exam 2 Flashcards
1
Q
Rate
Rhythm
Presence of ischemic changes
Chamber enlargement
Conduction blocks
A
12-lead EKG
2
Q
Good to give you a baseline
Cardiac, mediastinal, aortic silhouette
Pulm effusion, pulm congestion, PTX
Evidence of implantation/previous surgical marks
A
chest x-ray
3
Q
4 valves: stenosis and regurgitation
Systolic function: graded EF and presence of any regional wall motion abnormalities (RWMA)
Presence of effusions, air, thrombus, vegetation, or anatomical abnormalities (i.e., PFO/ASD, etc.)
A
echo
4
Q
SCREENING test
performance summary including:
EF
EKG or uptake abnormalities
Failure criteria
Regional perfusion distribution
A
stress test
5
Q
DIAGNOSIS test
CO measurement
Specific vessel findings and severity
EF estimate
A
heart cath
6
Q
aortic stenosis:
the higher the gradient, the _______ the disease
A
worse
7
Q
forced air warmer should especially be used for
A
OFF pump cases
8
Q
____________ changes temp first*
A
esophageal
9
Q
represents CORE temp
A
bladder temp
10
Q
closer to the great vessels
A
esophageal
11
Q
what is the best representation of TISSUE temperature
best option
A
bladder
12
Q
looking at blood flow to the brain
A
cerebral ox
13
Q
looking at awareness, better choice
A
BIS
14
Q
CO monitoring is by what
A
arterial line
or
PA catheter
15
Q
iSTAT, TEG monitors = 4 things
A
ACT, ABGs, lytes, blood count
16
Q
3 labs needed
A
ABG
ACT
Hct
17
Q
6 drugs required for induction
A
versed
fentanyl
etomidate
Sch (anectine)
non-depolarizer
lidocaine
18
Q
key reason heparin is used in heart surgery
A
prevent blood clotting in the bypass machine
19
Q
true or false
inadvertant administration of protamine can be FATAL
do NOT pre-prepare protamine
A
true
20
Q
true or false
IV drips AND syringes should be primed and ready
A
true
21
Q
beta agonist
A
epi
22
Q
alpha agonist
A
neo
23
Q
arterial/venous dilator
A
nitroglycerin
24
Q
a coronary patient who has IHD is hypotensive, the best drug to improve BP
A
neo
(alpha agonist)
25
6 drugs to have IV push
neo
CaCl
nitro
epi
ephedrine
norepi
26
true or false
antibiotics are facility specific
true
27
most used antibiotic
cephalosporin
28
best antibiotic for implant/valve
vancomycin
29
4 types of pacemakers
esophageal
PA cath
transcutaneous
epicardial
30
When in close proximity to the heart it creates a stimuli
esophageal
31
Generally not done, external pads sometimes in case they need to be defibrillated
transcutaneous
32
Goes directly on the heart, conducting tool
epicardial
33
what is doppler used for
Making sure there is flow through bypass graft
34
what 2 tests for blood should be done
Type and screen, type and cross
35
Choice of agent to use depends on
Availability
Comfort level of the clinician
Side effects
36
To select the best drug for the specific clinical scenario, must know
o Class
o MOA
o Side effects
o Clinical use
o Dose
37
only drug that provides phosphodiesterase inhibition
milrinone
38
indirect beta (2 drugs)
dopamine
ephedrine
39
epi
low dose=
high dose=
low dose = beta
high dose = beta + alpha
40
epi:
avoid for ____
SVR
41
chronotropy
HR
42
inotropy
EF
contractility
43
dromotropy
conduction
(good for HB to SR)
44
3 components of BP
(think of triangle)
HR
SV
SVR
45
SV is influenced by _________ + ____________
preload + contractility
46
contractility:
regional issues =
regional = ischemia/poor blood flow
47
contractility:
global issues =
global = beta blocker, excess agent, hypoxia, acidosis
48
LAD supplies the
_______ +________ wall
septal + anterior wall
49
How do you determine which parameter is at fault (the cause) to choose the correct drug
TEE
Best determinant of the SV end of the equation
50
Choice of therapy should address the ___________ factor
causative
51
reason the SV may be high in these cases of low SVR
such little resistance (afterload) may cause the heart to eject slightly more than normal
52
Reserve minimum of ___ PRBCs for the patient
2
53
with cell saver, it is just PRBCs, you may need ________ + _____
plasma + PLTs
54
true or false
you can have a normal Hct but still need FFP
true
55
For each 2.5-3 liters of blood loss, __ liter of red cells are returned
1
56
with blood loss:
you get __/__ of it back
1/3
57
heparin pontentiates (increases) the action of the endogenous _____________ ____
antithrombin III
it increases this
58
antithrombin III increases __________ 1000x
thrombin
59
dose of heparin
300 units/kg
generally 30ml
60
target ACT
> or = 400
61
if ACT does NOT increase, what should you consider
heparin resistance (additional dosing provided)
deficiency of ATIII
62
deficiency of ATIII
what is the treatment
more heparin
or
FFP + then heparin
or
synthetic ATIII + then heparin
63
heparin induced thrombocytopenia
true or false
do NOT have heparin anywhere near them (remove from supply area)
true
64
when is protamine given
when CPB is completely disengaged
65
dose for protamine
1mg for every 100 units
example: 30,000 units of heparin = 300mg protamine
66
where and how should protamine be given
central line or PIV
give SLOW
67
MOA of protamine
electrostatic binding/inactivation of heparin
68
what does Amicar do
helps prevent clot breakdown
(keeps clots; stops bleeding)
69
ANTI-fibrinolytic agents
2 drugs
Amicar
TXA
70
what does ANTI fibrinolytic do
helps prevent clot breakdown (keeps clots)
stops excess bleeding
71
true or false
TXA does NOTTT effect ACT
true
72
when should TXA be given
AFTER therapeutic ACT has been achieved
(to avoid heparin interference)
73
SVR = (_____ -_____) / ____ x 80
(MAP-CVP) / CO x 80
74
CO = ____ x ____
HR x SV
75
EF = (_____-____) /____ x100
(EDV-ESV) / EDV x100
76
CARDIAC Perfusion Pressure (CPP) = _____ -_______
CPP = DBP - LVEDP
77
CARDIAC perfusion pressure (CPP)
Pressure in the coronaries (DBP) – the pressure that remains inside the LV during rest (LVEDP)
78
CVP range
5-10
79
PAP range
___-___ / ___-___
15-30 / 5-10
80
SVR range
700-1600 DYNES
81
CI range
2-4
L / min / m2
82
3 factors that contribute to myocardial oxygen DEMAND
1) wall stress
2) HR
3) contractility
83
4 factors that contribute to myocardial oxygen SUPPLY
1) coronary blood flow (PRIMARY FOCUS)
2) O2 content of perfusing blood
3) Oxyhemoglobin dissociation curve
4) O2 extraction
84
What is the most vulnerable section of the heart muscle
SUB-endocardium of LV
85
why is sub-endocardium LV considered most vulnerable
do NOT result in the classic ST elevation that most clinicians monitor for
86
for coronary disease, what are the 5 main guidelines for supply + demand
1) keep the heart "unloaded" (DECREASE preload)
2) MAINTAIN afterload to ensure CPP
3) DECREASE contractility (beta blocker)
4) DECREASE/minimize HR (beta blocker)
5) maintain adequate blood O2 (Hct and FiO2)
87
what is Sanford's preference for starting vascular access
induction followed by line placement
88
what is the best option for vascular access
aline PRIOR to induction, then all the others AFTER
89
what is best technique for induction
amnesia =
pain/analgesia =
ongoing amnesia =
muscle relaxant
balanced!
amnesia = benzo
pain/analgesia = fentanyl
ongoing amnesia =
inhalational agent
muscle relaxant
90
etomidate risk
adrenal suppression/exhaustion
91
ketamine risk
CAD
(increases HR + SV)
AVOID in large doses
92
propofol risk
myocardial depression
AVOID in critical patients
93
most important thing to understand about induction
make it SMOOTH (no coughing/bucking) AND QUICK
94
2 indications for RSI
full stomach
TEE
95
7 things that affect metabolism of muscle relaxants
temp
pH
organ perfusion
renal output
Vd, rewarming, circulatory arrest
96
2 major times that redosing may be needed
sternotomy
re-warming
on bypass(?) Vd is greater
97
aline
what is an issue with optimum/fluctuating scale
keeps the wave screen full no matter the pressure
(can be deceiving)
98
radial artery site
when is it FALSELY LOW
(2 times)
cold
vasopressors
99
radial artery site can be FALSELY LOW by ___-___ points
10-30 points
100
true or false
when on NO pressors + being rewarmed, radial artery site will correlate with other arterial sites
true
101
___-sided alines are preferred
L-sided
102
best place for CVL
R IJ
103
true or false
cerebral oximetry and BIS have NO specific established guidelines regarding usage
true
104
what demonstrates tissue perfusion
cerebral ox
105
body is < ____C following bypass
< 34C
106
What is the primary means of cooling and warming
CPB
107
What patients can the BLADDER temp read a false/inaccurate number?
oliguric patients
(dialysis, systemic hypovolemia, decreased renal flow)
108
what kind of temp monitoring should be used for oliguric patients
RECTAL temp is the best
109
best device
TEE
(transesophageal echocardiogram)
110
2 primary assessments of TEE
1) volume
2) contractility
111
specified area is pumping less than normal
hypokinesis
112
specified area is NOT pumping
akinesis
113
specified area is moving in the opposite direction of normal
dyskinesis
114
pulm artery catheter is placed into ___-sided circulation
R-sided
115
PAC assesses ___+___ heart function
BOTH R+L
116
things PAC does
volume status
CO
initiates pacing
pulm function
117
withdraw ____ catheter PRIORRRRR to bypass by ___-___ cm
withdraw PA catheter PRIOR by 3-5cm
(As patients heart collapses during CPB, the swan can further advance, this can result in pulm infarction)
118
patients with ___BBB can get a complete heart block!
L
119
3 keys to success with cardiac patients
vigilance
understanding of supply/demand
drug proficiency
120
size ETT (use larger!!)
male
female
male= 8-8.5
female = 7.5-8
121
Vt range
6-8 ml/kg
122
3 ways to "stay ahead" respiratory system
1) alveolar recruitment maneuver
2) PEEP
3) mild HYPOcapnia
123
AVOID ______carbia
(it causes systemic acidosis)
hypercarbia
124
once the lungs are deflated, periodic _____ should be given, especially ________ seperating from bypass
ARM should be given
BEFORE sepating from bypass
125
______ sedation is required during sternotomy
deep
126
APL valve should be _____ turned to ___ during sternotomy (to deflate)
OPEN (0)
127
which mammary artery is most commonly used
L
128
________ Vt during dissection to remain free of surgical field
decrease
129
___ arterial line may be dampened if retractor for IMA compresses the subclavian artery
L
130
CONTRAindication for IMA
subclavian stenosis
(since the origin of IMA is the subclavian artery)
131
3 most common grafting vessels
internal mammary artery (IMA)
saphenous vein
radial artery
132
most common grafting site
saphenous vein
133
which arm is used for HARVESTING
non-dominant
134
which arm is used for aline placement and MONITORING
dominant
135
________ infusion will be started post bypass
cardizem
(helps to avoid spasm of radial artery)
136
ACT is obtained ___-___ min after heparin administration
3-5 min
137
during cannulation
NO MORE THAN < ___-___ SBP
90-100 SBP
138
arterial cannula
______-luminal within the ___________ ______
intra-luminal
within ascending aorta
139
what 3 things can result in inability to deliver blood back to the patient
dissection
false lumen
improper placement
140
venous cannula
located in the
R atrial appendage/RA/IVC
141
improper placement of a venous cannula results in
venous engorgement
obstructive compartments (SVC syndrome)
risk of stroke/tissue damage
142
when the patient is placed on bypass, ventilation is _____________
discontinued
143
who manages hemodynamics during bypass period
perfusion/perfusionist
144
true or false
all infusions are D/C for bypass
true
145
why is the patient cooled
to reduce brain and body metabolism
146
what does the aortic cross clamp do
isolates coronary blood flow (not perfused)
147
what area is filled with cardioplegia
aortic root
148
where is aortic root located
between aortic valve + aortic cross clamp
149
what is the cardioplegia fluid
cold solution
high potassium (makes the heart stop beating)
150
what is the treatment if cardioplegia cannot be distributed to all the tissue
retrograde route
151
where is retrograde route catheter placed
coronary sinus
152
3 types of way to cool patient
1) topical ice slush
2) cardioplegia
3) systemic cooling (cold blood)
153
distal temp during CABG
___-___ C
10-15 C
154
as cardioplegia is washed away and heart is warmed, the heart _______ _______
heart starts itself
155
true or false
NO blood is yet moving through heart it via automaticity
true
156
3 drugs for hyperkalemia and reperfusion dysrhythmias
lidocaine
calcium
magnesium
157
when heart is beating slow, give
chronotrope
158
when heart is beating bad, give
inotrope
159
when heart is fine + BP is low, give
alpha agonist
160
true or false
you must MANUALLY reinflate the lungs following bypass
true
161
true or false
use careful recruitment withOUT over-pressurizing to avoid damage to lungs
true
162
bypass pump is ____________ clamped to allow flow into the heart
partially
163
with bypass pump being gradually weaned, TEE monitoring should include
absence of intracardiac air
cardiac volume
contractility
valve evaluation
164
when are cannulas removed
when heart is pumping well
+
re-initiation of bypass is NOT a threat
165
after giving protamine, ACT should be
120
166
where are chest tubes placed (2)
pleural
+
mediastinal
167
during closure of sternum, lungs should be ____________ reinflated
MANUALLY
168
while in the ICU, be able to
pacing (epicardial)
ventilation settings
lab values + CXR
vital signs
documentation/handoff
169
extubation goal of __-__ hours
6-8 hours
170
what does a short intubation time help with
shorter hospital stay
reduced cost
reduced infection
less complications
171
extubation > ___ hours was considered prolonged/abnormal
> 24 hours
172
how can you facilitate < 8 hour extubation
avoid postop NMBs
reverse NMBs
use short-acting narcotics and sedatives
173
average pump prime volume
1500 ml
174
reduce viscocity means
thinner
175
why do we AVOID reducing viscosity
1) anemia
2) reduced O2 carrying
176
true or false
arresting the heart allows surgical access, however, may NOT decrease O2 demand
true
177
3 techniques to reduce O2 consumption
stopping the heart
cooling the heart
systemic cooling
178
cardioplegia temp ___-___C
10-15 C
179
systemic temp ___C
28 C
180
antegrade =
aortic root
to myocardial tissue
181
retrograde =
coronary sinus
to aortic root
182
benefit retrograde prime
prevents 1500ml extra fluid
allows patient's blood volume to backfill
183
true or false
retrograde prime does NOT drop the Hct
true
184
PRIOR to bypass, limit crystalloid to < __ L
< 1 L
185
regurgitation GOAL
"fast, full, forward"
186
what are 3 things important with STENOSIS
full preload
AVOID tachycardia
SVR/afterload CONTROL
187
what are 3 things important for REGURGITATION
full preload
maintain HR
DECREASE afterload
"fast, full, forward"
188
off-pump CABG
does NOT arrest the heart
does NOT go on cardiac bypass
189
true or false
you MUST have an aline for offpump CABG
true
190
true or false
off-pump CABG:
EKG and TEE may be INaccurate
(due to mechanical displacement of heart)
true
191
OFF-pump CABG
2 treatments for stress of heart
1) fluid bolus
2) trendelenburg
(fills the heart)
192
when is OFF-pump CABG indicated
single bypass cases
(IMA to LAD)
193
OFF-pump CABG
ACT ____-____
300-400
194
true or false
OFF PUMP CABG
there is NO CPB utility for rewarming
true
195
true or false
stablization device is designed to facilitate a MOTIONLESS surgical site, withOUT arresting the heart
true
196
what vessel is best choice for OFF-pump CABG
mammary artery (IMA)
197
why is IMA a good choice for off-pump
does NOT require anastomosis (it has a native blood supply)
198
advantages of off-pump
NO dilution, LESS capillary permeability, LESS renal, LESS inflammatory
199
disadvantages of off-pump
risk of ischemia from stress (no "rest/relax")
anesthesia provider must be more vigilant since there is no bypass interval
heart is tilted, so it can kink the SVC (reduces preload), can have tamponade effects
200
3 indications for balloon pump (IABP)
ischemia
potential ischemia
poor CO
201
3 CONTRAindications for balloon pump (IABP)
aortic disease
aortic valve disease
surgery on the aorta (surgical insult)
202
balloon INflating =
diastole
203
balloon DEflating =
just PRIOR to systole
204
balloon inflating helps with what*
improves SUPPLY
improving oxygenation
205
balloon deflating helps with what*
reduces DEMAND
less SVR, ejects easier
206
balloon tip should be DISTAL to the ___ ___________ ________
L subclavian artery
207
what is goal of IABP
improve CPP
reduce workload
208
IABP
augmented ___________ pressure should exceed > UNASSISTED ________ pressure
DIASTOLIC > SYSTOLIC
209
How would we improve CPP with drugs
neo (this is finite)
210
what part of the body sees the boost in pressure
only PROXIMAL/ABOVE the balloon
211
highest number for IABP
diastole/inflation
212
the larger the gradient, the _____ you need the balloon
larger gradient =need it MORE
213
impella is a _____
VAD (ventricular assistive device)
214
3 indications for impella
acute MI
cardiogenic shock
post-bypass period
215
true or false
an IMPELLA would keep the patient alive if the heart stopped
(you could maintain CO)
true
216
where does an IMPELLA reside
LV
217
why is epi used (3)
1) chronotropic (HR)
2) inotropic/contractility (EF)
3) dromotropic (conduction)
218
what is cell saver
PRBCs only
219
similar to a VAD
tandem heart
220
When cardiac bypass fails, use this!
tandem heart
221
Device can function simply as a pump or with the aid of an oxygenator as ECMO
tandem heart
222
best option to view awareness
BIS monitor
223
true or false
TAVR
native valve STAYS in place
true
224
1 indication for TAVR
severe aortic STENOSIS
225
cerebral ox tells us what
FLOW
226
trans-_______ (of the LV)
distal aortic route (femoral route)
TAVR
trans-apical
227
TAVR
once the valve is positioned inside the native valve, _______ _____________ __________ is initiated to MINIMALIZE CO
rapid ventricular pacing
228
true or false
MAC and GA can both be used for TAVR
(NO difference in outcomes)
true
229
true or false
TAVR is HIGH risk
true
calcium buildup
balloon over/underinflation
230
1 reason for retrograde*
presence of CAD
231
L heart cath monitors __________
pressure
232
what is the primary substrate of metabolism in the brain*
glucose
233
_______glycemia WORSENS hypoxic injury
HYPOglycemia
234
adult human brain weighs ______-______ grams
1300-1400
235
_____-_____ml of blood flow per MINUTE
650-700 ml
236
____% total CO = brain
14%
237
the BRAIN ITSELF can increase blood flow to as much as ____-____% CO
15-20%
238
Cerebral blood flow AVERAGE
____ml/_____grams/min
50ml
/100gm/min
239
Cerebral blood flow SLOWING of EEG
____ml/_____grams/min
25ml
/100gm/min
240
Cerebral blood flow ISOELECTRIC EEG
____ml/_____grams/min
15-20ml
/100gm/min
241
Cerebral blood flow IRREVERIBLE INJURY
____ml/_____grams/min
<10 ml
/100gm/min
242
_____________ + ___________ = more sensitive to hypoxic brain injury than other parts of the brain
Hippocampus + cerebellum
243
CEREBRAL perfusion pressure = _____-_____ or _____
MAP - ICP or CVP,
whichever is HIGHER
244
CEREBRAL perfusion pressure =
MAP
245
CEREBRAL perfusion pressure (CPP)
< ____ torr = EEG changes, autoregulation diminished
< 50 torr
246
CEREBRAL perfusion pressure (CPP)
< ____ torr = irreversible injury
< 25 torr
247
autoregulation occurs at MAP 50-150 _____
torr
248
*when Vm (minute ventilation) DOUBLES,
_____ DECREASES by 1/2
CBF
249
CBF increases ___-___% for every 1 C temp
5-7%
250
volatile anesthetics have uncoupling > ___-___ MAC
> 1-1.5 MAC
251
luxury perfusion
_____ > _______
CBF > CMRO2
252
__________ can be neuroprotective at high doses
volatiles
(they decrease CMRO2)
253
____ anesthetics PRESERVE coupling
IV
reduced CMRO2
decrease CBF (vasoconstrict)
254
what 2 drugs INCREASE CMRO2
and ICP + CBF
nitrous
Sch
255
what drug INCREASES ICP + CBF only
ketamine
256
propofol is isoelectric EEG at ____mcg/kg/min
500
257
what drug can cause seizures in patients with seizure history
etomidate
258
what drug has a metabolite that can cause seizures
Demerol (normeperidine)
259
CONTRAindication for benzos
patients with increased ICP,
due to RESPIRATORY DEPRESSION (leads to rise in CO2)
260
ketamine increases ICP
> ___%
> 80%
261
CONTRAindications to Sch (3)
denervated muscle
CVA
motor neuron lesion
262
**____________ drugs, such as __________, cause an INCREASE in dose requirements for NON-depolarizers
anticonvulsant drugs, such as dilantin
263
NON-expandable "closed box"
1) Brain tissue (___%)
2) Blood (___%)
3) CSF (__%)
1) Brain tissue (80%)
2) Blood (12%)
3) CSF (8%)
264
true or false
brain tissue has almost NO nociceptive (pain) nerve tissue
true
265
*Cushing's REFLEX (not triad)
INCREASING ICP =
HTN
bradycardia
266
true or false
increase in ICP CAN damage brain
true
267
what type of epi effects are prominent for neuro
beta 2
268
goal is a "________" brain
relaxed
269
_______ventilation
and
_______carbia
should be used for brain surgery
HYPERventilate
HYPOcarbia
270
normal brain surgery, maintain Hct ____-____%
30-35%
271
keep brain patients ______volemic
NORMO
272
______ volume expansion helps reduce vasospasm
mild
273
AVOID ________ and ____ fluids
limit __________ to 1-1.5 L
dextrose + LR
limit hetastarch
274
true or false
it is MORE important to accomplish a SMOOTH induction rather than any particular drug combo
true
275
keep patient ________tensive during neuro surgery
NORMOtensive
HTN = increased ICP/CBF
HoTN = ischemia, decreased CPP
276
maximize venous drainage
avoid excessive neck ________
avoid flexion
277
keep HOB > ___
> 15**-30
278
*when should neuro function/spontaneous breathing be intact?
PRIOR to skin closure, pin removal
otherwise, the removal of the noxious stimuli (pins) will lead to delay of return of spontaneous respirations
279
what type of awakening should be used
rapid
(promotes neuro assessment)
280
CPP
level of the _____________
external auditory meatus
+
tragus
281
CPP has a ________ pressure than the heart
lower pressure
282
* 1 mmHg for every _____cm
1.25 cm
283
CPP: avoid < ____
< 50
284
4 types of intracranial mass lesions
1) congenital
2) neoplastic
3) inflammatory/infectious
4) vascular
285
2 types of neoplastic lesions
benign
malignant
286
2 types of inflammatory/infectious lesions
cyst
abcess
287
2 types of vascular lesions
AVM
hematoma
288
***when you suspect neuro insult to the brain, give ________
it prevents brain swelling!
steroids/decadron
289
why are anticonvulsants metabolized fast
CP450
290
mass lesions symptoms
headache
seizures
reduction in cognitive/neuro
focal neuro deficits
291
for mass lesions, you want to AVOID _______ benzos/opioids
PREOP
292
elevated ICP symptoms (5)
headache
N/V
papilledema
focal neuro deficits
AMS
293
poor outcome after ischemic events (AVOID)
____________ blood glucose
____________ brain temp
avoid
increased blood glucose
increased brain temp (avoid warmers)
294
where are majority of masses
_______tentorial
__________ fossa surgery
SUPRAtentorial
ANTERIOR fossa surgery
295
4 common symptoms of SUPRAtentorial
headache
seizures
hemiplegia
aphasia
"HSHA"
296
2 symptoms of INFRAtentorial
cerebella dysfunction
-ataxia, nystagmus
brain stem compression
-altered mental status, altered respirations
297
slow growing lesions are
usually Asymptomatic
298
fast growing lesions
acute neuro deficits
299
what would be affected by altered respirations/mental status
INFRAtentorial
POSTERIOR fossa surgery
300
RAS, ANS, some cranial nerves
circulatory/respiratory centers
POSTERIOR fossa surgery
301
how can we monitor damage to respiratory center during posterior fossa surgery
spontaneous ventilation
302
VAE can occur when
wound is _______ heart
ABOVE
303
highest incidence of VAE
sitting craniotomy
304
symptoms of VAE (5)
decreased/flat ETCO2
decreased O2
sudden HYPOtension
circulatory arrest
ET nitrogen absorption
305
*most sensitive NON-invasive monitor
precordial DOPPLER
mill-wheel roaring sound
306
*most sensitive INVASIVE monitor
TEE
transesophageal echo
0.25 ml air detected
307
treatment for VAE (2)
wax+saline
L LATERAL DOWN/DECUBITUS position
308
what is a PARADOXICAL air embolism
air entering SYSTEMIC circulation
309
3 types of defects that can cause paradoxical air embolism
PFO
atrial
ventricular septal
310
What is the leading cause of subarachnoid non-traumatic hemorrhage
sacular aneurysm rupture
311
2 risk factors for CEREBRAL ANEURYSM
age 55-60
female
312
Where are majority of aneurysms (2)
Internal carotid bifurcation
+
ANTERIOR cerebral artery
313
subarachnoid bleed symptoms (2)
intense headache (85%)
transient LOC with N/V
314
avoid ______tension with cerebral aneurysm
AVOID HYPOtension
(we want perfusion!)
315
true or false
cerebral aneurysm
EKG changes are NON-ischemic, NON-cardiac in origin, with NO adverse outcome
true
316
cerebral aneurysm
what is the major cause of mortality and morbidity
vasospasm
317
cerebral aneurysm
surgical intervention with
> ___ mm
>7 mm
clipping
318
vasospasm
keep Hct < ___
< 32
319
vasospasm
true or false
will need to correct the HYPOnatremia (due to the hemodilution)
true
320
treatment for vasospasm
"Triple H"
HEMOdilution
HTN
HYPERvolemia
321
vasospasm
2 drugs for treatment
inotropes
calcium channel blockers
(nimodipine, nicardipine)
322
subdural hematoma
where does blood collect
between dura and arachnoid
323
what kind of bleeding causes subdural hematoma
venous
324
subdural hematoma
symptoms
headache, drowsiness, cognitive decline, obtunded
325
subdural hematoma
treatment
craniotomy
burr holes
326
subdural hematoma
______capnia is desired
NORMOcapnia
327
AV malformation
_______cerebral hemorrhage
INTRAcerebral
328
risk factor (1) for AV malformation
age 10-30
"little AV"
329
AV Malformation
treatment (2)
1st neuroradiology treatment
2nd surgical resection
HYPERventilation + mannitol
330
what surgery can have extensive blood loss
AV malformation
331
hypersecretory tumors can cause
acromegaly (growth hormone) and hyperglycemia
this can lead to possible
difficult intubation
332
pituitary surgery
types of resections
1) trans-phenoidal (MAJORITY)
2) intracranial
333
pituitary surgery
ETT should be placed to the ___ side
L side
334
pituitary surgery
**opposite of the other surgeries
use ______ventilation
________carbia
HYPOventilation
HYPERcarbia
you want a bulging/tight brain
335
malformation where MEDULLA protrudes through foramen magnum
arnold-chiari malformation
336
arnold-chiari
risk factor (1)
females
337
Infratentorial masses can obstruct CSF at __th ventricle and lead to obstructive hydrocephalus
4th
338
arnold-chiari
anesthesia implications
same as those for posterior fossa surgery
339
head trauma
symptom: _____tension
HYPOtension
340
true or false
head trauma
RSI is NOT best option
(due to cricoid pressure)
true
341
head trauma
maintain CPP at ____-____
70-110
342
head trauma
treatment
robinul (for enhanced vagal tone)
AVOID peep until AFTER dura is opened
leave intubated/paralyzed
343
true or false
ortho patients have more positioning challenges than any other surgery
true
344
ortho
best positions
supine
sitting lateral decubitus
prone
345
ortho
Excellent advantages, but can be UNreliable
Used more for UPPER extremity surgery
regional
346
Rheumatoid Arthritis
Immune related, ___________ inflammation of synovial joints
progressive
347
rheumatoid arthritis
Atlantoaxial subluxation:
C-spine films to evaluate + determine if awake fiberoptic intubation is indicated = > ___mm = instability
> 5mm
348
true or false
it is OKAY to use LMA with lateral positioning (shoulder surgery)
true
349
shoulder surgery
we want _____tension
HYPOtension is good!
350
arthroscopic surgery
keep BP _____
irrigation fluid ___-___ mmHg
BP should be LOW
irrigation fluid 60-80 mmHg
351
TMJ dysfunction can lead to
limited jaw opening
352
Atlantoaxial instability can lead to
limited neck ROM
353
which surgery should you check distal pulses
CERVICAL spine
(use ear probe oximeter)
354
CERVICAL spine surgery
true or false
coughing or bucking MUST be PREVENTED
true
355
what is a risk with LUMBAR spine surgery
brachial plexus
arms/shoulders should be LESS THAN < 90
356
LUMBAR spinal surgery
diaphragm has moved __________/________
decreases FRC + Vt
CEPHALAD/upward
357
ortho
long procedure,
greater blood loss,
use cell saver and type/crossmatch
spinal fusion
358
scoliosis have __________ lung disease
restrictive
359
anterior/posterior approach
Neuromuscular monitoring is indicated, due to artery of _____________
adamkiewicz
360
hip fracture
____________ arm is placed on chest
IPSI-lateral
361
hip FRACTURE
_________ position
supine
362
hip REPLACEMENT
_______ __________ position allows for greater ROM
lateral decubitus
363
**Bilateral hip surgery is CONTRAindicated if declining pulm function occurs after ___ hip surgery (O2 sat drops 94ish)
1st
364
ortho
what surgery has high incidence of DVT
knee replacement
more distal = higher risk
365
knee replacement
regional:
femoral 3-in-1
LFC, obturator, femoral
366
true or false
knee surgery is MORE painful
true
367
Very short procedures
"popping" back into place
short-acting paralysis + propofol
closed reduction
368
Used to bind prosthetic to bone
Exothermic reaction occurs
-Hardens cement and expands
-Lysis of blood cells and marrow
Methylmethacrylate Cement
369
Embolization of air, fat, marrow, cement
intermedullary HTN
370
Systemic absorption of cement
leads to
decreased SVR (HYPOtension, vasoDILATION)
371
release of tissue thromboplastin,
platelet aggregation, microemboli formation
hammering
372
Bone Cement Implantation Syndrome
(migration to pulm system)
HYPOtension
Hypoxia
Reduced CO
Dysrhythmias
Shunt
Pulm HTN
373
treatment for Bone Cement Implantation Syndrome (2)
increase FiO2
adequate hydration
374
exsanguination
cuff should overlap ____º from nerve bundle
180 degrees
375
____ torr over SBP = LOWER extremity
100 torr
376
____ torr over SBP = UPPER extremity
50
377
tourniquet
neuro damage may occur if >___ hrs or if over nerve bundle
> 2 hours
378
Pneumatic Tourniquet
physiologic effects
INFLATION
INCREASE in SVR, CVP, PVR
displaced/added blood volume (300-500ml)
379
treatment for "tourniquet pain"
opioids added to LA
deflation (10-15 min)
380
Pneumatic Tourniquet
physiologic effects
DEFLATION
metabolic acidosis
tachycardia
HYPOthermia
HYPOtension (most common)
381
why does HYPOtension occur with deflation
sudden reduction of SVR/PVR
washout of ischemic metabolites (thromboxane)
382
when does tourniquet pain occur
after 1 hour
383
DVT, PE, VAE common
long bone fractures
(especially hip + knee)
384
___________ anesthesia REDUCES risk of DVT
regional
(epidural/spinal)
385
why does regional technique reduce risk of DVT
Higher levels of plasminogen + plasminogen activators
HYPERkinetic blood flow
386
**Fat Embolism Syndrome/Triad
1) petachaie (axillary/subconjuctival)
2) dyspnea
3) confusion, mental changes
387
**Fat Embolism Syndrome/Triad
occurs ___-___ hours later
12-24 hours
388
other symptoms with fat embolism
tachycardia (ST segment changes)
fat in urine, sputum, conjuctiva
389
risk factor for PULMONARY fat embolism
lung disease
390
treatment for fat embolism (4)
O2
fluids
steroids
aggresive ventilation!
391
ortho postop pain management
best option
multimodal + regional
(NSAIDs + opioids + regional)
392
VAE
large air bubbles can lead to INCREASED ___ afterload and decreased ___
INCREASED RV
decreased CO
393
true or false
pituitary is RARELY metastatic
20-50% are NON-secretory
true
394
shoulder surgery
VAE is possible with
beach chair position
395
shoulder surgery
what type of block
interscalene
396
how can you avoid airway swelling
steroids
397
*what is most common with deflation of tourniquet
hypotension
398
pinprick tingling
A-delta
399
dull aching pain
C
