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Flashcards in Welliver Paper Questions-Josh Deck (63):
1

Discuss the goals associated w/ anesthestic management that is associated w/ intracranial tumor debulking:

what are the 2 main goals to optimize cerebral circulation and Oxygenation?

 

  1. maintain or acheive normal ICP
  2. Maintaining CPP at minimum 70 mmHg

 

2

Discuss the goals associated w/ anesthestic management that is associated w/ intracranial tumor debulking:

why would you want to avoid narcotics preop?

  • depress respiratory fxn and raise PCO2 causing cerebral vasodilation and thus increased ICP

3

List the S/S of elevated ICP:

 

  • H/A
  • Difficulty concentrating
  • Memory disturbances
  • Vision Disturbances
  • Vertigo
  • Syncope
  • Nausea
  • Vomiting
  • Cushing Reflex
  • Cushing Triad
  • Sz
  • Coma

4

Do all Intracranial tumors increase ICP

  • Nope

5

The location of most neurosursical procedures for tumor resection is ____-tentorial and involes the ____ _______

  • Supratentorial
  • Cerebral Hemisphere

6

the cerebral hemispheres are divided by the _____- ______ fissure

(not on test per se but just in case)

Medial longitudinal

7

the right and left hemispheres are connected by a bundle of nerve fibers called the ______ _____

Corpus Callosum

8

The cerebral Cortex is compromised of the _______, ______, ______, and _______ lobes

  1. Frontal
  2. Parietal
  3. temporal
  4. occipital

9

_________ refers to the location of the brain stem

Infratentorial

10

Infratentorial consist of the ______, ______, _______, and _____ and is the major motor and sensory pathways and the cranial nerve nuclei

  • Midbrain
  • Medulla
  • Cerebellum
  • Pons

11

Positioning:

Infratentorial usually require a ___ or ____ position

  • Prone
  • Lateral

12

Positioning:

the Sitting position is associated w/ increased risk of _____ and excessive neck flexion

VAE

13

what are the 4 primary concerns during induction

Hypoxia

Hypercarbia

HTN

Hypotension

 

14

___-tension decreases CBF and risk further ischemic injury to the brain tissue

HYPOtension

15

____-tension risk increasing ICP ompedind adequate cerebral circulation

HYPERtension

16

what are the 3 primary intraoperative goals of anesthesia care fro the pt w/ elevated ICP?

  1. Decreasing intracranial volume  to prevent further increase in ICP
  2. Maintaining adequate CPP (by manipulating BP)
  3. Decreasing CMRO2

17

what are 3 ways you can lower CMRO2?

  1. IV agents
  2. VAAs
  3. Temperature

18

CMRO2: IV agents

The IV agents _____, _____, and _____ all lower CMRO2

  1. Thiopental
  2. etomidate
  3. propofol

19

CMRO2: IV agents

how do the IV agents lower CMRO2?

  • The mdulation of GABA receptors lowers neuronal activity whch corresponds w/ lower Cerebral O2 consumption

20

CMRO2: IV agents

____ coma is sometimes induced to maximally supress CMRO2 and is reflected by an isoelectric EEG

Barbiturate

21

CMRO2: VAA

VAAs decrease _____ and increase _____

CMRO2

CBF

22

CMRO2: VAA

how do VAAs lower CMRO2

  • they decrease neuronal activity which lowers O2 and Glucose consumption by brain tissue,
  • the Vasodilatory effects provide additional O2 to the brain

23

CMRO2: Temperature

Some CRNA's allow a mild _____ in body temperature to help lower CMRO2

decrease

24

CMRO2: Temperature

Each __C in body temp corresponds to a __-__% decrease in CMRO2

  • 1
  • 7-8%

25

CMRO2: Temperature

what is the rational for the hyPOthermia

  • to lower CMRO2 and metabolite formation in order to protect brain tissue, but this remains controversal

26

CMRO2: Temperature

there is no conclusive objective data stating that supports the use of  HYPOthermia as an independent varible that decreases morbidity and mortality for a pt w/ space occupying lesions. This being said _______ should be avoded as it has been found to be detrimental

Hyperthermia

27

Explain the word "Coupling" in relationship of CMRO2 to CBF

  • coupling is the direct relationship of CMRO2 and CBF
  • an INCREASE in one corresponds to an INCREASE in the other.
  • thus during normal activity increases in cerebral metabolic activity will corrolate w/an increase in CBF

28

"Coupling"

_____, _____, and ____ all decrease CMRO2 and allow normal regulatory decreases in CBF (aka Coupling)

Hint answers are meds

  • Benzo
  • Barbs
  • Prop

29

"Coupling"

what and how does VAAs do to Coupling

  • Uncouple
  • they disrupt or "uncouple" this relationship by decreasing CMRO2 while increasing CBF
  • Basicallly change the direct relationship of CMRO2 and CBF to an inverse relationship

30

If VAAs decrease CMRO2 why do we only ise 1/2 MACs?

  • A decrase in CMRO2 is beneficial to ischemic brain tissue , but increases in CBF may cause detrimental increases in ICP and possibly divert blood flow away from ischemic areas to non-ischemic areas. AKA Steal phenomenon

31

Methods used to lower intracranial pressure address the need to decrease one or more of the 3 components of the Cranial Vault producing ICP. what are those 3 components?

  1. Brain
  2. Blood
  3. CSF

32

________ the volume of any of the 3 components reduces intracranial pressure

  • Decreasing

33

what is 3 ways to decrease the brain component to lower ICP

  1. Diuretic (loop/mannitol)
  2. Hypertonic saline (3%)
  3. Corticosteroids

34

whata re 3 ways to lower the Blood component to decrease ICP

  1. Hyperventilation
  2. Limit IV fluids (<1L)
  3. Elevate the HOB (30 degrees)

35

What is 3 ways to decrease the CSF component of ICP

  1. Ventriculostomy
  2. Subdural drain
  3. Lumbar Drain

36

how do diuretics decrease brain size to lower ICP

  • decrease blood and brain volume
  • Shrink the brain size
  • Lasix- lowers blood volume
  • Mannitol- extracts fluid from brain tissue
  • HYpertonic NS- Osmotically decreases brain water w/o causing hypovolemia
  •  

37

how do corticosteroids decrease Brain size to lower ICP

  • bnloock inflammatory responses and may prevent further brain edema

38

How does hyperventilation decrease blood in the brain?

 

  • decreases PaCO2 causing cerebral vasoconstriction
  • PaCO2<30mmHg - the vasoconstriction lowers the amount of blood within the vault

 

39

How does limiting fluids decrease blood in the brain?

  • prevents increases in IV volume

40

How does CSF drainage decrease CSF in the brain?

  • removes volume from the cranial vault

41

HYPERventilation is a universal treatmetn for acute increase in ICP, so Describe why HyPERventilation is beneficial for pt's w/ increased ICP

  •  b/c hypocarbia causes cerebral vasoconstriction which decreases the amount of blood w/in the cranial vault.
  • Vasoconstriction is though to occur in areas of the breain that ARE NOT ISCHEMIC
  • the ischemic areas contain mediated vasodilator substances and are not likely to respond to hyperventilation and vasoconstriction
  • provide robinhood effect or reverse steal- whereas CBF is diverted toward ischemic areas of the brain and away from adequatly oxygenated areas.

42

PaCO2 is usually __-___mmHg higher then EtCO2

5-10 mmHg

43

what fluids are good

NS or LR

44

why  shoulf you avoid dextrose solutions?

  • metobolism of the glucose will lower teh osmotic pressure of the fluid
  • also they oppose the goal f decreasing cerebral metobolism

45

Risk associated w/ head in prongs

  1. excessive flexion
  2. airway swelling
  3. cervical cord compression
  4. decreased outflow

 

46

Risk associated w/ head in prongs

what crainial nerves are at risk which control airway patency, respiration, and hemodynamics

  • IX
  • X
  • XI
  • XII

47

CN IX

  • glossopharyngeal
  • tongue, larynx
  • swallowing, larynx elevation

48

CN X

  • Vagus

49

CN XI

Accessory nerve

50

CN XII

Hypoglossal

51

Risk associated w/ VAE in what position

fucing sitting (this better be a mother fucking question for as mouch as Ive seen the mother fucker)

52

Risk associated w/ VAE, as the air enters the Venous system it travels to the ___ ___ and ___ _____ entering the pulmonary arterioloes

Right atrium

Right Ventricle

53

Risk associated w/ VAE, once in the pulmonary arterials a ___ ____ ___ is created and can cause hypoxia, CO2 retention, decrease EtCO2, and heart failure

 

Right Ventricular Airlock

 

54

Risk associated w/ VAE, additionaly to the right ventricular airlock, the reflec pulmonary and bronchial constriction occurs d/t release of endothelial mediators causing _____ ___ and increased ___ ___ ___

  • Pulm HTN
  • Peak Inspiratory Pressures

55

list the Most sensitive to least sensitive monitoring tech used to detect VAE (9)

  • TEE
  • Precordial doppler
  • EtCO2
  • Pulmonary artery cath
  • CO
  • CVP
  • ECG changes
  • BP
  • Precordial stethoscope

56

when air is present in the right atrium the sound is described as a ____ murmur and it is distinctly different from baseline Heart sounds

Millwheel

57

treatment for VAE

steps

  1. Notify surgeon
  2. Flood area w/NS bone wax on bone edges
  3. lower pt head
  4. immediatly aspirate blood and air w/60mL syringe
  5. d/c N2O use 100% O2

58

which is not considered a component of the cranial Vault?

  1. Blood
  2. Brain
  3. Bone
  4. CSF

3.Bone

59

whch factor can decrease ICP?

  1. Hypoxia
  2. Hyperventilation
  3. Delivery of VAAs
  4. Hypercarbia

 

2.Hyperventilation

60

Which is not a potential consequence of elevated ICP

  1. Confusion or lethargy
  2. Cushing Response
  3. Cushing Syndrome
  4. Cushing Triad

3.Cushing Syndrome

61

Which is the mechanism of action by whoch mannitol protects brain tissue?

  1. Venous engorgement and increased permeability
  2. Osmotic Diuresis and Free radical scavenging
  3. Hypotension and decreased tissue perfusion
  4. Osmotic diuresis and decreased CMRO2

4.Osmotic diuresis and decreased CMRO2

62

 

Which events Cause physiologic stimulation during a tmor debulking procedure?

  1. Induction, Intubation, skin incision, bone sawing, brain tissue resection
  2. Intubation, skin incision, skull peristeal scraping, brain resection
  3. Intubation, skin incision, skull periosteal scrapping, emergence
  4. All events during tumor debulking are equally stimulation

3. Intubation, skin incision, skull periosteal scrapping, emergence

(this is the answer I think.. there is no key but thats what I would saw)

63

Guess what chicken butt..... you done!!!