Basics exam 2 Flashcards
Lactic acidosis due to hypoperfusion should be treated with what before administering bicarbonate? (2)
- fluid resuscitation
2. oxygen
A positive base excess indicates what acid base disturbane?
Metabolic alkalosis
What is the correct formula for administration for bicarbonate (dose calculation) :
Dose of sodium bicarbonate=body weight (kg) X deviation of plasma bicarbonate concentration from 24 mEq/L X extracellular fluid volume as a fraction of body mass (0.2
What disease involves the renin-angiotensin system and potassium ion concentration.
hyperaldosteronism
What disease is characterized by increased reabsorption of Na+ and loss of potassium and H+ ions?
hyperaldosteronism
A decrease in CO and a left shift in the oxyhbg dissociation curve can be associated with what metabolic state?
metabolic alkalosis
In metabolic alkalosis, which direction would you see the oxyhbg dissociation curve shift?
left
Where is there (anatomically) high ventilation but no perfusion (dead space)?
trachea
What are the s/s of nerve damage in the lateral recumbent position?
Brachial plexus - burning sensation and weakness in arm and hand
What physiological changes would you expect to see in a pt who is in the lateral recumbent position?
- Increase in HR (85 to 97)
- Decrease in MAP
*dr. hammon accepted both
How would you prepare a pt to prevent ulnar nerve damage in the supine position? (2)
1-Avoid excessive pressure on the post condylar groove of the humerus
2- Hand and arm position will need to be either supinated and/or in the neutral position.
What physiological change happens in your body at first when you are put in trendelenburg position?
- 1Min: 9% increase in CO
- 10min: CO returns to baseline
Compression or stretch injury to the ______ is common in Trendelenburg position.
Brachial plexus
When in prone position and your arms are up by the head; your shoulders should be :
< 90 degrees
While the patient is in prone position, proper padding and rotation of the arms is essential for prevention of what major complication?
Ulnar Nerve Compression
Invasive arterial blood pressure should be monitored at what level in the sitting position?
External auditory meatus to optimize cerebral perfusion pressure
As a SRNA you are well aware of the risk factors associated with the sitting position, so when your patient develops a venous air embolism, you remain calm and do the following. Select all that apply:
A. Discontinue N2O immediately and deliver 100% oxygen with anesthetic inhalation
B. Attempt to aspirate central venous catheter to retrieve entrained air
C. Implement Bilateral jugular vein compression
Major Risk for sitting position:
Venous Air Embolism
Formula for EBV =
Female = 65ml x kg Obese = 70ml x kg Male = 75 ml x kg Infant = 80ml x kg Full Term = 85ml x kg Preterm = 95ml x kg
Volume associated with a surgical lap:
100-150ml
volume associated with a 4x4:
10ml
What sources of loss to you look to for calculating EBL?
- Laps
- 4x4’s
- Suction canisters
- blood on floor/drapes, etc
- subtract irrigation
How would you know if the suction canister is all blood loss?
ask the circulator /tech how much irrigation was used
Formula for ABL =
[EBV x (starting HCT - Target HCT)] / Starting HCT
When would you give blood?
Blood loss greater than 30%
*15% is strongly suggested
What are the steps to checking blood?
5 Rights
- check pt
- check band/s
- check blood
- consent?
- verify with 2nd licensed professional
- dilute with fluids, warm, 170mcg filter?
ABG Interpretation:
pH: 7.21
CO2 47
HCO3: 31
Partially compensated respiratory acidosis
You have lost 300ml of blood. You have 20 4x4 sponges soaked and 10 lap sponges soaked.
What is your EBL?
1500ml (or between 1500-2000ml)
What are the 2 most common physiological complication of a Spinal?
Bradycardia
Hypotension
Two causes of cardiac arrest in a spinal (2):
- increased vagal response
2. Decreased Preload
Metabolic acidosis and an anion gap <12 (normal) may be indicative of:
hypo-aldosteronism
Renal Compensation during metabolic acidosis includes: (3)
- Increased reabsorption of filtered HCO3
- increased ammonia production
- increased excretion of acid
PaCO2 increases approximately ___ for each ____ increase in HCO3?
1:1
Which of the following could be a case of respiratory acidosis?
Malignant Hyperthermia
Patient with RR of 32, complaining of dyspnea and has a K+ of 5.9 and a hx of COPD. Without an ABG, what would you expect?
Respiratory Acidosis
Respiratory alkalosis can be controlled during neurosurgery to decrease ICP. A paCO2 of ____ may produce cerebral ischemia.
< 20mmHg
Hanging the 12th bag of PRBCs on a trauma patient. What acid/base imbalance would you expect?
metabolic alkalosis
Pituitary gland tumor (pituitary adenoma) is associated with what disease?
Cushing’s syndrome
Pituitary gland tumor (pituitary adenoma) is associated with Cushing’s syndrome. What two consequences result:
- Secretes excess amount of ACTH
- Increased cortisol from adrenal glands
Most common villous adenoma:
tubular
What disease can result from an adrenal adenoma?
cushing’s syndrome
Excessive level of cortisol is responsible for:
cushing’s syndrome
Preoperative preparation for a pt with cushing’s syndrome includes:
- tx of htn
- dm
- normal fluid volume
Excessive secretion of aldosterone is characterized by:
increase in sodium reabsorption and the loss of potassium and hydrogen ions
The principle site of action of aldosterone is:
the distal nephron
The principle regulator of ____ synthesis and secretion are the renin-angiotensin system potassium ion concentration
aldosterone
Where is aldosterone exclusively produced?
Zona glomerulosa of the adrenal cortex
What is a major circulating mineralocorticoid in the human body?
aldosterone
Name three body buffers:
- ammonia
- hemoglobin
- intracellular proteins
which line of defense describes the kidneys ability to retain and excrete bicarbonate, synthesize ammonia and eliminate potassium ions.
third line defense
Which line of defense acts within minutes and its max effect is within 12-24 hours. H2CO3 is produced and converted to CO2 for elimination:
2nd line defense
H2CO3 produced and converted to CO2 for elimination. Increase in alveolar ventilation.
2nd line defense
Identify the Henderson-Hasselbach equation:
pH = pKa + log {A-} /
{HA}
A decrease in pH would result in: (2)
- increase H+ ions
2. More acidity
Wilson table is used for patient. A post-op complication risk for this patient would include:
postop vision loss
Laminectomy patient positioning:
Prone position. Place arms close to their side.
What drug could be used to distinguish b/w MH and NMS?
Rocuronium
What would you expect to see with hyperthermia (2)?
- Increase MV
- Increased CO2
40% of heat loss in the OR is due to:
radiation loss
Hypothermia would shift the oxyhgb -dissociation curve in which direction?
Left
Hypothermia would increase the consumption of what? by how much?
Oxygen consumption up to 300%
Shivering may increase Oxygen
consumption up to five fold
Shivering is associated with
Myocardial Ischemia
Patients at risk for hypothermia : (2)
- male gender (not female)
2. may be as frequent as 65% with GA (not 50%)
What gender is at greater risk for hypothermia with GA?
Male
Hypothermia may be as frequent as ___ % with GA?
65%
85 yo uroseptic patient is getting 11th unit of blood. What would you expect could happen?
Citrate intoxication from blood administration
*metabolic alkalosis , dilutional thrombocytopenia, diultional coagulopathy
85 yr in OR lost 500ml of blood. What is crystalloid replacement rate in second hour?
1500ml (3:1 replaement)
NPO Deficit formula =
NPO deficit= hourly maintenance rate x hours NPO
Maintenance Rate Calculation =
4,2,1 rule
or + 40 to pt wt in kg
Hourly output formula =
0.5-1ml/kg/hr
IBW formula =
100lbs for first 5ft
Females + 5lbs /inch
Males + 7lbs/ inch
- obesity 20% above IBW
- Morbid obesity= twice the IBW
5’ 3”, 45kg female. Are they at their IBW?
IBW = 115lbs ABW = 99
no, not at IBW
Maintanance rate of a 130lbs pt:
99ml/hr
Universal Donor blood type:
O -
Rarest blood type:
AB -
Most malignant hyperthermia deaths are due to : (2)
- Organ failure
2. Delay in dantrolene tx
What order of MH indications would you expect to see in the clinical setting? (3)
- masseter muscle rigidity
- increased ETCO2
- Increased temp
Little Johnny is 8 years old. What size ETT does he require?
Diameter: 5.5, 6, 6.5 mm sizes
Little Johnny is 8 years old. What ETT cut length does he require?
18 cm
A 28 year old woman undergoing surgery and is anesthetized with an inhalant and she is also given iv succ. She develops a HR of 129, increased co2 and a rising temp. This is due to?
Interferes with the release of calcium from the sarcoplasmic reticulum
Patient starts having dysphonia, mydriasis, weakness, and dyspnea after a spinal. What would be the next appropriate action of the SRNA?
prepare to intubate
After receiving a spinal, Nausea would be due to? (2)
- Systemic hypotension that would be sufficient enough to produce cerebral ischemia
- Predominance of the parasympathetic activity d/t the sympathetic nervous system being selectively blocked.
Patient has a headache after receiving a spinal. Conservative measures regarding treatment of a post dural puncture headache would include the following: (Choose two)
- fluids
- 500mg caffeine
A 25 gauge needle and A pencil pointed needle are associated with :
a lower incidence of post procedure headache
T6 dermatome level:
xyphoid
Neuromuscular-blockage reversal is a risk factor associated with:
PONV
LMA size for 68kg pt:
size 4
Adjusted Body Wt =
(IBW + Actual Body Weight ) / 2
Hourly Maintanance rate for 196lbs
196 = 89kg 89+40 = 129ml/hr
ABG interpretation for :
Compensated metabolic acidosis
Bupivicaine 0.75% with added epi is extended to what DOA time?
100-150 mins
w/o epi 90-120mins
Respiratory Compensation in response to metabolic alkalosis and metabolic acidosis. You can adjust and anticipate corrections….
If you know HCO3 is 27, what should the pH equal?
pH expected to be 7.42 (HCO3 + 15)
Differential Diagnosis associated with Hyperthermia? (3)
“conditions associated with hyperthermia (slide 34)”
- pheochromocytoma
- MH
- Thyroid Storm
*not on exam: transfusion reactions, sepsis, infection, NMS, medications, hypothalamic lesions
Patient received a spinal but still has quite a bit of feeling remaining… What would prudent CRNA do?
give a second dose
- combo of two doses should not exceed max dose
Elevated anion gap is likely associated with:
Ketoacidosis (metabolic acidosis)
MH is most common in what population?
Young males
Renal compensation during metabolic acidosis does what 3 things:
- increased reabsorption of HCO3
- increased excretion of titratable acids (H+)
- increased ammonia production
Best place to get temperature ?
esophagus
How much does a patients temperature decrease in the first hour when warming is not initiated?
1-2 degrees Celsius in first hour
Dantrolene dose and administration:
2-10mg/kg
- 6hr half life
- give 1mg/kg q 6h after for 24hrs
- can cause phlebitis
Compared to a spinal, an epidural (2):
- requires 10-fold increase in the dose
- much slower onset
A patient presents with back pain and leg weakness. What do you suspect and do?
- signs of epidural hematoma
- Needs STAT CT/MRI and surgical decompression in 6-8 hrs
Dural sac ends where in adults?
S2
Occurs when MV is insufficient to eliminate CO2 production w/o an increased capillary-alveolar CO2 gradient:
respiratory acidosis
(Depicts a patient with respiratory acidosis) This can commonly be seen with:
- a pt with COPD
- Exhausted soda lime
Neo is preferred when you want to keep HR the same and increase BP, why?
Pure alpha agonist (A1 > a2)
Early sign of MH:
MMR
Late sign of MH:
Hyperthermia
rises 1 degree C every 5 mins
MH most SENSITIVE sign:
unanticipated doubling or tripling of ETCO2
ABG you would expect to see with MH?
mixed metabolic and respiratory acidosis
Video question:
Of 27 yr of female, hx of schizophrenia, recent d/c from psych hospital. taking haldol. Temp 101.7F, BP 157/104, HR 122, RR 24. Stiff, difficulty swallowing, remulous, diaphretic and confused. CPK is elevated. Infection negative. What is the likely diagnosis?
Neuroleptic malignant syndrome
most important buffer for extracellular fluid compartment:
bicarbonate
urinary buffer?
ammonia
Anesthetic Implications for Alkalemia?
Respiratory alkalosis prolongs duration
of opioid induced respiratory depression
Licorice Poisoning Causes
hypokalemia, hypernatremia, and water retention
Cushing’s Syndrome:
Excessive cortisol that is produced in adrenal glands, occurs from excess production by one or both adrenal glands or overproduction of ACTH
Hyperaldosteronism:
- Aldosterone produced in zona glomerulosa,
- major circulation mineralcorticoid in humans,
- principal site of action of aldosterone is in the distal nephron,
- characterized by excessive secretion of aldosterone which causes increase in sodium reabsorption and loss of potassium and hydrogen.
Positive value base excess =
metabolic alkalosis
negative value base excess =
metabolic acidosis
