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Perioperative Care > Critical Care > Flashcards

Critical Care Flashcards

1
Q

Level 0 care

A

Normal ward

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2
Q

Level 1 care

A
  • Enhanced care
  • 3:1 ratio of patients to nurses
  • Monitored
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3
Q

Level 2 care

A
  • High dependency (HDU)
  • 2:1 ratio of patients to nurses
  • Single organ failure (not ventilated)
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4
Q

Level 3 care

A
  • Intensive care (ICU)
  • Recovery units
  • 1:1 ratio of patients to nurses
  • Multiorgan failure
  • Ventilation
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5
Q

Criteria for discharge to ward from recovery

A
  • Spontaneous airway maintenance
  • Awake and non-drowsy
  • Comfortable and pain free
  • Haemodynamically stable
  • No evidence of haemorrhage
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6
Q

Pulse oximetry infrared wavelength

A

660-940nm

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7
Q

How does pulse oximetry calculate oxygen saturation

A
  • A constant ‘background’ amount of infrared light is absorbed by skin, venous blood, fat
  • A changing amount is absorbed by the pulsatile arterial blood
  • The difference between the constant and variable amount is calculated
  • Oxygenated Hb and Deoxygenated Hb absorb different amounts at the two wavelengths the saturated Hb can be calculated from the ratio between the two
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8
Q

What can be the delay between a fall in PaO2 and SaO2

A

15-20 seconds

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9
Q

What can limit the effectiveness of pulse oximetry

A
  • Delay
  • Abnormal pulses e.g. AF
  • Abnormal Hb or pigments e.g. carbon monoxide poisoning
  • Interference e.g. shivering, diathermy
  • Poor tissue perfusion
  • Nail varnish
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10
Q

Indications for intra-arterial monitoring

A
  • Critically ill/shocked patients
  • Major surgery
  • Surgery for phaeochromocytoma
  • Induced hypotension
  • Those requiring frequent ABG e.g. lung disease
  • Monitoring use of inotropes
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11
Q

Complications of intra-arterial monitoring

A
  • Embolisation
  • Haemorrhage
  • Arterial damage and thombosis
  • AV fistula formation
  • Distal limb ischaemia
  • Sepsis
  • Tissue necrosis
  • Radial nerve damage
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12
Q

Normal CVP range

A

8-12cmH2O

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13
Q

What can CVP monitoring be useful for

A
  • Assessing circulating volume status
  • Assessing myocardial contractility
    (- Also for administering TPN or toxic drugs)
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14
Q

Where should the tip of the CVP lie

A

SVC

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15
Q

When during respiration should the CVP reading be taken

A

During respiratory end expiration

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16
Q

Common complications of CVP lines

A
  • Sepsis
  • Pneumothorax
  • Incorrect placement (should be confirmed with CXR)
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17
Q

How is cardiac output calculated using TOE

A
  • US records the change in frequency of the signal that is reflected of the RBCs in the ascending aorta = velocity
  • Velocity is multiplied by the cross-sectional area of the aorta = stroke volume
  • Stroke volume x heart rate = CO
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18
Q

Where should the tip of a Swan-Ganz (pulmonary artery pressure) catheter lie

A
  1. Right atrium to be inflated (proximal lumen remains here)

2. Floated through right ventricle into pulmonary artery (distal lumen/tip)

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19
Q

What is CVP monitoring best for

A

Assessing adequacy of intravascular volume status by testing with fluid challenge (should cause a prolonged rise in CVP)

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20
Q

What can be measured using a Swan-Ganz catheter

A
  • Stroke volume
  • SVR
  • Pulmonary artery resistance
  • Oxygen delivery (and consumption)
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21
Q

How is cardiac output calculated using Swan-Ganz catheter

A

Fick principle

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22
Q

What is the tidal volume

A
  • Volume of air moved on quiet respiration
  • 0.5L in males
  • 0.34L in females
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23
Q

What is the inspiratory reserve volume

A
  • Maximul volume inspirable following normal inhalation

- 3L

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24
Q

What is the expiratory reserve volume

A
  • Maximum volume expirable after tidal volume expiration

- 1L

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25
Q

What is residual volume

A
  • The volume remaining in the lungs after maximum expiration
  • FRC-ERV = 1.5L
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26
Q

What is vital capacity

A
  • The volume that can be expired after a maximum inspiratory effort
  • 5.6L
  • 70ml/KG
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27
Q

What is functional residual capacity

A
  • Volume of air remaining in the lungs at the end of normal expiration
  • RV + ERV = 2.5L
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28
Q

What is forced vital capacity

A

The volume of air that can be maximally forcefully exhaled

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29
Q

How is respiratory minute volume calculated

A

Tidal volume x respiratory rate

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30
Q

What constitutes anatomical dead space

A
  • Mouth
  • Nose
  • Pharynx
  • Larynx
  • Trachea
  • Bronchi
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31
Q

What constitutes alveolar dead space

A

Volumes of disease parts of the lung unable to perform gaseous exchange

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32
Q

What is the physiological dead space

A

Anatomical dead space plus alveolar dead space

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33
Q

Typical volume of dead space

A

150ml

34
Q

What is the effect of ventilators on dead space

A

Increased due to the length of tubing

35
Q

How can type 1 respiratory failure be managed

A

CPAP

36
Q

How can type 2 respiratory failure be managed

A

BiPAP

37
Q

Diagnostic features of acute lung injury

A
  • Pulmonary infiltrates on CXR
  • Pulmonary artery wedge pressure <18
  • Hypoxaemia
  • Known cause
38
Q

ARDS mortality rate

A

50-60%

39
Q

Preferred intubation method in paediatrics

A

Nasal intubation

40
Q

Contraindications to nasotracheal intubation

A
  • Apnoea
  • Basal skull fractures
  • Facial fractures
41
Q

Male and female ET tube diameters

A
  • Male = 8-9mm

- Female = 7-8mm

42
Q

Male and female ET tube lengths (to teeth)

A
  • Male = 23cm

- Female = 21cm

43
Q

Role of the cuffed end of the ET tube

A
  • Creates a seal
  • Helps prevent aspiration
  • Can cause stenosis and tracheomalacia if high pressure
44
Q

Hazards of ET tube insertion

A
  • Oesophageal intubation (hence end-tidal CO2 is measured)
  • Tube advanced too far to right main bronchus
  • Airway damage or rupture
45
Q

Effect of tracheostomy on dead space

A

Reduced

46
Q

Early complications of percutaneous tracheostomy

A
  • Asphyxia
  • Aspiration
  • Creation of false track
  • Laceration of oesophagus or trachea
47
Q

Late complications of percutaneous tracheostomy

A
  • Vocal fold paralysis/hoarseness
  • Cellulitis
  • Laryngeal stenosis
  • Tracheomalacia
48
Q

Site of percutaneous tracheostomy

A

Between 2nd and 4th tracheal rings

49
Q

Role of PEEP

A
  • Prevents alveolar collapse at the end of expiration

- Recruits collapsed alveoli

50
Q

Disadvantages of PEEP

A
  • Reduces physiological shunting
  • Reduces venous return
  • Barotrauma
51
Q

Advantages of PEEP

A

Increases lung volume and improves oxygenation

52
Q

Advantages of CPAP

A
  • Increases lung volumes and oxygenation
  • Reduces respiratory effort
  • Reduces cardiac work by reducing transmural tension
53
Q

Benefits of BiPAP over CPAP

A

Allows lower overall airway pressures to be used, reducing the risk of barotrauma

54
Q

List the four processes involved in nociception (pain)

A
  1. Transduction (anti-inflammatories act here)
  2. Transmission (local anaesthetics act here)
  3. Modulation (TENS exploits this)
  4. Perception (opiates act here)
55
Q

Describe transduction of pain stimuli

A

Translation of noxious stimuli into electrical activity at the sensory endings of nerves

56
Q

What is primary hyperalgesia

A

Decreased nocicpetive threshold in damaged tissue resulting in exaggerated response

57
Q

What is secondary hyperalgesia

A

Lower pain threshold in areas beyond the site of injury

58
Q

What innervates peripheral nociceptors

A
  • A fibres (fast)

- C fibres (slow - unmyelinated)

59
Q

What type of pain do A fibres transmit

A

Acute sharp pain

60
Q

What type of pain do C fibres transmit

A

Slow chronic pain

61
Q

Where do A fibres terminate in the dorsal horn

A

Lamina 1 and 5

62
Q

Where do C fibres terminate in the dorsal horn

A

Lamina 2 and 3 (Substantia gelatinosa)

63
Q

Neurotransmitter between A/C fibres and second-order neurones in the dorsal horn

A

Substance P

64
Q

How do pain stimuli ascend the spinal cord to the brain

A
  • Second order neurones cross over in the white commissure one segment rostrally
  • Ascend in the lateral spinothalamic tract
  • Becomes the spinal lemniscus in the brainstem
  • Synapse in the thalamus (ventral posterolateral nucleus)
65
Q

How do pain stimuli travel from the ventral posterolateral nucleus of the thalamus to the somaesthetic area of the brain

A
  1. Third-order neurones pass through the internal capsule

2. Reach the somaesthetic area in the postcentral gyrus of the cerebral cortex

66
Q

Where do C fibres terminate

A

Reticular formation

67
Q

Describe the central mechanism for the modulation of pain

A
  • Descending anti-nociceptive tract in the dorsal horn of the spinal cord
  • Enkephalins cause presynaptic inhibition of incoming pain fibres
68
Q

Describe the mechanical inhibition of pain

A
  • Stimulation of mechanoreceptors in the area of the body where pain originates can inhibit pain
  • Occurs by stimulating large A fibres
  • How TENS works
69
Q

How is visceral pain from the thoracic and abdominal viscera transmitted

A

C fibres within the sympathetic nerves

70
Q

Where is pain perceived

A

Thalamus and sensory cortex

71
Q

What causes referred pain

A

Branches of visceral pain fibres synapse in the spinal cord with some of the same second-order neurones that receive pain fibres from the skin

72
Q

What do tracheostomy sizes correlate to

A

Their inner diameter

73
Q

What is the minimum time from insertion should a tracheostomy be changed

A

At least 3 days to permit track formation

74
Q

NSAID mechanism of action

A
  • Cyclo-oxygenase inhibitor

- Results in the inhibition of prostaglandin synthesis which sensitises pain receptors to noxious stimuli

75
Q

Why do NSAIDs cause peptic ulceration

A

Prostaglandins are necessary for gastric mucous and bicarbonate production

76
Q

Preferred pain management option for extensive abdominal laparoscopy

A

TAP block

77
Q

First line analgesic for neuropathic pain

A
  • Amitriptyline OR

- Pregabalin

78
Q

Second line analgesic regime for neuropathic pain

A

Amitriptyline AND pregabalin

79
Q

Flow through a cannula is proportional to

A

Radius to the power of 4

80
Q

Where is the basilic vein identified for venous cut-down

A

2cm medial to the brachial artery

81
Q

By what method are central venous catheters inserted

A

Seldinger technique

82
Q

From where can the IJV be accessed

A
  1. Posterior border of SCM (most common)
  2. Anterior border of SCM
  3. Lower end between the two heads of SCM

Perioperative Care (6 decks)

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