
- Scopolamine
- Catapres-tts (clonidine)
91
Blood in 4x4
10 mL
92
blood in ray-techs
10-20mL
93
blood in lap sponges
100 mL
94
Primary physiologic response to blood loss
- Increased HR
- Hyperventilation
- Vasoconstriction
- Increased RV filling
95
Secondary physiologic response to blood loss
BP increase by hormones and catecholamines
96
Tertiary physiologic response to blood loss
redistribution of water from extravascular to intravascular space
97
Intrinsic coagulation factors
8, 9, 11, 12
98
What measures intrinsic coagulation
aPTT and ACT
- Heparin
99
What measures extrinsic coagulation
PT and INR
- coumadin
100
Common coagulation can be measured by ____
PT and INR
101
Extrinsic coagulation factors
3 and 7
102
Which coagulation pathway releases tissue factors
Extrinsic
103
Normal platelet value
150k - 400k /mm^3
104
Thrombocytopenia
105
Thrombocytosis
> 400,000 platelets
106
Petechiae
small red or purple spots caused by bleeding into the skin
- Thrombocytopenia
107
DIC
Disseminated Intravascular Coagulation
- accelerated platelet consumption
- caused by sepsis, trauma, burn...
- high levels of FSP
108
ACT
Activated Clotting Time
- measures the amount of time required for whole blood to clot in a test tube
- monitors *Heparin*
109
Normal ACT
70-180 sec
CPB > 400 seconds
110
2 Types of ACT
- Hemochron
+ uses a magnet
- HemoTec
+ photodetector
111
PTT
Partial Thromboplastin Time
- measures the clotting time via factor 7, 9, 11, and 12
- intrinsic (Heparin)
112
Prolonged PTT
- cirrhosis
- DIC
- hemophilia
- malabsorption
- von Willebrand's disease
lupus
113
Prothrombin Time (PT)
measures 7 (extrinsic) and common
- normal 10-14 seconds
114
Increased PT times
- bile duct obstruction
- cirrhosis or hepatitis
- vitamin K deficiency
- Coumadin therapy
115
INR
International Normalized Ratio
- mathematical calculation that corrects for PT variability due to sensitivities (ISI) of the thromboplastin agents
116
ISI
International Sensitivity Index
117
Normal INR
1. 0
| - 2-3 is recommended for prophylaxis
118
TEG
Thromboelastogram
- measure of the time it takes for a blood clot to form, consolidate, and lyse
- R, k, alpha angle, MA, and MA60
119
TEG variables
```
R - period of time
k - dynamics of clot formation
alpha angle - acceleration of fibrin build up and cross-linking
MA - maximum amplitude
MA60 - stability of the clot
```
120
Low MA on TEG
platelets indicated
- MA is a function of platelet count, function, and fibrinogen level
121
High MA60 on TEG
antifibrinolytics indicated
122
Prolonged R on TEG
FFP indicated
123
Absolute Blood Loss (ABL)
ABL = EBV * [(HCTi - HCTf)/(HCTi)]
124
Estimated blood volumes
Adult male - 70 mL/kg
thin female - 65
Muscular - 75
Obese - 60
125
Estimate blood volumes in pediatrics
Premie 90-100 ml/kg
| Term 80-90
126
Type and Screen
Recipient's blood has been typed for A, B, and Rh antigens and screened for common antibodies
127
Type and Cross
Recipient's blood is incubated with the donor blood product
128
Type A blood
Contains an *A antigen*
Anti-B antibodies present
129
Type O blood
No antigens present
Both A and B antibodies
130
PRBC
Packed Red Blood Cells
- 1 unit contains 250-300mL with 70-80% hematocrit
- Hemoglobin increases 1 g/dL
- Hct will increase by 3%
131
Platelets
- mostly used in CPB
- 6 units will increase platelet 25,000
- DO NOT warm
- use filter
132
Fresh Frozen Plasma
Fluid portion obtained form a single unit of whole blood
- indicated when PT, PTT, or both are at least 1.5 times longer than normal
133
Cryoprecipitate
Fraction of plasma that precipitates when FFP is thawed
- 200mg fibrinogen and 100 units of Factor VIII
- used in hemophilia A or hypofibrinogenemia
134
Incidence of Hepatitis B in blood transfusion
1 in 205,000
135
Incidence of Hepatitis C in blood transfusion
1 in 1.9 million
136
Incidence of HIV in blood transfusion
1 in 2.1 million
137
POC
Point of Care
138
Are creatinine and hematocrit POC tests?
No
139
POC hemoglobin
photometer uses 570 and 880 wavelength
- erythrocytes are trasformed into methemoglobin and then into azidemethemoglobin
- *range 0-25.6 g/dL*
140
Hemocue
Detects anemia
| - 75% sensitivity, 100% specificity
missed event likely to occur when anemic
141
Main POCTs
- blood gas analysis
- glucose
- hemoglobin
- ACT
Quarter 3
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