basics exam 2 rvw for final Flashcards
Lactic acidosis due to hypoperfusion should be treated with what before administering bicarbonate? CHOOSE 2
Fluid resuscitation
Oxygen
A positive base excess indicates what acid base disturbance?
Metabolic alkalosis
What is the correct formula for administration for bicarbonate?
a. 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 happens in metabolic alkalosis?
Decrease CO and Left shift in oxyhemoglobin dissociation curve
Where is there high ventilation but no perfusion (dead space)?
Trachea
What are the signs and symptoms 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 from 85 to 97 and Decrease in MAP. (Hammon accepted both answers)
How would you prepare a pt to prevent ulnar nerve damage in the supine position? (choose 2)
Avoid excessive pressure on the post condylar groove of the humerus
AND hand and forearm 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?
CO/BP goes up initially
at 1 Min: 9% increase in Cardiac Output,
at 10 Min: C.O. returns to baseline
Compression or stretch injury to the ____________is common in Trendelenburg positions
Brachial plexus
When in prone position and your arms are up by their head, your shoulders should be?
less than 90 degrees
While the patient is in the 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
Discontinue N2O immediately and deliver 100% oxygen with anesthetic inhalation
Attempt to aspirate central venous catheter to retrieve entrained air
Implement Bilateral jugular vein compression
Risk for sitting position?
Venous air embolism
How much blood in a sponge, how much in a lap?
4x4 fully soaked = 10ml
laps fully soaked = 100-150ml
How would you know if a suction canister is all blood loss?
Ask the circulating nurse how much irrigation has been used and subtract that from what is in the canister.
Allowable blood loss formula?
EBV X (starting Hct - Target Hct) / starting Hct
When to give blood over crystalloids?
give blood if blood loss is greater than 30%; 15% is strongly suggested.
Steps for giving blood?
Check patient, blood, patient arm band and blood band with second licensed professional
Dilute with fluids and warm them
Use 170 mcg filter
Your pH is 7.21, CO2 47, HCO3 31
Partially compensated respiratory acidosis
You have lost 300cc of blood with 20 sponges soaked and 10 lap 4x4 sponges soaked, what is your total loss?
between 1500-2000
What are the 2 most common physiological complications of Spinal ???
Bradycardia
hypotention
Two causes of cardiac arrest in spinal (select 2)?
Increased vagal response
decreased preload
Metabolic Acidosis and an anion gap <12 (normal) may be indicative of?
HYPOaldosteronism
Renal compensation during metabolic acidosis includes?
Increased reabsorption of filtered HCO3
Increased ammonia production
Increased excretion of acid
PACO2 increases approximately — hg for each meq increase in HCO3?
1
Know causes of respiratory acidosis- (on exam one cause was?)
malignant hyperthermia
Patient with respiratory rate of 32. Complaining of dyspnea and has a K+ of 5.9 and a history of COPD. Without ABG, what would you expect?
Resp. acidosis
Respiratory alkalosis can be controlled during neurosurgery to decrease ICP, but PaCO2 ____mmHg may produce cerebral ischemia.
less than 20
Hanging 12th bag of PRBCs on trauma patient. What acid base imbalance would you expect?
Metabolic alkalosis
You are giving blood, what’s the proper identification?
Right patient, drug, dose, route, time. Check with a licensed provider. Check pt armband.
Pituitary gland tumor (pituitary adenoma) =?
Cushing’s syndrome
Pituitary gland tumor (pituitary adenoma) would cause what?
Secretes excess amount of ACTH
Increased cortisol from adrenal glands
Villous adenoma most common?
Tubular
Which of the following is true regarding cushing’s syndrome?
Can be produced by adrenal adenoma
Excessive level of cortisol are responsible for cushing’s syndrome
Preoperative preparation initial treatment of htn, dm, and normal fluid volume
Excessive secretion of aldosterone is characterized by?
Decrease in sodium reabsorption and the loss of potassium and hydrogen ions
Which of the following is true regarding aldosterone? Choose 2
Principle site of action is the distal nephron
Principle regulator of synthesis and secretion of renin-angiotensin system potassium ion
Which of these is true about aldosterone?
● Made exclusively in the Zona glomerulosa
● Major circulating mineralocorticoid in the human body
Which of the following are body buffers choose three?
● Ammonia
● Hemoglobin
● Intracellular proteins
Which of the following describes the kidneys ability to retain and excrete bicarbonate, synthesize ammonia and eliminate potassium ions.
3rd line defense
Acts within minutes and max effect in 12-24 hours. H2CO3 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
Which one is a Henderson-Hasselbach equation?
pH = pKa + log{A-} /{HA}
A decrease in pH would result in (becoming more acidotic) (choose 2)
increased hydrogen ions (more hydrogen, more acidic)
more acidity
Wilson table is used for a patient with (shit ton comorbidities hinting at just shit circulation), a postoperative complication of this patient would include
postoperative vision loss
Laminectomy- what position will you place the patient in?
Place patient arms close to their side while in the prone position.
What drug could distinguish between MH and NMS?
any NMB but on exam the answer was Rocuronium
What would you see with hyperthermia (choose 2)?
Increased min. ventilation
increased CO2
40% of heat loss in the OR is due to?
RADIATION
Hypothermia (chose 2)
Left shift of the hemoglobin- dissociation saturation curve
increases O2 consumption up to 300%
Shivering: (choose 2)
May increase oxygen consumption up to fivefold
associated with myocardial ischemia
Patients at risk for hypothermia: (choose 2)
GA
Male gender
Patients at risk for hypothermia: (choose 2)
GA (frequent as 65%)
Male gender
85 y/o uroseptic patient getting 11th unit of blood, what would you expect could happen?
citrate intox from blood administration
85 y/o in OR lost 500 ml of blood. What is crytalloid replacement rate in 2nd hour?
1500ml (bc it is 3 times the blood loss for crystalloids)
How do you calculate the NPO deficit?
NPO deficit - maintenance rate x hours NPO
How do you calculate the hourly maintenance rate?
4, 2, 1, rule
4cc a kg for the first ten kgs
2cc a kg for the next ten kgs
and then 1cc for all remaining kgs
(if they weigh at least 20kg then that = 60ml)
adequate urinary output during surgery is?
0.5-1.0ml/kg/hr
Know how to calculate IBW for a male and female.
female IBW = 100lb for first 5 feet then five pounds for every inch after.
Male IBW = 100lb for the first 5 feet then 7 lb for every inch afterwards.
5’3 45kg Female. Are they at their IBW?
IBW=115 lbs., Actual BW= 99.
No, not at IBW.
What is the maintenance rate for a 130lbs patient?
99ml/hr
UNIVERSAL DONOR and rarest blood type?
UD= O- rarest = AB-
Most malignant hyperthermia deaths are due to?
organ failure
delay in dantrolene treatment
What order of malignant hyperthermia indications would you expect to see in the clinical setting?
Masseter muscle rigidity, Increased end tidal co2, Increased temperature.
Know that increased temp is a LATE sign, that masseter rigidity is earliest sign and end tidal CO2 is most sensitive sign.
Little joey is 8 years old. He is getting his tonsils removed, what size of ett does little joey require?
Diameter 5.5, 6, 6.5 mm in sizes
Length of ett tube is 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? (Choose 2)
Systemic hypotension that would be sufficient enough to produce cerebral ischemia
Predominance of the parasympathetic activity due to the sympathetic nervous system being selectively blocked
Which of the following would be expected to lower the incidence of post procedure headache?
a 25 guage needle (25 or under is good)
A pencil pointed needle. (punctures instead of tears)
T6 dermatome level?
xyphoid
T10 dermatome level?
umbilicus
T4-T5 dermatome level?
cardiac accelerators
Which of the following is a risk factor associated with postoperative nausea and vomiting?
Neuromuscular - blocking reversal
A 68 kg male patient that has to undergo a procedure would most like be a candidate for which of the following LMA sizes?
4
A 38 year old female patient weighing 82 kg has a history of pseudocholinesterase deficiency. Which of the following drugs would you remove from your induction?
Succinylcholine
Blood volumes of infant, full term, and preterm?
a. Infant is 80 ml X wt in kg, full term is 85 ml X wt in kg, and preterm is 95 ml X weight in kg
Jack is an 85 year old male who is scheduled for a radical prostatectomy and weighs 196 pounds and has been NPO for 12 hours. You would expect his 3rd space loss to be 6 ml/kg/ hour. What is his rate of hourly maintenance?
129 ml/hr → 89 kg with 4-2-1 rule = 129
How do you calculate Adjusted Body weight?
Adjusted BW = (IBW+ Actual BW) /2
buvpiCAINE and vasopressors- how long does it extend with epinephrine added?
Bupivacaine 0.75% extends local 100-150 minutes
90-120 minutes without epi
saying to know the structures for a spinal or an epidural?
● Some Say Sister Ida Loves Doing Acid → spinal
● Some Say Sister Ida Loves Either → Epidural
Possible causes of hyperthermia? (medical conditions)
● Pheochromocytoma
● MH
● Thyroid Storm
If you give a spinal and it is not fully effective and you want to give another dose, what do you have to consider, or rule you must follow?
combination of the two doses should not exceed max dose of spinal as one dose. This is bc you assume the first dose made it into the space correctly.
Elevated anion gap most likely caused by? (so not normal)
ketoacidosis
Best place for a temp? (not too expensive or too invasive for a CRNA, but also very accurate.)
ESOPHAGUS
How much does a patient’s temperature decrease in the first hour when you do not attempt to warm an anesthetized patient?
1-2 degree C during the first hour
Tell me everything you know about Dantrolene?
give 2mg/kg and up to 10mg/kg until symptoms subside.
after the above give 1mg/kg q 6 hr for first 24 hours.
takes 86 sec to mix 20cc sterile water with 1 vial of normal dantrolene.
half life is 6 hours
can cause phlebitis so it is best to have a CVL.
Epidurals compared to spinals?
require ten fold dose increase
much slower onset
T4 dermatome is?
nipples
Lady with signs of epidural hematoma (developed back pain and leg weakness) what do you do?
Surgical emergency! need CT or MRI stat to diagnose and must be surgically decompressed within 6-8 hours or damage to brain will be permanent.
Where does the dural sac in adults end?
S2
Occurs when minute ventilation is insufficient to eliminate CO2 production without an increased capillary-alveolar CO2 gradient?
Respiratory acidosis
(Depicts a patient with respiratory acidosis) This can commonly be seen with?
patient with COPD
Exhausted soda lime
pre-existing condition that makes sux contraindicated?
Plasma cholinesterase or cholinesterase deficiency
what pressor will keep HR the same but increases BP? How does it do this?
Pheneylephrine (neo) bc it is a pure alpha agonist!
what type of lab work would you expect to see with MH?
mixed metabolic and respiratory acidosis.
Patient is a paranoid schizophrenic on haloperidol. After her last injection she appears strange, stiff, temulous, elevated temp, pulse is up, high resp. increased tone in her neck and extremities, confused. infection workup is negative and she has elevated serum creatine phosphokinase, what is most likely her diagonosis?
Neuroleptic malignant syndrome
A 28 year old woman is undergoing surgery and is anesthetized with an inhalant anesthetic. She is also given an IV dose of Succinylcholine. Within minutes, she develops a heart rate if 124 and increasing core body temperature. What is the mechanism of action of the drug of choice for this patient’s condition?
It interferes with the release of calcium from the SR.
Mechanisms of heat loss and percentages associated with them.
Radiation = 40 % Evaporation = 20% Convection = 30% Conduction = 5%
How do you tell the difference between NMS and MH?
Administering nondepolarIzing NMB - causes flaccid paralysis with NMS but not with MH
Most important buffer for EXTRAcelluar fluid compartment?
body buffer for BICARBONATE
what is an example of a urinary buffer?
Ammonia
if someone has a high serum potassium, where Hydrogen is going into the cell and potassium is coming out that would be inductive of what?
acidosis
what is the 2ndary buffer system?
Respiratory: H2CO3 “carbonic acid” produced to convert CO2 and excreted by lungs.
what is the third buffer system?
Renal system: regulate pH by excreting H+ and reabsorbing HCO3-
what causes an increased anion gap (what metabolic process)
metabolic acidosis
if your base excess is positive that means? and if it is negative that means?
positive = metabolic alkalosis
negative = metabolic acidosis
Anesthetic Implications for Alkalemia?
Respiratory alkalosis prolongs duration of opioid induced respiratory depression
What do you know about HYPERaldosteronism?
Aldosterone produces 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.
What do you know about Cushing’s syndrome?
what are the S/S
Excessive cortisol that is produced in adrenal glands, occurs from excess production by one or both adrenal glands or overproduction of ACTH. buffalo hump moon face skinny arms and legs with big middle bruising elevated glucose (many many more)
what can cause the oxy - hb curve to shift left?
love of oxygen (increased affinity), low temp, low PCO2, low hydrogen (acidosis), low 2,3-DPG. (Think love of oxygen and everything else LOW)
what is the primary determinant of plasma pH?
The ratio of plasma PCO2 and HCO3
Most important buffer in the extracellular fluid comparment?
Bicarbonate buffer system which is a part of the immediate system. (carbonin acid bicarmonate system)
most importnat NON carbonic buffer system in the extracellular fluid?
Hemoglobin
All five body buffer systems?
bicarbonate hemoglobin ammonia phosphates intracellular proteins
Normal ABG measurements?
pH = 7.35-7.45 C02 = 35-45 HCO3 = 22-26
in alkalosis do you see low or high potassium?
low potassium (the hydrogen is coming out of the cells trying to increase the acid present in the blood thus potassium goes into the cell)
Metabolic alkalosis, causes?
you have chloride sensitive and chloride resistant causes.
chloride-resistant below: hyperaldosteronism cushings licorice bartters
Where is aldosterone produced?
zona glomerulosa of the adrenal cortex. It is the major circulating mineralcorticoid in humans.
hyperaldosteronism is characterized by?
excessive secretion of aldosterone, which causes increases in sodium reabsorption and loss of potassium and hydrogen ions.
What causes cushing’s syndrome? (what is in excess)
excessive levels of cortisol.
Where is cortisol produced and what does it do in the body?
Cortisol, which is produced in the adrenal glands, plays a variety of roles in your body. For example, cortisol helps regulate your blood pressure and keeps your cardiovascular system functioning normally.
Cortisol also helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy. However, when the level of cortisol is too high in your body, you may develop Cushing syndrome.
Most common s/s of cushing’s syndrome?
Buffalo hump, ruddy, moonface, balance issues, vertigo, blurred vision, acne, female baldness, water retention, menstrual cycle out of wack, (mimics diabetes), sleep disorders, depression.
Hyperglycemia, guys develop breast, fat on the back, dumpy looking middle with skinny arms and legs
Acid base imbalance seen with massive blood transfusion?
Met. Alk
PaCO2 below what may cause cerebral ischemia?
below 20 (20-30 is good)
potassium imbalances seen with acidosis?
elevated potassium
You would expect COPD, ARDS, PE to cause what acid base disorder?
Resp. Acidosis
What causes would you expect if someone has Met. acidosis?
DKA
severe diarrhea
renal failure
shock
largest anion gaps are caused by what two issues?
ketoacidosis and lactic acidosis
Renal response to metabolic acidosis is three fold, tell me the three things the kindneys do to increase base?
Increased reabsorption of filtered HCO3
Increased excretion of titratable acids
Increased ammonia production
How to prevent brachial plexus injury (placement of the patient)?
YOU WILL FIND A SECTION ON POSITIONING QUESTIONS IN BASICS EXAM 2 UNDER POSITIONING QUESTIONS
