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Principles II > Test 2 > Flashcards

Test 2 Flashcards

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1
Q

Stats for Geriatric Population in 2003, 2030, and 2050:

A

-By 2030, 20% of US will be >65 y/o
-By 2050, 2 billion ppl worldwide will be >60 y/o
-Compare to 2003: 12% US was >65 y/o

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2
Q

What % of hospitalizations do old ppl make up?

A

-1/3 of hospitalizations
-44% of hospital charges
-2-3x more surgeries
-longer hospitalizations

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3
Q

Memory Decline and Aging:

A

-present in 40% of ppl >60 y/o
-not inevitable, can be slowed by things like working out, reading, family connection, etc.

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4
Q

Brain Structure and Aging:

A

-cerebral atrophy
-decreased gray matter
-neuronal shrinkage (not much actual loss of neurons)
-decreased white matter
-INCREASE in ventricular size
-progressive loss of memory, imbalance and mobility

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5
Q

True or false: there is a decrease in glutamate.

A

-False! There is no change in glutamate.
-may be some decrease in NTM like dopamine, Ach, norepi, and serotonin based on animal studies

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6
Q

Why is EEG unchanged in old ppl?

A

-CRMO2 and CBF decrease in parallel fashion so the EEG remains unchanged

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7
Q

Neuraxial changes with aging:
^^Things that decrease LA dose

A

-decreased epidural space
-increased permeability of dura
-decreased volume of CSF
-decreased diameter/number of myelinated fibers in dorsal and ventral nerve roots

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8
Q

Peripheral Nervous System changes with aging:

A

-Inter-Schwann cell distance decreased
-Conduction velocity decreased due to reduction in myelination across the nerve fibers
-so, elderly more susceptible to neuraxial blocks and peripheral nerve blocks

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9
Q

Heart changes with aging:

A

-decreased number of myocytes
-LV wall thickens
-SA node cells decrease
-conduction velocity decreases
-thickened and calcified aortic valve
-decreased contractility
-increased ventricular stiffness-HIGHER LV filling pressures

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10
Q

What are the implications of their being less beta-adrenergic sensitivity in the elderly?

A

-decreased maximal heart rate and EF during stress…more prone to decompensation during these periods and with neuraxial anesthesia

-so HR doesn’t spike up as much in times of need to aid in maintaining adequate CO

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11
Q

Cardiac Vessel changes with aging:

A

-vascular stiffness
-breakdown of collagen and elastin
-less endogenous NO (less vasodilation of coronaries)
-early wave deflection-increased afterload along with diastolic dysfunction

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12
Q

Pulmonary: Structural changes with aging:

A

-LOSS of ER and Surfactant
-increased lung compliance (think COPD)
-enlarged bronchioles and alveolar ducts

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13
Q

What does the early collapse of small airways during exhalation for elderly cause?

A

-increased anatomic dead space
-increased closing capacity
-impaired gas exchange
-lower baseline sats, increased arterial CO2

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14
Q

What does the loss of vertebral height and calcification of vertebra and intercostal cartilage in the elderly cause?

A

-barrel chest
-diaphragmatic flattening
chest wall stiffness…increased work of breathing-contribute to dyspnea on exertion

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15
Q

Pulmonary: functional changes with aging:

A

-decreased vital capacity
-increased closing capacity
-increased residual volume
-TLC stays the same due to compensation
-decreased muscle mass and increased closing capacity
-weaker pharyngeal muscles

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16
Q

How much does FEV1 decrease per decade?

A

-decreases by 6-8% per decade

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17
Q

What is closing capacity again?

A

Combination of closing volume and RV

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18
Q

What are the implications of the elderly having weaker pharyngeal muscles?

A

-decreased clearance of secretions
-less efficient coughing
-decreased esophageal motility
-less protective upper airway reflexes

ASPIRATION RISK

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19
Q

VQ mismatch with aging:

A

-gap between FRC and closing capacity WIDENS
-FRC increases slightly, but CC increases much more
-this is the MOST important MOA for alveolar-arterial oxygen gradient mismatch

-shunt increases and arterial oxygenation declines

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20
Q

Renal changes with aging:

A

-GFR decreases (10 per decade)
-blunted responses to ALDO, vasopressin, and renin
-urinary retention and UTIs become more common

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21
Q

GI and Hepatic changes with aging:

A

-liver function declines
-drugs cleared via phase 1 are not ok: oxidation, hydrolysis via CYP450, reduction
-drugs cleared via phase 2 are ok: acetylation and conjugation
-LESS PONV!! so, avoid drugs like prochlorperazine, promethazine, and metoclopramide (not needed)

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22
Q

MSK changes with aging:

A

-muscle mass and strength declines
-subcutaneous fat thins
-impaired wound healing
-osteoarthritis

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23
Q

Thermoregulation changes with aging:

A

-temp is comparable in infants, children, and adults
-1 degree less for adults 60-80 y/o

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24
Q

Studies on old age and surgery risk:

A

-Denney/Denson: high mortality rate with pts 90 y/o and up
-Djokovi/Hedley-Whyte: ASA status predicted mortality
-Del Guercio/Cohn: uncorrected comorbidity in SICU: 100% mortality
-Finlayson: high mortality from nursing home residents

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25
Significant Predictors of 6 month-1 year mortality:
-impaired cognition -recent fall -hypoalbuminemia -anemia -functional dependence -comorbidities
26
Vulnerable brain chart:
-vulnerable brain (elderly) have a dysfunctional anti-inflammatory response and can have exaggerated neuro-inflammation and acceleration of AD pathology, leading to Long-term cognitive decline
27
What does POCD stand for?
-Post-operative Cognitive Dysfunction -can last months to years after surgery, or be indefinite
28
What are neurotoxicity factors? List examples.
-factors that play a role in the pathogenesis of dementia-vulnerable brains -Amyloid, Tau, Calcium, and Neuroinflammation factors
29
Tell me about amyloid:
-fragment of synaptic origin-so develop when synapses break down -unknown function, but accumulates extracellularly to form PLAQUES -these can aggregate but can also be eliminated -may disrupt cell membranes over time
30
How might amyloids affect anesthesia?
-first studied in halothane and mice -with amyloid plaque build up, the older mice have accelerated onset of alzheimers disease and dementia
31
Tell me about Tau:
-a protein -neurofibrillary tangle (NFT) -Phosphorylated and aggregated Tau protein -DESTABILIZES microtubules -decreases in temp of 2-3 degrees C INCREASES amount of Tau (Taupathy)
32
How do repeated exposures to Halothane, Isoflurane, and Sevoflurane affect Tau levels?
-Increased phosphorylated Tau -can then aggregate into plaques and destabilize microtubules -More Tau, more dementia
33
What's the idea behind Dantrolene treating neurotoxicity?
-It could decrease calcium release b/c CCB, but doesn't cross BBB so cant mitigate neurotoxicity -significant skeletal muscle weakness with this drug
34
How does neuroinflammation contribute to cognitive decline? What drugs do we give that could modulate this?
-through release of inflammatory factors like cytokines, IL-6, and TNFa -Dexamethasone, lidocaine, and Toradol
35
They gave 3 drugs that can alter CNS and ordered them based on how much they can cause cognitive decline. What were they and what was the order?
-Isoflurane > Desflurane > Propofol -so propofol is LEAST associated with cognitive decline -may be reason we TIVA elderly patients
36
Bedford 1955 Study:
-out of 1193 patients >50 years old receiving GETA, 10% have mental deterioration (long-term or permanent)
37
International Study of Postoperative Cognitive Dysfunction:
-1998 -non-cardiac patients >59 years old -POCD in these pts -22% higher at 1 week -7% higher at 3 months -p value 0.04% :) -risk factors: increasing age, duration of anesthesia, lesser education (lower SEC), second operation, post op infection, respiratory complications
38
True or false: surgery by itself can cause short term decline
-true! -anesthesia alone is also causative so surgery is additive to it -remember that pts have unknown vulnerabilities person to person
39
What are the issues with studies of anesthesia and surgery?
-underpowered -poorly designed -controversial
40
What would be ideal for studies looking at anesthesia and surgery?
-long, longitudinal surgeries -biomarkers...CSF -imaging like PET scans
41
Anesthesia implicants for cognitive decline and elderly:
-use neuraxial/regional when I can to avoid drugs affecting CNS -avoid long-acting NMBD and REVERSE completely!! (sugammadex DOC) -opioid sparing strategies -neutralize stomach acid with non-particulates -EEG based titration (BIS) -avoid hypotension -pad skin and nerves
42
Drug challenges in elderly related to the ehart:
-decreased CO and increase in circulatory time-takes longer for things to set in -slower distribution to initial site of action -slower redistribution -slower distribution to metabolic organs: kdineys and liver
43
Drug challenges to NMJ in elderly:
-increased distance b/w axon and motor end plate -decreased concentration of ACh receptors, amount of ACh in presynaptic vesicle, and release of ACh upon neuronal impulse
44
What's true for elderly patients if drugs are kidney/liver dependent for metabolism?
-prolongation of effect, decreased need for redosing during maintenance phase, delayed recovery phase for non-depolarizers (ROC)
45
Whats true in ther elderly pop if drugs are NOT kdiney/liver dependent for metabolism?
-no prolonged effect, same requirements during maintenance, no delay in recovery phase (think Nimbex good for elderly)
46
Pulmonary resection in elderly:
-mortality in 80-92 year olds: 3% -respiratory complications: 40% (2x younger ppl) -cardiac complications: 40% (3x younger ppl) -lobectomy mortality is not as bad, and less invasive techniques -pneumonectomy mortality is excessive
47
Algorithm for Preoperative Assessment: Thoracic (non-cardiac) surgery:
exercise tolerance affects decision -TTE can be done to rule out pulmonary HTN
48
Predictive Postoperative FEV1:
-predictor of postop outcomes -there are 42 lung segments total, 20 on left and 22 on right side -ppoFEV1= PreopFEV1% x (1-%lung tissue removed/100) -ex: if preopFEV1 was 70% and RLL removed: -70 x (1-(.29)/100))=50%
49
Triad of Pre-op Assessment:
-3 legged stool of pre-thoracotomy -We want VO2 max >15 mL/kg/min -PaO2 >60 -PaCO2 <45
50
Post-thoracotomy Anesthesia Management:
-FEV1 values let you know when to extubate -<30%, don't extubate yet!
51
Definition of POCD:
-Postoperative Cognitive Decline -objectively measured decline in cognitive function that persists beyond the period expected (beyond extubation)
52
Other name for hospital acquired infections:
Nosocomial infections: not present on or incubating at time of admission -in 1 in 3 hospitalized patients (CDC)
53
Sources of HAI:
-central line-associated sepsis -UTI (12.9%) -Surgical site infection (21.8%) -hospital-acquired pneumonia (21.8%) -ventilator-associated pneumonia -CDIFF (12.1%)
54
Risk factors for developing HAI:
-pt's immune status -infection control practices -prevalence of certain pathogens in the community -older age -longer hospital stays -multiple chronic illnesses -mechanical ventilatory support -critical care unit stays
55
Transmission of HAI's:
-direct contact with healthcare workers (biggest way) -contaminated environments (inguinal, perineal, axilla) -extraluminal migration -coag neg staphylococci (skin flora) migrate from lines into tissue
56
Symptoms suggestive of pre-existing infection:
-subjective fever -chills -night sweats -altered mental status -productive cough -shortness of breath -rebound tenderness -suprapubic pain dysuria -CVA tenderness (costovertebral tenderness)
57
Vital Signs:
-hypotension, tachypnea, low saturations, tachycardia
58
Devices we need to document on if coming into the facility with them, may replace them when they get here:
-Central line -Foley catheter -Insulin pump -Endotracheal tube -Intravenous liens
59
Which laboratory values do we look at for evidence of organ dysfunction?
-lactic acid -prothrombin time -BUN/Creatinine -Elevated WBC -Hypo/hyperglycemia -Cultures
60
When do Surgical site infections typically occur?
-within 30 days of surgery
61
What percentage of nosocomial infections are seen in surgical patients?
38%
62
How much cash money is spent yearly due to prolonged recovery/hospitalization from these SS infections?
3.5-8 billion!! -wound infections are COSTLY
63
Types of surgical site infections:
-Superficial incisional: just in incisional area -Deep incisional: beneath the incision area in muscles and tissues surrounding the muscle -organ or space: any area other than skin muscle: includes organs or space b/w organs
64
Signs of Surgical Site Infections:
-redness -delayed healing -fever -pain -warmth -swelling -drainage of pus (abscess)
65
Most common types of bacteria causing SSI:
-staphylococcus -streptococcus -pseudomonas
66
Risks for causing SSI:
-types of wound (clean, clean-contaminated, etc) -surgery lasting >2 hours -comorbidities -elderly -emergency or abdominal surgery
67
Clean wounds:
-not inflamed or contaminated, don't involve internal organs
68
Clean-contaminated wounds:
-no evidence of infection, do involve internal organs
69
Contaminated wounds:
-involve internal organ w/ spillage of contents from the organ -ex: organ rupture like rupture gallbladder, appendix, etc.
70
Dirty wounds:
-known infection at the time of surgery -ex: trauma, stab wound, you KNOW it's infected
71
How many SSI's are considered preventable?
-half!
72
What did the guideline for the prevention of SSI (2017) come up with?
-grading system: grading for recommendations, assessment, development, and evaluation -quality of evidence: very low, low, moderate high -170 studies appraised and synthesized
73
Grading Category: 1A
-strongly recommend, moderate to high quality of evidence
74
Grading Category: 1B
-strong recommendation, low quality evidence -prolly some bias
75
Grading Category: 1C
-strong recommendation required by state/federal regulation
76
Grading Category: II
-weak recommendation
77
Exclusions to the Guideline for the Prevention of SSI:
1. SSI was not reported as an outcome 2. all pts that had "dirty procedures" 3. the study only included dental or oral health procedures 4. the procedure did not include primary closure 5. the study includes wound protectors post-incision
78
Parenteral Antibiotics (IV):
-administer only when indicated (1B) -timed so that the agent is established in tissue upon incision (1B)
79
Non-parenteral Antibiotics:
-NO rec. for antibiotic irrigation -NO rec. for soaking prosthetic devices in antibiotic solution-not harmful -should only apply antibiotic ointment to incisions (1B)
80
Glycemic control:
-perioperative control (1A) -glucose targets <200 mg/dL (1A) -NO rec. for tighter control -NO rec. for A1C target
81
Normothermia:
-maintain peri-operative normothermia (1A) -NO rec. for specific strategies to maintain normothermia
82
Oxygenation Rec:
-(for increased FIO2 of 80%) -studies looked at pts with normal pulmonary function, GETA intraoperative and immediately after extubation (1A) -NO recs for increased FIO2 in pts --only intraop with GETA --neuraxial anesthesia --postop by mask or n/c --no trials r/t %/duration/delivery method **very contradictory, Dr. Shaffer SR
83
Antiseptic Prophylaxis:
-shower or bathe w/ soap or antiseptic pm before surgery the next day (1B) -intraoperative skin prep w/ alcohol-based antiseptic (1A) -Consider intraoperative iodine irrigation in deep tissues (II)
84
Are there any known benefits for intraop iodine irrigation in deep tissues?
Nope! -no benefit intraperitoneally -no benefit with iodine imbedded adhesive drapes -no benefit soaking prosthetic devices
85
Blood transfusion:
-do NOT withold needed transfusion from surgical pt as a means to prevent SSI (1B) ^^benefits outweigh the risks!
86
Systemic Immunosuppressive Therapy:
-Uncertain benefits/harm with systemic corticosteroids on risk of SSI in joint arthroplasty --infection most common indication for revision TKA --ex: if someone has diabetes, given zofran instead of decadron -uncertain benefit/harm with intra-articular corticosteroids preoperatively in planned joint arthoplasty
87
Antibiotic Prophylaxis-preop goal:
-adequate bactericidal concentration in serum and tissues WHEN INCISION IS MADE -MIC: minimum inhibitory concentration (based on evidence) -given by anesthesia
88
General principles of antibiotics:
1. should be active against common surgical wound pathogens 2. proven efficacy in clinical trials 3. must achieve MIC 4. shortest possible course effective...ideally 1 dose for entire case 5. newer antibiotics reserved fro more resistant infections 6. if all is equal: oldest, cheapest
89
Antibiotic timing:
-initiated within 1 hour of incision (30 min is better) -needs to circulate 15 min before incision at least -exception: vancomycin and fluoroquinolone: initiated within 2 hours -completely infused prior to tourniquet use -may hold antibiotics for cultures
90
Redosing of antibiotics:
-usually 2 half-lives or with excessive blood loss -may be redosed following cardiopulm bypass -redosing required for prolongest procedures --drug dependent, usually 2-4 hours while in OR --redosing only matters intraoperatively
91
Common surgical antibiotics:
-Beta lactams: penicillin, cephalosporin, carbapenems -Vancomycin -Aminoglycosides (gentamycin) -Fluoroquinolones (cipro) -Metronidazole (flagyl)
92
Penicillins-beta lactams
-inhibit bacterial cell wall synthesis -resistance develops overtime d/t beta-lactamase enzyme (resides on outer surface of cytoplasmic membrane) -DOC for streptococci, meningococci, pneumococci -most effective for gram-positive! -skin infections, catheter infections, URI's ex: penicillin G, methicillin, nafcillin, amoxicillin (newest gen)
93
Adverse reactions of penicillins-beta lactams:
-hypersensitivity: hx of reaction unreliable, ranges from skin rashes to anaphylaxis (0.05%) -GI upset -vaginal candidiases
94
Cephalosporins-beta lactams (ANCEF)
-more STABLE against beta-lactamases -broader spectrum, beta lactam rings bind to penicillin binding protein and ibhibit the normal activity of the protein (can't make a cell wall) -resistance occurs by protein altering its structure -DOC for surgical prophylaxis, can be used with PCN allergy EXCEPT for anaphylaxis
95
Generations of Cephalosporins: gen 1
-cefazolin: ancef, kefzol -does not penetrate BBB -most gram positive (staph and strep) -treats cellulitis, abscesses, URI, UTI
96
Generations of Cephalosporins: gen 2
-cefuroxime aka ceftin/zinacef -cefoxitin aka mefoxin -cefotetan aka cefotan -cefuroxime specifically has better gram negative coverage -treats H influenze pneumonia, UTI, and otitis media
97
Generations of Cephalosporins: gen 3
-cefotaxime aka claforan -ceftriaxone aka rocephin -ceftazidime aka fortaz -some cross BBB, better gram negative coverage than before, treats resistance -treats meningitis -Rocephin is good for gonorrhea
98
Generations of Cephalosporins: gen 4
-cefepime aka maxipime -most resistant to hydrolysis by lactamases! -usually reserved for multi-resistant organisms -penetrates BBB well!
99
Adverse reactions for Cephalosporins:
-hypersensitivity uncommon, can be rashes, fever, nephritis, anaphylaxis unlikely -potential production deficit of Vitamin K-choose a different abx if the pt has blotting disorders -common cause of colitis!! (3rd gen!) -cross-reaction to PCN approximately 1% -if TRUE anaphylaxis to PCN, use vanc or clindamycin instead
100
Carbapenem-beta lactam:
-good activity against gram NEGATIVE rods (pseudomonas aeruginosa) and enterobacter -can inhibit the beta-lactamse enzyme -possess the broadest spectrum of activity!! -bind to penicillin-binding protein -LAST LINE AGENTS (intra-abdominal, resistant UTIs, penumonia) -most penetrate BBB ex: ertapenem (Invanz), meropenem (Merren), and Imipenem (Primaxin)
101
Adverse Reactions to carbapenems
-N/V -diarrhea -rashes -injection site reactions-IM form contains lidocaine-LA allergie? -decreases valproic acid/ depakote up to 90%!! ^^use different abx in pts taking this for seizures, could make seizures return -cross sensitivity to PCN <1%
102
Vancomycin
-inhibits cell wall synthesis -active against gram-positive bacteria (too large to be able to penetrate gram-negative cell wall) -ONLY works if bacteria is ACTIVELY dividing -is very slow... -most valuable against blood-stream infection and endocarditis-blood stream infections caused by MRSA! -good for valvular surgeries, cardiopulm bypass
103
Adverse reactions for Vancomycin:
-frequent: phlebitis at injection site, chills, fever, nephrotoxicity (why we do peaks and troughs) and red man syndrome-inflammatory response we see in pts receiving vanc too quickly
104
Aminoglycosides:
-inhibit ribosomal proteins and cause mRNA to misread (bacteria cannot replicate) -significant post-antibiotic effect -synergistic with beta-lactams or vancomycin, especially useful in enterococcal endocarditis ex: gentamycin
105
Adverse reactions for Aminoglycosides:
-OTOTOXICITY!! why we give this drug slowly -nephrotoxicity: in elderly, >5 days tx, in renal insufficiency, higher doses, concurrent with loop diuretics -curare-like effect-more commonly with succx
106
Fluoroquinolone:
-inhibits DNA protein synthesis -excellent gram-negative organisms -treats UTI, bacterial diarrhea, bone/joint infections ^^often GU surgeries ex: ciprofloxacin (cipro) and levofloxacin (levaquin)
107
Adverse reactions for fluoroquinolones:
-N/V/D -PROLONGED QT INTERVAL -cartilage damage/tendon rupture-seen with renal insufficiency, concurrent steroid use, advanced age, 2016 warning about cartilage damage with these
108
Metronidazole:
-antiprotozoal/anerobic antibacterial -forms toxic byproducts that cause unstable DNA molecules -indicated for: intra-abdominal infections, vaginitis, and C-diff ex: flagyl
109
Adverse Reactions for metronidazole:
-nausea -peripheral neuropathy (in prolonged use) -disulfiram-like effect (with alcohol: flushing, dizzy, HA, chest or abdominal pain) ^^hangover phenomenon so abstain from alcohol when taking this drug!
110
How much ANCEF to give someone if <80 kg?
1 gram ANCEF
111
How much ANCEF to give someone if >80 kg?
2 gram ANCEF
112
How much ANCEF to give someone if >120 kg?
3 gram ANCEF
113
ANCEF instructions:
-given over 3 min -re-dose q4hr
114
How long is fluconazole given over?
120 min
115
How often is ampicillin redosed?
q2hr

Principles II (3 decks)

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