TL1 Flashcards
TEE findings in sepsis
Normal or increased CO with myocardial depression (due to released cytokines) It is now well accepted that most patients with sepsis have a degree of myocardial depression. Myocardial depression often occurs early and can be present despite a normal or increased cardiac output
Vaporizers and altitude
the delivered partial pressure remains the same however there is an increase in delivered concentration due to a decrease in barometric pressure
Carbon monoxide poisoning
- 200-300 higher affinity than O2
- displaces O2
- leftward shit
- creates lactic acidosis
- PaO2 is normal
- Pulse ox is falsely elevated
Abdominal compartment syndrome (risk factors)
- Decreased abdominal wall compliance: abdominal surgery, prone positioning, major trauma or burns
- Increased intraluminal contents: gastroparesis, ileus, volvulus
- Increased intraabdominal contents: acute pancreatitis, distended abdomen, intra-abdominal infection/abscess/tumors, laparoscopy with excessive inflation pressures, peritoneal dialysis
- Capillary leakage: acidosis, hypothermia, increased APACHE-II score, massive fluid resuscitation, massive transfusion
- Miscellaneous risk factors: age, bacteremia, coagulopathy, elevated head of the bed, obesity, PEEP > 10, peritonitis, pneumonia, sepsis, shock
Bronchialpleural fistula presentation
acute dyspnea, subcutaneous emphysema, tracheal deviation, and a lower or more inferior air-fluid level. Initially, serous fluid fills the lung after pneumonectomy. After the development of a BPF, this fluid is displaced by the entrained air from the BPF, thus lowering the air-fluid level. Classically, serial chest radiographs show initially a white-out except for a small apical fluid level, which is an appropriate postsurgical change, followed by an “improved” appearing chest radiograph that has a more caudad air-fluid level.
diabetic autonomic intability
loss of heart rate variability, resting tachycardia, dysrhythmias, impaired ventilatory responses, gastroparesis with increased risk of aspiration on induction, and unawareness of hypoglycemia
Sepsis treatment
Broad-spectrum antibiotics should be initiated within the first hour. Sepsis-induced hypoperfusion should be treated with at least 30 mL/kg of intravenous crystalloid within the first three hours (now a weak recommendation). For patients with septic shock, vasopressor therapy should be used in combination with volume resuscitation to target an initial MAP of 65 mmHg and the recommended initial vasopressor is norepinephrine
C section decreases risk for?
uterine rupture
Magnesium levels
Normal 1.8-2.5
5-6 mg/dL: Hypotension and bradycardia, lethargy, NV, diminished DTR
6-12 mg/dL: ECG changes including prolonged PR interval and widened QRS , somnolence, absent DTR, hypotension
18 mg/dL, the SA and AV node can become blocked leading to complete heart block., respiratory depression
20-25: Cardiac arrest (asystole) is generally seen
Increased risk for transient neurologic symptoms
lidocaine spinal anesthesia, the lithotomy position, and ambulatory surgery with early ambulation
anemia and coagulation cascade
Anemia is associated with a delay in the initiation of the coagulation cascade, a stronger clot, and a clot with superior viscoelastic properties
Hypoxic pulmonary vasoconstriction
Hypoxic pulmonary vasoconstriction occurs as a result of exposure of the pulmonary arteries to hypoxic lung segments and low alveolar oxygen tension. Direct inhibitors of the HPV mechanism include: hypocarbia, vasodilating drugs, infection, metabolic alkalemia, and volatile anesthetics >1 MAC. Indirect inhibitors of HPV include: hypervolemia, vasoconstricting drugs, hypothermia, thromboembolism, and a large hypoxic lung segment.
ECT and meds
- etomidate prolongs seizure
- brevital, ketamine, alfent and remi = no change
- thiopental, versed, propofol, lidocaine decrease
hyperoslmolar hyperglycemic state
- T2DM
- can progress to seizures
pediatrics tachycardias
- wide complex: synchronized cardioversion
- Narrow: adenosine or vagal (SVT)
QRS >0.9 seconds =wide
RLN damage
- complete cords are stuck in paramedian= aspiration risk, aphonia
- unilateral: hoarseness (may be delayed)
- bilateral partial: cords stuck with unopposed adduction- airway emergency
faster anesthesia induction in peds
- high percentage blood flow to vessel rich
preeclampsia
- elevated thromboxane A2 levels
- decreased prostacyclin levels
- decreased platelets
- leads to vasoconstriction, increased SVR, decreased blood flow,
tourniquet pressure
UE: 50 mmHg above systolic
LE: 100 mmHg above systolic
hypoxic ventilatory drive
-Peripheral O2 chemoreceptors are most sensitive to reductions in PaO2 between 65 and 50 mm Hg and respond by increasing minute ventilation. This is why patients who are dependent on a hypoxic ventilatory drive (COPD, people at high altitudes) typically have a resting PaO2 between 50-65 mm Hg.
induction in cardiac tamponade
keep it “fast, full, and tight.” Cardiac output is heart rate dependent (“fast”), stroke volume is fixed and dependent on adequate preload (“full”), and the vascular tone should be (“tight”). Transesophageal echocardiography is the best diagnostic tool for detecting a pericardial fluid collection.
- afterload reduction can be detrimental
- positive pressure can be bad- most likely awake intubation AVOID coughing
PAC
- endocarditis risk is increased two fold with non heparin coated catheter
- can cause both LBBB and RBBB and complete block
- hypothermia increases risk of PA rupture
hypothermia s/p ROSC
Induced hypothermia following cardiac arrest can reduce ischemic injury and improve neurologic outcomes. It is accomplished by various cooling methods for a duration of 12-24 hours post-resuscitation with a goal temperature of 32 °C to 36 °C. Rewarming should occur slowly to avoid major complications.
pyloric stenosis resuscitation
- best indicator is normalized chloride ( > 100)
- Patients with pyloric stenosis often develop a hyponatremic hypokalemic hypochloremic metabolic alkalosis
- bicarb < 30
