Exam 2 Flashcards
(214 cards)
1
Q
Standard monitors to place on patient when they are moved to OR table
A
pulse ox, EKG, and BP
2
Q
Purpose of pre-oxygenation
A
increase alveolar O2 and decrease alveolar N2 (denitrogenation)
3
Q
on room air what is the functional residual capacity
A
500mL of O2, about 2 minutes of apnea
4
Q
on 100% FiO2 how long can a patient be apneic
A
about 6-10 minutes
5
Q
what is functional residual capacity
A
amount of air in the lungs after exhalation
6
Q
goal ETO2 of pre-oxygenation
A
should be 90%
7
Q
how long should we preoxygenate
A
TV breathing for 3-5 minutes or 8 deep breaths in 60 seconds
8
Q
indications for RSI
A
full stomach, obesity, diabetic, bowel obstruction, appendectomy, hiatal hernia w/ reflux
9
Q
when does aspiration usually occur
A
induction and emergence
10
Q
pathophysiology of aspiration pneumonitis
A
aspirated substance cause immediate damage
atelectasis within minutes
inflammatory response 1-2 hours after w/ pulm edema
By 24 hours secondary injuries occur
11
Q
signs of aspiration
A
SpO2 <92%
tachypnea
tachycardia
HTN
chest Xray w/ infiltrates
alveolar-arterial gradient increase >300 on 100% O2
12
Q
what monitors and devices are placed during maintenance
A
temperature monitoring, bair hugger, OG/NG tube, ToF monitor
13
Q
appropriate MAC to render patient asleep and avoid recall
A
0.7-1 MAC
14
Q
things to include on handoff
A
Surgery
Past Med Hx
how was masking?
How was intubation? View?
Meds given with intubation
Twitches/last paralytic
complications
15
Q
how to eliminate inhaled anesthetic
A
turn off gas
increase FGF
increase ventilation
increase pressure support
16
Q
amount of blockade with 1 twitch present
A
90%
17
Q
amount of blockade with 2 twitch present
A
80%
18
Q
amount of blockade with 3 twitch present
A
75%
19
Q
amount of blockade with 4 twitch present
A
0-70%
20
Q
Neostigmine numbers
A
dose: .025 - .075mg/kg
onset: 5-15 minute
duration: 45-90 minutes
Elimination: 50% renal 50% plasma esterase
21
Q
Edrophonium numbers
A
Dose: .5 - 1mg/kg
Onset: 30 - 60 seconds
Duration: 5 - 20 minute
22
Q
Sugammadex onset
A
1-3 minutes
23
Q
Objective data for adequate reversal
A
4 twitches
TV > 5mL/kg
SpO2 > 90%
sustained tetanus >5 seconds without fade
vital capacity >15mL/kg
24
Q
subjective date for adequate reversal
A
5 second head lift
eyes opening
constant hand grip
tongue protrusion
25
advantages of awake extubation
airway reflexes present
decreased aspiration risk
spontaneous ventilation
26
disadvantages of awake extubation
increased CV stimulation
increased coughing and straining
27
advantages of deep extubation
decreased CV stimulation
decreased coughing and straining
28
disadvantages of deep extubation
absent or depressed reflexes
increased risk of aspiration
airway obstruction
hypoventilation
29
calculate total body water
ICV + ECV
ICV is 2/3
ECV is 1/3
29
normal total body water
60% of lean body mass (42L)
30
primary cation of intracellular fluid
potassium
31
primary anion of intracellular fluid
phosphate
32
primary anion of extracellular fluid
Chloride
33
primary cation of extracellular fluid
sodium
34
ECF is split into what
intravascular (25%)
interstitial (75%)
35
what are the 2 intravascular pressures
capillary hydrostatic pressure and plasma oncotic pressure
36
what are the 2 interstitial pressures
interstitial fluid pressure and interstitial oncotic pressure
37
what is capillary hydrostatic pressure
the intravascular blood pressure driven by CO and impacted by vascular tone
38
what is plasma oncotic pressure
the osmotic force of colloidal proteins in the vascular space
39
what is interstitial fluid pressure
the hydrostatic pressure of the interstitial space
40
what is interstitial oncotic pressure
osmotic force of colloidal proteins within the interstitial space
41
what causes fluid to filter into interstitial space
increases in capillary hydrostatic pressure + increases interstitial oncotic pressure
42
what causes fluid to be absorbed into intravascular space
increases in plasma oncotic pressure and increases in interstitial fluid pressure
43
what is positive net filtration
fluid exudation into the tissues (fluid exits the capillary)
44
what is negative net filtration
fluid is absorbed into the vasculature
45
what is glycolax
the gel layer on the luminal (interior) surface of the vascular endothelium
46
what happens when glycolax is damaged
creates a capillary leak which causes accumulation of fluid and debris in the interstitial space and reduces tissue oxygenation
47
explain RAAS
renin is released due to hypotension which reacts with angiotensinogen and forms antgiotensin 1
ACE released by lungs converts angiotensin I to II
angiotensin II causes vasoconstriction and release of aldosterone
aldosterone stimulates reabsorption of water and salt in the kidneys
48
what is ADH and where does it work
potent vasoconstrictor and works on V1 receptor
49
role of Atrial natriuretic peptide
in response to increased preload, stimulates kidney to release sodium and water to reduced circulating blood volume
50
normal plasma osmolarity
280-290
51
equation for plasma osmolarity
2Na + (glucose/18) + (BUN/2.8)
52
advantages of crystalloids
lack allergic potential
provide immediate restoration of circulating vascular volume
preserve microcirculatory flow
decrease hormone mediated vasoconstriction
lower cost
53
disadvantages of crystalloids
75-80% will transfer into interstitial space due to hemodilution of plasma proteins and loss of capillary oncotic pressure
dilutional effect of coags
54
Normal saline can cause what
hyperchloremia and hyperchloremic metabolic acidosis
55
why is normal saline used widely in neurosurgical patients
hyperosmolality
56
why is normal saline used in patients who have anuria
less potassium in fluid than other isotonic fluids
57
use for 3% saline
low doses for trauma and head injury patients since it promotes volume expansion that mobilizes intracellular and interstitial fluid into the vasculature
58
what is the buffering agent of LR and what does it do
sodium lactate, maintains electrochemical balance and neutral pH of solution
59
advantages of LR
better at preserving intravascular fluid than NS
60
disadvantages of LR
lactate can cause gluconeogenesis
may contribute to alkalosis
mildly hypotonic so may cause transient serum hyperosmolality
contains calcium so contraindicated with blood products
61
why is Dextrans not used anymore
coagulopathic effects due to impairment on von willebrand factor
62
Dextrans osmolarity
high molecular weight (40-70kDa), hyperosmolar and have life of 6-12 hours
63
Gelatins molecular weight and half life
molecular weight of 30-35 kDa, half life 2-4 hours
64
disadvantages with gelatins
interfere with platelet function
cause nephrotoxicity
high chance to cause anaphylaxis
65
disadvantages of hydroxyethyl starches
can cause allergic reaction if allergic to the starchy plants
associated with coagulopathy and kidney injury
66
disadvantages of albumin
costly
can cause anaphylaxis
67
what is albumin made from
made from fractioned blood product from pooled plasma
68
molecular weight of albumin
65-69 kDa
69
calculation for maximum allowable blood loss
EBV x (initial Hct - lowest acceptable Hct) / initial Hct
70
4-2-1 rule
4cc/hr for first 10kg
2cc/hr for 2nd 10kg
1cc/hr for remaining kg
71
4-2-1 rule for 86kg patient
4cc x 10kg = 40cc
2cc x 10kg = 20cc
1cc x 66kg = 66cc
combined is 126cc/hr
72
what is estimated fluid deficit
maintenance fluid requirement x fasting hours
73
problems with 4-2-1 rule
does not account for comorbidities
74
what SVV indicates patient may benefit from fluid bolus
>13%
75
requirements for SVV
mechanically ventilated with 7-8mL/kg TV
no arrhythmias
peep <15
76
hyper vs hyponatremia
hyper = shrinkage
hypo = swelling
77
what is the main regulator of potassium
alodsterone
78
EKG with hypokalemia
flattened T wave, U wave
79
EKG with hyperkalemia
peaked T waves, widened QRS in extreme levels
80
normal value of calcium
9-10.5
81
what is the primary regulator of calcium
parathyroid hormone
hyperparathryoid =hypercalcemia
82
hypocalcemia symptoms
Chvostek sign - facial spasms with touch of facial nerve
Trousseau sign - provoked carpal spasm after inflation of BP cuff
Prolonged QT
83
hypercalcemia symptoms
shortened QTc
hypertension
confusion/somnolence/seizure
N/V, constipation
84
treatment for hypercalcemia
volume expansion with NS
85
hypomag symptoms
fatigue, muscle weakness
Flat T wave
presence of U wave
prolonged QT
wide QRS
86
hypermag symptoms
depression of PNS and CNS
prolonged PR
prolonged QT
wide QRS
potentiation of NMB
87
hypophos symptoms
left shift oxyhem curve
hypoxia
heart blocks
seizures
come
88
hyperphos symptoms
same as hypocalcemia
brady
long QT
chvostek sign
trousseau sign
tetany
muscle weakness
89
what is hypoxis
state of insufficient oxygen to support tissues
90
what is hypoxemia
state of low concentration of oxygen in blood (PaO2 <80)
91
what is FiO2
concentration of oxygen in inspired gas
92
what is PaO2
partial pressure of oxygen in arterial blood
93
what is PAO2
partial pressure of oxygen in alveoli
94
what is SaO2
percent of hgb binding sites in the blood that are carrying oxygen
95
four factors that impact FiO2 of low flow oxygen
reservoir
oxygen flow rate
patient's ventilation pattern
proper fit
96
each 1L of nasal cannula increase increases FiO2 by ____
4%
97
max FiO2 of nasal cannula
44%
98
for nasal cannula, how is FiO2 related to MV
FiO2 decreases as MV increases
99
simple mask FiO2 with 5-8L
35-60%
100
why should flows on simple mask be at least 5L
avoid rebreathing of CO2
101
what is FiO2 of partial rebreathing mask
60-80%
102
flows and FiO2 of face tent
4-8L, FiO2 30-55%
103
FiO2 of trach mask
up to 90%
104
what is absorption atelectasis
80% of gas in alveoli is nitrogen which holds alveoli open, O2 washes it out leading to collapse
105
high compliance causes
emphysema
neuromuscular disorders
PEEP
106
low compliance causes
pulm edema
ARDS
bronchoconstriction
Pneumo
insufflation of abdomen
inadequate muscle relaxation
107
high resistance causes
ETT kinked
airway obstruction
bronchospasm
airway edema
high gas flow (turbulence)
108
Low resistance causes
bronchodilators
increased lung volume
109
Flow volume loop for obstructive lung disease
low (flattened) peak inspiratory flow
low peak expiratory flow
failure of expiratory flow curve to reach 0 (gas trapping)
scooped out expiratory flow
110
what would be seen on flow volume loop with restrictive lung disease with PRESERVED compliance
loop appears normal but is small with reduced TV
111
what would be seen on a flow volume loop with restrictive lung disease and DECREASED compliance
reduced TV
rapid (steep) decreased in inspiratory flow
rapid (steep) expiratory flow
high peak expiratory pressure
*pulmonary fibrosis
112
what is seen in a flow volume loop with circuit leaks
expiratory phase not returning to original start
113
what is seen in flow volume loop with water/secretions
fluctuations on both curves
114
what pressure volume loop is used in anesthesia
dynamic pressure volume loop
115
Describe points of pressure volume loop
upper right point = PIP and TV
Lower left = zero volume and the set PEEP
116
what direction does a pressure volume loop flow
counter clockwise (inspiratory on right, expiratory on left)
117
how to calculate compliance
change in volume divided by change in pressure
118
what is normal compliance
50-100cmH2O
119
how does decreased compliance shift pressure volume loop
more horizontal
rotated right
120
how does increased compliance shift pressure volume loop
more vertical
rotated left
121
what does the area within the loop of pressure volume loop represent
work of breathing (hysteresis)
larger area means increased work to ventilate(increased resistance or reduced compliance)
122
what is peak airway pressure (Ppeak or PIP)
maximum pressure achieved during inspiration when air pushed into lungs
reflects resistance, compliance and TV
123
what should Ppeak (PIP) be
< 40 cmH2O
124
what is mean airway pressure
average pressure over whole ventilatory cycle
dynamic pressure measured by vent
optimizes oxygen
125
what 5 settings impact mean pressure
PIP, PEEP, rate, iTime, flow
126
what are the expected "Pmean" values for SV, MV, airflow obstruction, and ARDS
SV: 3-5
MV: 5-10
Obstruction: 10-20
ARDS: 15-30
127
what is Pplat
static pressure in alveoli achieved at end of full inspiration
should be < or = 30
128
what does it mean if you have high PIP and normal PP
increased airway resistance
129
what does it mean when you have high PIP and high PP
decreased lung compliance
130
what are the goals of mechanical ventilation
oxygen, ventilation, reduce work of breathing
131
what does PEEP do
improves oxygenation by maintaining airway pressures more than 0 during EXHALATION, preventing alveoli collapse and improving recruitment of atelectactic areas
132
what does PEEP do to FRC
increases
133
what are the aspects of protective ventilation
LOW V: 5-7mL/kg IBW
PIP < 35
Pplat: <28
Driving pressure <16
recruitment maneuvers
PEEP 5-8
Avoid FiO2 >.8
use lowest FiO2 for SpO2 88-95
134
what is the goal of protective ventilation
reduce overdistention and cyclic atelectasis
135
how do you calculate MV
TV x RR, should be 5-10L/min
136
what is normal TV
5-12 mL/kg of IBW
137
what is normal I time
1.7-2 seconds
138
explain maximum pressure (Pmax) set on vent
max lung pressure provider determines safe, if reached the vent will stop allow pt to exhale and alarm will sound
139
normal Pmax
12-100cmH20
140
what is Ppeak or PIP
max pressure needed to deliver TV, dependent on airway resistance and lung compliance
141
why use I:E 1:3 in COPD/asthma
reduces risk of air trapping
142
why use a 4:1 ratio
increased alveolar recruitment, increase hemodynamic effects
decrease CO2 clearance
used in severe hypoxia with poor lung compliance (ARDS)
143
what is constant variable in VC
tidal volume
144
what is dependent variable in VC
pressure, varies depending on respiratory mechanics and pt effort
145
recommended initial adult VC settings
TV: 5-7mL/kg IBW
RR: 6-12
I:E 1:2
PEEP: 5-10
146
what is constant variable in PC
pressure
147
what is dependent variable in PC
volume
148
In PC, how is TV effected if compliance increases or resistance falls
TV increases
149
in PC, how is TV effected if compliance decreases or resistance increases
TV decreases
150
in low compliance, how does PC differ from VC
in low compliance there is a higher TV compared to VC
151
recommended initial adult PC settings
Pressure limit: 12-20
RR: 6-12
I:E 1:2
PEEP 5-10
152
in VC, increased airway resistance or decreased lung resistance leads to what
PIP increases
153
in PC, increased airway resistance or decreased lung compliance leads to what
TV decreases
154
explain SIMV-VCV
initial settings mirror VC but allows patient to breath spontaneously between synchronized breaths
155
explain SIMV-PCV
initial settings mirror PC but allows patient to breath spontaneously between synchronized breaths
156
explain SIMV PCV-VG
mirrors PCV, delivers a set RR o PC breaths with guaranteed volume to them
157
explain PSV-Pro
spontaneously breathing patient, adds pressure to patients inspiratory effort while having apnea back up settings
158
explain APRV
similar to BiPAP but high CPAP during cycle
159
when does atelectasis develop during surgery
first 2-3 minutes
160
goals of lung recruitment maneuvers
reducing atelectasis
161
what are some lung recruitment maneuvers
manual ventilation with set inspiratory pressure 30-40 and hold pressure for 30-60 seconds
ventilator vital capacity maneuver
ventilator cycling maneuver
CPAP
PEEP
162
PEEP recommendations for BMI
<25: 6-7
26-30: 7-8
>30: 8-12
>40: 12-15
>50: 15
163
typical CPAP setting for NPPV
5-10
164
typical BiPAP settings for NPPV
IPAP: 8-10 max 20
EPAP: 3-5 max 10
165
in supine position, if the head is not in neutral position what nerve could be injured
brachial plexus
166
what is trendelenburg's effect on starling curve
shift to right
167
complications from trendelenburg
shoulder braces can cause injury to brachial plexus, edema to facial structures, unrecognized hypovolemia
168
when is reverse trendelenburg commonly used and what is the complication
laparoscopic procedures
reduces perfusion to brain
169
why in lithotomy are the legs elevated and lowered at the same time
prevent hip dislocation, spinal torsion, or postop back pain
170
in lithotomy what dose acute abduction and external rotation of hips cause
femoral nerve or lumbosacral plexus stretch injuries
171
in lithotomy what does flexion of hips greater than 90 degrees do
injury to sciatic and obturator nerves
172
what are done with the legs in lateral decubitus
nondependent leg is straight, dependent leg is flexed at knee and hip
173
what is Bezold-Jarisch reflex
occurs when patient is in sitting position, hypotension and bradycardia from decrease in venous return
174
CV effects of sitting, prone, and flexed lateral positions
CO and BP decreased
175
when placing in different positions, what should the anesthetist do about MAC
slow increase, shouldn't be at 1 MAC prior to sitting in beach chair
176
if trendelenburg increases venous return, when should precaution be taken with this
people with reduced heart function may not be able to handle the increased volume return
177
lateral position effect on ventilation/perfusion in both spontaneously breathing patients and mechanically ventilated
Spontaneous: dependent lung greater in ventilation and perfusion
Mechanical: nondependent (upper) better for ventilation and dependent (lower) lung better for perfusion causing V/Q mismatch
178
abdominal viscera effects in prone position
contents may limit diaphragm excursion due to compressing the body
179
abdominal viscera effects in lateral position
moves hemidiaphragm of dependent lung upward decreasing ventilation
180
abdominal viscera effects in sitting position
not much effect
181
abdominal viscera effects in trendelenburg position
diaphragm is moved cephalad which causes the movement of diaphragm to be limited and decreases FRC
182
abdominal viscera effects in supine position
FRC and total lung capacity are decreased
183
transection nerve injury
from cut
184
compression nerve injury
forced on bony prominence
185
stretch nerve injury
from stretch
186
conditions that can contribute to perioperative nerve injuries
HTN, DM, PVD, peripheral neuropathies, alcoholism
187
what is one of the most frequently reported injuries after surgery and may take 48-72 hours to report
ulnar nerve neuropathy
188
claw hand is from what
ulnar nerve injury
189
ape hand is from what
median nerve injury
190
wrist drop is from what
radial nerve injury
191
5 causes of non-ophthalmic vision loss
ischemic optic neuropathy
central retinal artery occlusion
central vein occlusion
cortical blindness
glycine toxicity
192
what 2 account for more than 80% of all cases of POVL
central retinal artery occlusion and ischemic optic neuropathy
193
vision loss from ION occurs when
24-48 hours after surgery, no pain associated
194
how does CRAO present
unilateral vision loss immediately after surgery
195
goals of MAC
sedation, amnesia, anxiolysis, and analgesia
196
what are the parameters of minimal sedation (anxiolysis)
normal response to verbal stimuli
unaffected airway
unaffected spontaneous ventilation
unaffected cardiovascular function
197
what are the parameters of moderate sedation
purposeful response to verbal or tactile stimulation
no airway intervention
adequate spontaneous ventilation
CV function usually maintained
198
what are the parameters for deep sedation
purposeful response after repeated painful stimuli
airway intervention may be required
spontaneous ventilation may be inadequate
CV function is usually maintained
199
what are the parameters of general anesthesia
unarousable
airway intervention often required
spontaneous ventilation is frequently inadequate
CV function may be impaired
200
fasting guidelines for MAC
same as GA
201
BIS target for MAC vs GA
MAC: 60-80
GA: 40-60
202
PaO2 equation
(FiO2 x (Patmos - PH2O)) - (PaCO2/RespQ)
203
levobupivacaine doses
max dose: 2mg/kg
Max total dose: 150mg
204
Bupivacaine doses
max dose: 2mg/kg
Max total dose: 175mg
205
Bupivacaine w/ epi doses
max dose: 3mg/kg
max total dose: 225mg
206
Ropivacaine doses
max dose: 3mg/kg
Total max dose: 200mg
207
lido doses
max dose: 4.5mg/kg
max total dose: 300mg
208
lido w/ epi doses
max dose: 7mg/kg
max total dose: 500mg
209
mepivacaine doses
max dose: 7mg/kg
max total dose: 400mg
210
prilocaine doses
max dose: 8mg/kg
max total dose: 500-600mg
211
procaine doses
max dose: 7mg/kg
max total dose: 350-600mg
212
chloroprocaine doses
max dose: 11mg/kg
max total dose: 800mg
213
