Podcast
Questions and Answers
What is the optimal device positioning for arterial blood pressure monitoring in neurosurgery?
What is the optimal device positioning for arterial blood pressure monitoring in neurosurgery?
What is the recommended cuff size width for non-invasive blood pressure monitoring?
What is the recommended cuff size width for non-invasive blood pressure monitoring?
What is the effect of underdamping on arterial waveform analysis?
What is the effect of underdamping on arterial waveform analysis?
What is the principle behind pulse oximetry?
What is the principle behind pulse oximetry?
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What is the effect of carboxyhemoglobin on pulse oximetry?
What is the effect of carboxyhemoglobin on pulse oximetry?
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What is the treatment for carboxyhemoglobin poisoning?
What is the treatment for carboxyhemoglobin poisoning?
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What is the normal percentage of methemoglobin?
What is the normal percentage of methemoglobin?
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What is the purpose of the double-burst stimulation test?
What is the purpose of the double-burst stimulation test?
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What is the frequency of the stimulus in the tetanus test?
What is the frequency of the stimulus in the tetanus test?
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What is the purpose of the post-tetanic count?
What is the purpose of the post-tetanic count?
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What is the effect of an air bubble in the tubing or low pressure on arterial waveform analysis?
What is the effect of an air bubble in the tubing or low pressure on arterial waveform analysis?
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What is the purpose of the pulse oximeter sensor?
What is the purpose of the pulse oximeter sensor?
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What is the effect of sulfahemoglobin on pulse oximetry readings?
What is the effect of sulfahemoglobin on pulse oximetry readings?
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What is the recommended position for non-invasive blood pressure cuffs in relation to IV sites?
What is the recommended position for non-invasive blood pressure cuffs in relation to IV sites?
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What is the recommended frequency of non-invasive blood pressure monitoring?
What is the recommended frequency of non-invasive blood pressure monitoring?
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What is the effect of methemoglobin on pulse oximetry readings?
What is the effect of methemoglobin on pulse oximetry readings?
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What is the primary reason for minimizing stopcocks in arterial blood pressure monitoring?
What is the primary reason for minimizing stopcocks in arterial blood pressure monitoring?
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What is the effect of a small amount of fluid in the arterial blood pressure monitoring system?
What is the effect of a small amount of fluid in the arterial blood pressure monitoring system?
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What is the effect of sulfahemoglobin on pulse oximetry readings?
What is the effect of sulfahemoglobin on pulse oximetry readings?
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What is the primary advantage of using ETCO2 monitoring in moderate sedation or higher?
What is the primary advantage of using ETCO2 monitoring in moderate sedation or higher?
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What is the effect of underdamping on arterial waveform analysis?
What is the effect of underdamping on arterial waveform analysis?
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What is the recommended frequency of non-invasive blood pressure monitoring?
What is the recommended frequency of non-invasive blood pressure monitoring?
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What is the minimum monitoring requirement for anesthesia care?
What is the minimum monitoring requirement for anesthesia care?
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Which of the following factors optimize the accuracy of arterial blood pressure monitoring?
Which of the following factors optimize the accuracy of arterial blood pressure monitoring?
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Arterial transducers are typically positioned at what level?
Arterial transducers are typically positioned at what level?
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What is unique about an underdamped arterial waveform?
What is unique about an underdamped arterial waveform?
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What is the primary cause of underdamping in an EKG rhythm?
What is the primary cause of underdamping in an EKG rhythm?
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What does overdamping look like on an arterial waveform?
What does overdamping look like on an arterial waveform?
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In both overdamping and underdamping, MAP is accurate
In both overdamping and underdamping, MAP is accurate
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Frequent BP measurements can cause nerve damage or IV extravasation
Frequent BP measurements can cause nerve damage or IV extravasation
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What percentage of the extremity should the BP cuff encircle?
What percentage of the extremity should the BP cuff encircle?
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What is the impact of blood pressure cuff readings if the cuff is too small or too loose?
What is the impact of blood pressure cuff readings if the cuff is too small or too loose?
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In critically ill patients, why can SPO2 readings be different?
In critically ill patients, why can SPO2 readings be different?
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What principle is used by pulse oximeters to measure oxygen saturation?
What principle is used by pulse oximeters to measure oxygen saturation?
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What law states that light absorbed by a solution is related to its concentration?
What law states that light absorbed by a solution is related to its concentration?
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What is true about reduced hemoglobin?
What is true about reduced hemoglobin?
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What does SPO2 measure?
What does SPO2 measure?
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What components are typically found in a pulse ox sensor?
What components are typically found in a pulse ox sensor?
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What do fractional saturation and co-oximetry measure in anesthesia monitoring?
What do fractional saturation and co-oximetry measure in anesthesia monitoring?
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What results from the presence of iron in oxidized form?
What results from the presence of iron in oxidized form?
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Methemoglobin absorbs light less than Hgb
Methemoglobin absorbs light less than Hgb
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What is the treatment for methemoglobinemia?
What is the treatment for methemoglobinemia?
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What results from irreversible binding of sulfur to hemoglobin?
What results from irreversible binding of sulfur to hemoglobin?
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What is the characteristic of blood in sulfahemoglobin-induced cyanosis?
What is the characteristic of blood in sulfahemoglobin-induced cyanosis?
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What are the causes of methemoglobinemia?
What are the causes of methemoglobinemia?
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What are the causes of sulfahemoglobin?
What are the causes of sulfahemoglobin?
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What is the treatment for sulfahemoglobin?
What is the treatment for sulfahemoglobin?
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What are the limitations of pulse oximetry?
What are the limitations of pulse oximetry?
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What is the main difference between capnometry and a capnogram?
What is the main difference between capnometry and a capnogram?
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What do the four phases of capnography in ETCO2 monitoring represent?
What do the four phases of capnography in ETCO2 monitoring represent?
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What is ETCO2 measured at?
What is ETCO2 measured at?
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Which of the following are methods used for ETT placement confirmation?
Which of the following are methods used for ETT placement confirmation?
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What does observing positive ETCO2 on 3 consecutive breaths suggest about ETT placement?
What does observing positive ETCO2 on 3 consecutive breaths suggest about ETT placement?
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Endotracheal tubes (ETT) with leaks are likely to do what to ETCO2?
Endotracheal tubes (ETT) with leaks are likely to do what to ETCO2?
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What is true about peripheral nerve stimulators?
What is true about peripheral nerve stimulators?
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What is the effect of PNS placement on the Adductor pollicis muscle?
What is the effect of PNS placement on the Adductor pollicis muscle?
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What is the effect of PNS stimulation on the facial nerve at orbicularis oculi and corrugator supercilii muscles?
What is the effect of PNS stimulation on the facial nerve at orbicularis oculi and corrugator supercilii muscles?
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What type of movement does PNS stimulation at the posterior tibial nerve at the flexor hallucis brevis muscle cause in the big toe?
What type of movement does PNS stimulation at the posterior tibial nerve at the flexor hallucis brevis muscle cause in the big toe?
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In peripheral nerve stimulator placement, which lead is proximal and closest to the heart?
In peripheral nerve stimulator placement, which lead is proximal and closest to the heart?
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Where is the onset of neuromuscular blockade best measured?
Where is the onset of neuromuscular blockade best measured?
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Which nerve best approximates the conditions of the laryngeal adductor muscles?
Which nerve best approximates the conditions of the laryngeal adductor muscles?
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Where does blockage develop faster and recover more quickly in the airway?
Where does blockage develop faster and recover more quickly in the airway?
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During neuromuscular blocker monitoring, which muscle should recover before the adductor pollicus?
During neuromuscular blocker monitoring, which muscle should recover before the adductor pollicus?
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Where is neuromuscular blockade recovery best measured at?
Where is neuromuscular blockade recovery best measured at?
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What is the purpose of single twitch stimulation during induction?
What is the purpose of single twitch stimulation during induction?
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What is the purpose of the train of four, which involves 4 supramaximal stimuli at 0.5 sec intervals (2 Hz)?
What is the purpose of the train of four, which involves 4 supramaximal stimuli at 0.5 sec intervals (2 Hz)?
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If zero twitches are present during TOF monitoring, what is the state of the neuromuscular blockade?
If zero twitches are present during TOF monitoring, what is the state of the neuromuscular blockade?
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If 1-2 twitches are present during TOF monitoring, what is the state of the block?
If 1-2 twitches are present during TOF monitoring, what is the state of the block?
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What percentage of receptor occupancy of a non-depolarizing NMB can occur even at a TOF count of 4 and TOF ratio >0.9?
What percentage of receptor occupancy of a non-depolarizing NMB can occur even at a TOF count of 4 and TOF ratio >0.9?
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What is a benefit of double burst stimulation when assessing neuromuscular blockade?
What is a benefit of double burst stimulation when assessing neuromuscular blockade?
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What is tetanus in peripheral nerve stimulation and why should it be used sparingly?
What is tetanus in peripheral nerve stimulation and why should it be used sparingly?
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What is a TET fade over 5 seconds equivalent to?
What is a TET fade over 5 seconds equivalent to?
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What are the indications for post-tetanic count (PTC) stimulation?
What are the indications for post-tetanic count (PTC) stimulation?
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When TOF and double burst are absent, what type of nerve stimulation is indicated?
When TOF and double burst are absent, what type of nerve stimulation is indicated?
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What does a count of less than 8 during post-tetanic count stimulation indicate?
What does a count of less than 8 during post-tetanic count stimulation indicate?
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What happens to Ach in post tetanic count stimulation when intense stimulation is applied transiently?
What happens to Ach in post tetanic count stimulation when intense stimulation is applied transiently?
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What is the definition of fade in anesthesia monitoring?
What is the definition of fade in anesthesia monitoring?
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How many twitches must be present to administer a reversal agent?
How many twitches must be present to administer a reversal agent?
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What criteria must be met before a patient is considered ready for extubation, and reversal of neuromuscular blockade is considered complete?
What criteria must be met before a patient is considered ready for extubation, and reversal of neuromuscular blockade is considered complete?
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When should a PNS be placed during general anesthesia?
When should a PNS be placed during general anesthesia?
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What are the signs of inadequate blockade recovery?
What are the signs of inadequate blockade recovery?
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Why is PNS (Peripheral Nerve Stimulation) used during the maintenance phase of general anesthesia?
Why is PNS (Peripheral Nerve Stimulation) used during the maintenance phase of general anesthesia?
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What are the indications for central venous pressure (CVP) monitoring?
What are the indications for central venous pressure (CVP) monitoring?
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What does CVP approximate?
What does CVP approximate?
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What is the primary risk associated with central line access in the right internal jugular (IJ) vein?
What is the primary risk associated with central line access in the right internal jugular (IJ) vein?
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What are the complications of central venous pressure (CVP) insertion?
What are the complications of central venous pressure (CVP) insertion?
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In atrial fibrillation, what is unique about the CVP waveform?
In atrial fibrillation, what is unique about the CVP waveform?
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What does the 'a' wave in a CVP (Central Venous Pressure) indicate?
What does the 'a' wave in a CVP (Central Venous Pressure) indicate?
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What does the 'c' wave in CVP indicate?
What does the 'c' wave in CVP indicate?
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Why is bispectral index (BIS) monitoring used in total intravenous anesthesia (TIVA)?
Why is bispectral index (BIS) monitoring used in total intravenous anesthesia (TIVA)?
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What is the BIS target for sedation?
What is the BIS target for sedation?
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What is the BIS target for general anesthesia?
What is the BIS target for general anesthesia?
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What are the characteristics of a perfect emergence during anesthesia?
What are the characteristics of a perfect emergence during anesthesia?
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In which of the following situations is bispectral index (BIS) monitoring contraindicated?
In which of the following situations is bispectral index (BIS) monitoring contraindicated?
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Which of the following pressures most closely approximates LVEDP?
Which of the following pressures most closely approximates LVEDP?
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In which of the following clinical situations may PAOP not accurately reflect LVEDP?
In which of the following clinical situations may PAOP not accurately reflect LVEDP?
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What are some complications related to PA catheter use?
What are some complications related to PA catheter use?
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Which of the following statements is true about methods of CO monitoring?
Which of the following statements is true about methods of CO monitoring?
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What is normothermia?
What is normothermia?
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What temperatures in Celsius are typically classified as hypothermia and hyperthermia?
What temperatures in Celsius are typically classified as hypothermia and hyperthermia?
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What is the most common type of heat loss in the operating room?
What is the most common type of heat loss in the operating room?
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Intraoperative hypotension in adults is a MAP <55-60 mmHg
Intraoperative hypotension in adults is a MAP <55-60 mmHg
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Where is the V lead placed in an EKG?
Where is the V lead placed in an EKG?
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5 lead EKGs preferred in adults. 3 lead EKG preferred in pediatrics
5 lead EKGs preferred in adults. 3 lead EKG preferred in pediatrics
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V3-V5 are useful for detecting ischemia in 5 lead EKG
V3-V5 are useful for detecting ischemia in 5 lead EKG
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Lead II and V5 are the best leads for intraoperative monitoring of dysrhythmias and ischemia
Lead II and V5 are the best leads for intraoperative monitoring of dysrhythmias and ischemia
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3 lead monitoring is inadequate for diagnosing complex arrhythmias
3 lead monitoring is inadequate for diagnosing complex arrhythmias
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Junctional rhythms are common under anesthesia
Junctional rhythms are common under anesthesia
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LBBB occurs in healthy individuals while RBBB is an ominous sign
LBBB occurs in healthy individuals while RBBB is an ominous sign
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What is the recommended setting for ST segment alarms in relation to the baseline in patients with Coronary Artery Disease (CAD)?
What is the recommended setting for ST segment alarms in relation to the baseline in patients with Coronary Artery Disease (CAD)?
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What myocardial wall abnormalities are associated with myocardial infarction?
What myocardial wall abnormalities are associated with myocardial infarction?
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What is the effect of a loss of atrial kick during atrial fibrillation on ventricular filling?
What is the effect of a loss of atrial kick during atrial fibrillation on ventricular filling?
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What is hypokinesia?
What is hypokinesia?
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What is the normal range of the QT interval?
What is the normal range of the QT interval?
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Study Notes
Monitoring Standards
- For every anesthetic monitor, the following parameters should be monitored: BP, HR, EKG, RR, Pulse Ox, and ETCO2 when using moderate sedation or higher (deep or GA)
- HR and RR should be monitored continuously, while BP should be monitored continually every 5 minutes
BP Monitoring
Arterial Blood Pressure Monitoring
- Accuracy is optimized by using stiff catheters and tubing, a small amount of fluid in the system, shorter length of tubing, and minimizing stopcocks
- Transducers must be zeroed and positioned at the level of the RA (typically), or at the circle of Willis (in neurosurgery for cerebral perfusion)
- Complications can be mitigated by using small catheters, minimizing attempts, and monitoring sites
- Arterial waveform analysis can be used to assess for damping, with:
- Fast flush to assess for damping
- Underdamping: multiple artifacts present in waveform, overestimates SBP, underestimates DBP, and MAP is accurate
- Overdamping: dicrotic notch is lost, underestimates SBP, overestimates DBP, and MAP is accurate
Noninvasive Blood Pressure Monitoring
- Cuff size should be 40% of the extremity circumference and encircle 80% of the extremity
- If the cuff is too small, readings obtained are falsely high
- Position the cuff opposite to the IV if possible, and change position for longer cases
- Frequent measurements can cause nerve damage or IV extravasation
Pulse Oximetry and Co-Oximetry
Pulse Oximetry
- Arterial O2 sat is typically 95-100%
- Numbers should correlate but not exactly match PaO2
- Works through absorption spectrometry, measuring light absorption of a chemical substance as it passes through a solution
- Based on Beer-Lambert Law, where light absorbed by a solution is related to its concentration
- SPO2 is the ratio of oxyhemoglobin to hemoglobin
- Pulse ox sensor contains 2 LEDs and a photodetector, measuring the ratio of infrared and red light, and averaging data over a time period to calculate SPO2
Co-Oximetry
- Fractional saturation and co-oximetry measure the ratio of oxyhemoglobin to Hgb, carboxyhemoglobin, methemoglobin, and other forms of hemoglobin
- Carboxyhemoglobin:
- Has a higher affinity for Hgb than O2 (250x)
- Hgb binding sites occupied by CO cannot carry O2
- SPO2 will read falsely high
- Treatment is 100% FiO2
- Signs and symptoms: cherry red lips
- Methemoglobin:
- Results from the presence of iron in an oxidized form
- Normally 1%
- Falsely high for sats 40%, pulse ox will read 80-85%
- Treatment is methylene blue 1-2 mg/kg as 1% solution over 3-5 minutes
- Sulfahemoglobin:
- Results from irreversible binding of sulfur to Hgb
- Normally 0.9%
- May be caused by certain medications, such as migraine medication and certain antibiotics
Monitoring Standards
- For every anesthetic monitor, the following parameters should be monitored: BP, HR, EKG, RR, Pulse Ox, and ETCO2 when using moderate sedation or higher (deep or GA)
- HR and RR should be monitored continuously, while BP should be monitored continually every 5 minutes
BP Monitoring
Arterial Blood Pressure Monitoring
- Accuracy is optimized by using stiff catheters and tubing, a small amount of fluid in the system, shorter length of tubing, and minimizing stopcocks
- Transducers must be zeroed and positioned at the level of the RA (typically), or at the circle of Willis (in neurosurgery for cerebral perfusion)
- Complications can be mitigated by using small catheters, minimizing attempts, and monitoring sites
- Arterial waveform analysis can be used to assess for damping, with:
- Fast flush to assess for damping
- Underdamping: multiple artifacts present in waveform, overestimates SBP, underestimates DBP, and MAP is accurate
- Overdamping: dicrotic notch is lost, underestimates SBP, overestimates DBP, and MAP is accurate
Noninvasive Blood Pressure Monitoring
- Cuff size should be 40% of the extremity circumference and encircle 80% of the extremity
- If the cuff is too small, readings obtained are falsely high
- Position the cuff opposite to the IV if possible, and change position for longer cases
- Frequent measurements can cause nerve damage or IV extravasation
Pulse Oximetry and Co-Oximetry
Pulse Oximetry
- Arterial O2 sat is typically 95-100%
- Numbers should correlate but not exactly match PaO2
- Works through absorption spectrometry, measuring light absorption of a chemical substance as it passes through a solution
- Based on Beer-Lambert Law, where light absorbed by a solution is related to its concentration
- SPO2 is the ratio of oxyhemoglobin to hemoglobin
- Pulse ox sensor contains 2 LEDs and a photodetector, measuring the ratio of infrared and red light, and averaging data over a time period to calculate SPO2
Co-Oximetry
- Fractional saturation and co-oximetry measure the ratio of oxyhemoglobin to Hgb, carboxyhemoglobin, methemoglobin, and other forms of hemoglobin
- Carboxyhemoglobin:
- Has a higher affinity for Hgb than O2 (250x)
- Hgb binding sites occupied by CO cannot carry O2
- SPO2 will read falsely high
- Treatment is 100% FiO2
- Signs and symptoms: cherry red lips
- Methemoglobin:
- Results from the presence of iron in an oxidized form
- Normally 1%
- Falsely high for sats 40%, pulse ox will read 80-85%
- Treatment is methylene blue 1-2 mg/kg as 1% solution over 3-5 minutes
- Sulfahemoglobin:
- Results from irreversible binding of sulfur to Hgb
- Normally 0.9%
- May be caused by certain medications, such as migraine medication and certain antibiotics
Monitoring Standards
- For every anesthetic monitor, the following parameters should be monitored: BP, HR, EKG, RR, Pulse Ox, and ETCO2 when using moderate sedation or higher (deep or GA)
- HR and RR should be monitored continuously, while BP should be monitored continually every 5 minutes
BP Monitoring
Arterial Blood Pressure Monitoring
- Accuracy is optimized by using stiff catheters and tubing, a small amount of fluid in the system, shorter length of tubing, and minimizing stopcocks
- Transducers must be zeroed and positioned at the level of the RA (typically), or at the circle of Willis (in neurosurgery for cerebral perfusion)
- Complications can be mitigated by using small catheters, minimizing attempts, and monitoring sites
- Arterial waveform analysis can be used to assess for damping, with:
- Fast flush to assess for damping
- Underdamping: multiple artifacts present in waveform, overestimates SBP, underestimates DBP, and MAP is accurate
- Overdamping: dicrotic notch is lost, underestimates SBP, overestimates DBP, and MAP is accurate
Noninvasive Blood Pressure Monitoring
- Cuff size should be 40% of the extremity circumference and encircle 80% of the extremity
- If the cuff is too small, readings obtained are falsely high
- Position the cuff opposite to the IV if possible, and change position for longer cases
- Frequent measurements can cause nerve damage or IV extravasation
Pulse Oximetry and Co-Oximetry
Pulse Oximetry
- Arterial O2 sat is typically 95-100%
- Numbers should correlate but not exactly match PaO2
- Works through absorption spectrometry, measuring light absorption of a chemical substance as it passes through a solution
- Based on Beer-Lambert Law, where light absorbed by a solution is related to its concentration
- SPO2 is the ratio of oxyhemoglobin to hemoglobin
- Pulse ox sensor contains 2 LEDs and a photodetector, measuring the ratio of infrared and red light, and averaging data over a time period to calculate SPO2
Co-Oximetry
- Fractional saturation and co-oximetry measure the ratio of oxyhemoglobin to Hgb, carboxyhemoglobin, methemoglobin, and other forms of hemoglobin
- Carboxyhemoglobin:
- Has a higher affinity for Hgb than O2 (250x)
- Hgb binding sites occupied by CO cannot carry O2
- SPO2 will read falsely high
- Treatment is 100% FiO2
- Signs and symptoms: cherry red lips
- Methemoglobin:
- Results from the presence of iron in an oxidized form
- Normally 1%
- Falsely high for sats 40%, pulse ox will read 80-85%
- Treatment is methylene blue 1-2 mg/kg as 1% solution over 3-5 minutes
- Sulfahemoglobin:
- Results from irreversible binding of sulfur to Hgb
- Normally 0.9%
- May be caused by certain medications, such as migraine medication and certain antibiotics
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Description
Learn about the standards for monitoring patients under anesthesia, including EKG rhythms, blood pressure monitoring, and other vital signs. Understand how to optimize arterial blood pressure monitoring and transducer usage.