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1
Q

↑PVR

A

Hypoxia
Low FiO2 < 30%
Acidosis ↓pH ↑H+
Hypercarbia ↑CO2
PEEP ↑ITP or airway pressures
Mechanical ventilation
Light anesthesia/pain
Surgical stress SNS stimulation
Vasoconstrictors
HPV response to atelectasis
Trendelenburg
Nitrous oxide N2O
Desflurane & Ketamine
Hypothermia

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2
Q

↓PVR

A

Hyperoxia ↑PaO2
↑FiO2 100%
Alkalosis ↑pH ↓H+
Hypocarbia ↓CO2
Hyperventilation
No PEEP ↓ITP
Low airway pressures
Spontaneous ventilation
Deep anesthesia
Vasodilators iNO, NTG, PDEi, PGE1, PGI2, CCBs, ACEi

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3
Q

Pulmonary Vascular Resistance

A

PVR = [(Mean PAP - PAOP) / CO] x 80
Normal 150-250 dynes/sec/cm

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4
Q

Acidosis

A

↑CBF ↑ICP
↑P50 (R shift)
↑SNS tone ↑dysrhythmias risk ↓contractility
↑PVR
Hyperkalemia

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5
Q

Anion Gap

A

= Na+ - (Cl¯ - HCO3¯)

Normal 8-12 mEq/L

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6
Q

When to calculate the anion gap?

A

Metabolic acidosis

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7
Q

Metabolic Acidosis
Normal AG Causes

A

HARDUP
Loss HCO3¯ or ECF dilution
NS hyperchloremia

Hypoaldosteronism
Acetazolamide
Renal tubular necrosis
Diarrhea
Uretosigmoid fistula
Pancreatic fistula

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8
Q

Metabolic Acidosis
Elevated AG Causes

A

MUDPILES
> 12 mEq/L

Methanol
Uremia
Diabetic ketoacidosis
Paraldehyde
Isoniazid
Lactate ↓DO2, sepsis, cyanide poisoning
Ethanol or ethylene glycol
Salicylates inhibit the Krebs cycle

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9
Q

Alkalosis

A

↓CBF ↓ICP
↓P50 (L shift)
↓coronary blood flow
↑dysrhythmias risk
↓PVR
Hypokalemia
↑ionized Ca2+

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10
Q

Metabolic Alkalosis
Causes

A

Loops diuretics
Vomiting
Antacids
Hyperaldosteronism

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11
Q

Oxyhemoglobin Curve
Left Shift

A

Alkalosis ↑pH ↓H+
Hypocarbia ↓CO2
↓2,3 DPG
Hypothermia
Fetal/Met/CO Hgb
Lungs
HaLdane

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12
Q

Oxyhemoglobin Curve
Right Shift

A

Acidosis ↓pH ↑H+
Hypocarbia ↑CO2
↑2,3 DPG
Hyperthermia
Tissues
Bohr O2 offloading

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13
Q

PAO2

A

Alveolar O2 partial pressure
= FiO2 x (760 - 47 mmHg) - [PaCO2 / RQ]

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14
Q

CO2 Production

A

200 mL/min

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15
Q

O2 Consumption

A

250 mL/min
OR
3.5 mL/kg/min

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16
Q

How does body temperature affect O2 consumption?

A

Direct correlation
↓core body temperature ↓O2 consumption
Every 1°C ↓5-7%

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17
Q

Acute Hypercarbia

A

↑CO2 10 mmHg > 40 ↓pH 0.08

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18
Q

Chronic Hypercarbia

A

↑CO2 10 mmHg > 40 ↓pH 0.03

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19
Q

Hypoxia Causes:

A
  1. Hypoxic mixture
  2. Hypoventilation
  3. Diffusion limitation
  4. V/Q mismatch
  5. Shunt
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20
Q

↓FiO2

A

Normal A-a gradient
+FiO2

Hypoxemic mixture
O2 pipeline failure
High altitude

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21
Q

Hypoventilation

A

Normal A-a gradient
+FiO2

Opioid overdose
Residual anesthetic agent or NMB
Neuromuscular disease
Obesity hypoventilation

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22
Q

V/Q Mismatch

A

Most common hypoxemia cause***
↑A-a gradient
+FiO2

COPD
OLV
Impaired HPV
Embolism - air, gas, amniotic fluid

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23
Q

Diffusion Impairment

A

↑A-a gradient
+ FiO2

Pulmonary fibrosis
Emphysema
Intestitial lung disease

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24
Q

Shunt

A

↑A-a gradient
FiO2 does NOT help

Atelectasis
Pneumonia
Bronchial intubation
Intercardiac shunt
Anatomic shunt

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25
What inhibits HPV?
Volatiles MAC > 1.5 Hypoxia Alkalosis ↑pH ↓H+ ↓CO2 Hypocarbia/hyperventilation Vasodilators - PDEi or SNP Vasoconstrictors Excessive PEEP ↑VT Hypervolemia LAP > 25 Hemodilution Hypothermia
26
SpO2:PaO2
SpO2 80 : PaO2 50 mmHg 70 : 40 60 : 30
27
Soda Lime Reaction
CO2 + H2O → H2CO3 (carbonic acid) H2CO3 + 2NaOH (sodium hydroxide) → Na2CO3 (sodium carbonate) + H2O + heat Na2CO3 + Ca(OH)2 → CaCO3 (calcium carbonate) + 2NaOH
28
Soda Limb Absorption Capacity
26L CO2 per 100g absorbent
29
How does soda lime neutralize CO2?
NaOH = weak base CO2 = acid
30
KOH
Potassium hydroxide Dessication → CO & compound A
31
Amsorb
Ca(OH)2 No CO NO compound A Expensive $$$ Low absorptive capacity Only able to absorb 10.6L CO2 per 100g
32
Baralyme
Removed from the market Sevo + baralyme → increased breathing circuit fire risk
33
Dead Space
Vd 2 mL/kg or 150 mL
34
1 Atmosphere
Patm 760 mmHg 760 Torr 1 bar 100 kPa 1,033 cmH2O
35
A - a Gradient
PAO2 - PaO2 Normal < 15 mmHg
36
What ↑A-a Gradient?
Shunt V/Q mismatch Diffusion defect Aging Vasodilators R → L shunt
37
Trachea
Begins at C5 Ends at T4-5
38
Carina
T4-5 Angle of Louis
39
Pneumocytes
Type 1 provide gas exchange surface Type 2 produce surfactant & type 1
40
Tracheobronchial Functional Airway Divisions
Conducting zone = trachea, bronchi, & bronchioles 0-4 Transitional zone = respiratory bronchioles 17 Respiratory zone = alveolar ducts & alveolar sacs 20-23
41
Reynolds Number
Re = (Density x Velocity x Diameter) / Viscosity Laminar flow [viscosity] < 2,000 Transitional 2,000-4,000 Turbulent [density] > 4,000
42
Dynamic Compliance
Cdyn = VT / (PIP - PEEP)
43
Static Compliance
Cstat = VT / (Pplat - PEEP) Normal 35-100 mL/cmH2O
44
↑PIP + Normal Pplat
↑resistance OR ↑inspiratory flow rate Kinked ETT Endotracheal tube cuff herniation Bronchospasm Bronchial secretions Airway compression Foreign body aspiration
45
↑PIP & ↑Pplat
↓total lung compliance OR ↑VT Endobronchial intubation Pulmonary edema Pleural effusion Tension pneumo Atelectasis Chest wall edema Abdominal insufflation Ascites Tburg Inadequate muscle relaxation
46
Volatile Anesthetics MOA Unconsciousness
Cerebral cortex Thalamus RAS
47
Volatile Anesthetics MOA Amnesia
Amygdala Hippocampus
48
Volatile Anesthetics MOA Autonomic Effects
Pons Medulla
49
Volatile Anesthetics MOA Analgesia
Spinothalamic tract
50
Volatile Anesthetics MOA Immobility
Spinal cord ventral horn Where the upper & lower motor neurons synapse
51
Mapleson A
Spontaneous ventilation > FGF 0 = APL <
52
Mapleson D
Controlled ventilation 0 APL = FGF <
53
Mapleson E
Ayre T-piece No reservoir bag or APL = FGF <
54
Mapleson F
Jackson-Rees No APL 0 = FGF <
55
Opioid MOA
Pre-synaptic ↓Ca2+ release Post-synaptic ↑K+ hyperpolarizes the cell membrane ↓RMP
56
Mu 1
Supraspinal & spinal analgesia Bradycardia Euphoria Low abuse potential Miosis Hypothermia Urinary retention
57
Mu 2
Spinal analgesia Bradycardia Respiratory depression Constipation Physical dependence
58
Delta
Enkephalins Supraspinal & spinal analgesia Respiratory depression, physical dependence, urinary retention, & pruritis
59
Kappa
Dynorphins Supraspinal & spinal analgesia Miosis, diuresis, & hypoventilation Agonist-antagonist MOA Anti-shivering Sedation, dysphoria, delirium, & hallucinations
60
AGM O2
1. O2 pressure failure alarm 2. O2 pressure failure device (failsafe) 3. O2 flowmeter 4. O2 flush valve 5. Ventilator drive gas
61
EKG Normal Axis
-30° → +90° Lead I + aVF +
62
Poiseuille
= (π∙r^4∙∆P) / 8ηl
63
Stenosis Anesthesia Management
Full, slow, & constricted Maintain or ↑afterload
64
Aortic Stenosis
Normal aortic valve orifice 2.5-3.5 cm^2 SEVERE < 0.8 cm^2
65
Mitral Stenosis
Normal mitral valve orifice 4-6 cm^2 SEVERE < 1 cm^2
66
Insufficiency/Regurgitation Anesthesia Management
Full, fast, & forward AVOID bradycardia
67
Pulsus Parvus
Aortic stenosis → narrow PP & small amplitude
68
Pulsus Tradus
Aortic stenosis → slower systolic upstroke & delayed peak
69
Bisferiens Pulse
Aortic regurgitation → biphasic systolic peaks Sharp upstroke & low DBP Wide pulse pressure
70
Pulsus Alternans
Severe LV failure Alternate ↑↓A-line waveform
71
Pulsus Paradoxus
Cardiac tamponade ↓SBP > 10 mmHg w/ inspiration
72
Thoracoaortic Aneurysm Classifications
Crawford Most common classification system*
73
Crawford Type
1. All or most descending thoracic aorta + only upper abdominal aorta 2. All or most descending + most abdominal 3. Only lower descending + most abdominal 4. No descending + most abdominal
74
Aortic Dissection Classification
Stanford & DeBakey
75
Stanford
Type A - Ascending Type B - Does not involve the ascending aorta
76
DeBakey
1. Tear in ascending aorta + dissection along entire aorta B 2. Tear in ascending aorta + dissection only in ascending aorta A 3. Tear in proximal descending aorta D a. Dissection limited to thoracic aorta b. Dissection along thoracic & abdominal aorta
77
Antiarrhythmics 1a
Na+ channel blockers (phase 0) Disopyramide Norpace Quinidine Procainamide
78
Antiarrhythmics 1b
Na+ channel blockers (phase 0) Lidocaine Phenytoin Mexiletine
79
Antiarrhythmics 1c
Na+ channel blockers (phase 0) Flecainide Propafenone Moricizine
80
Antiarrhythmics 2
β blockers -olol SA node phase 4
81
Antiarrhythmics 3
K+ ion channel blockers (phase 3) Amiodarone Sotalol Ibutilide DofetilideA
82
Antiarrhythmics 4
Ca2+ channel blockers (phase 2) Verapamil Nifedipine Diltiazem Nicardipine
83
Antiarrhythmics 5
OTHER Adenosine Atropine Magnesium Digoxin
84
Microshock
20-100 μA → V fib
85
MACROshock
1 mA = perception threshold 5 = max harmless current 10-20 = "let go" current 50 = pain or possible mechanical injury 100-300 mA → V fib
86
Line Isolation Monitor
Alarms when > 5 mA detected 1st fault OR grounded
87
What is the maximum current leakage allowed in the OR?
10 μA

APEX (18 decks)

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