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S5 - Anesthesia Pharm II - Test 2 > Deliberate Hypotension > Flashcards

Deliberate Hypotension Flashcards

1
Q

What are the 3 different BP goals used depending on the institution for deliberate hypotension? (systolic goal vs. MAP goal vs. % reduction from baseline)

A
  • reduction of systolic BP to 80-90mmHg
  • MAP 50-65mmHg
  • 30% reduction of baseline MAP (this is what TC said was the best choice to go by)
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2
Q

5 main benefits of DH

A
  • reduced blood loss
  • facilitation of surgical dissection
  • reduction of oozing beneath skin flaps
  • prevention of aneurysmal rupture
  • reduction in intravascular tension
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3
Q

What benefits occur bc of the reduced blood loss associated with DH

A
  • conserve blood supply
  • avoidance of transfusion reactions
  • decreased transmission of blood-borne disease
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4
Q

What benefits related to the facilitation of surgical dissection are seen in DH

A
  • idnetifies malignant vs. nonmalignant tissue and vital structures
  • reduces the amount of cauterized tissue, debris, and wound infection
  • reduction in operative time
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5
Q

What specific surgical specialty benefits from reducing oozing beneath skin flaps?

A

Better plastics outcome, improved wound healing

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6
Q

What are the 6 common indications for DH

A
  • Neurosurgery
  • Large ortho cases- total hip, spinal fusions, arthroplasty
  • surgery on large tumors-pelvic
  • Head or Neck, maxillo-facial, middle ear
  • plastics
  • patients in whom transfusion is undesirable
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7
Q

What has allowed for the decrease in contraindications for DH

A

Improved drugs and monitoring

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8
Q

Contraindications for DH

A
  • Hypovolemia
  • Severe anemia
  • untreated hypertension
  • realtive contraindications : H/O cerebrovascular disease, renal dysfunction, liver dysfunction, severe peripheral claudication, MI, or angina
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9
Q

Is DH safe in treated HTN patients?

A

Yes, treatment returns cerebral autoregulation toward normal

DH in untreated HTN is associated with increased risk of death

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10
Q

Arterial bleeds are related to what BP parameter?

reduced by?

abolished by?

A

MAP

reduced by decreased MAP and HR

Abolished by tourniquet

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11
Q

Capillary Bleedis dependent on?

reduced by?

A
  • Dependent on local flow in the capillary bed
  • reduced by decreased BP and local vasoconstriction
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12
Q

Venous bleed related to?

abolished by?

A
  • related to venous return, venous tone, and dependent posture
  • aboilshed by spinal or epidural and direct vasodilators
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13
Q

How can body positioning be used to achieve hypotension

A
  • Operative site above the level of the heart
  • For each 2.5cm of vertical height above the heart, the local arterial pressure is reduced by 2mmHg
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14
Q

How does PEEP contribute to hypotension

A

decreased venous return

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15
Q

How does PPV cause hypotension

A

decreased venous return and CO

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16
Q

What effect on BP does decreasing SV and HR have

A

decreased BP duh

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17
Q

What 2 mechanical methods can be used to decrease BP

A
  • tourniquets
  • local infiltration with epinephrine
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18
Q

What 2 things are crucial to monitor with the use of tourniquets

A
  • Duration: 60min upper limb, 90min lower limb
  • Pressure: 250mmHg in the arm, 300mmHg in leg
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19
Q

Pharmacologic methods to achieve DH (6)

A
  • volatiles
  • sympathetic ganglionic blockers
  • Alpha-blockers
  • Beta-blockers
  • vasodilators
  • spinal and epidural anesthesia
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20
Q

Isoflurane can be used for DH, but what response has the greatest effect on BP?

~plz reword, my brain is strugglin~

A

Vasodilation

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21
Q

Effects of using Iso for DH (6)

A
  • minimal effect on myocardial contractility
  • vasodilation effect easily adjusted
  • great for a moderate reduction in BP
  • less on an effect on ICP than halothane
  • decreased CMRO2
  • minimizes reflex vasoconstriction or tachycardia
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22
Q

Iso effect on CO?

Nitro effect on CO?

A

both maintain CO

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23
Q

Iso likelihood of causing tachycardia? Nipride?

A

Iso- rare

Nipride-frequent

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24
Q

Iso effect on pulmonary shunting? Nipride?

A

iso-unchanged

nipride- increases pulmonary shunting

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25
Q

iso effect on cerebral blood flow? nipride?

A

both maintain per that chart but also the vasodilator ppt says Nipride increases CBF sooooooooooooooooooooooooooooooooooooooooooooo cool

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26
Q

iso effect on CMRO2? nipride?

A

iso-decreases

nipride- unchanged

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27
Q

Iso’s effect on cerebrovascular CO2 reactivity? nipride?

A

iso- preserves

nipride- impairs

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28
Q

Monitoring of EEG and SSEP with iso? nipride?

A

iso- may not be possible

nipride- no interference

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29
Q

hepatic blood flow with iso? nipride?

A

both are maintained

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30
Q

prolonged recovery with iso? nipride?

A

iso: possible dependent on dose and duration
nipride: none

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31
Q

What is more precise, the use of Iso or nipride for DH?

A

Nipride is more precise

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32
Q

Is the onset time with iso or nipride faster? what is the negative to the fast onset?

A

Nipride has a quicker onset at the expense of possible overshoot

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33
Q

Which agent iso or nipride is associated with rebound hypertension

A

Nipride

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34
Q

What agent is associated with the risk of toxic metabolites iso or nipride? what is the metabolite?

A

Nipride- can rarely produce cyanide and thiocynate toxicity

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35
Q

How can Sevo be used with DH?

A
  • minimize HR fluctuations that occur with the use of nitro, nicardipine, or alprostadil to achieve hypotension
  • decreased sympathetic activity
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36
Q

Trimethaphan( Arfonad) response that makes it a possible DH medication?

A

Interruption of sympathetic outflow, vasodilation

-historical, not still used for DH today

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37
Q

benefit of pretreating with clonidine

A

reduces the required infusion of PGE 1 needed to maintain DH and reduces the blood loss by 45%

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38
Q

Alpha-adrenergic blockers used for DH (2)

A
  • Phentolamine(Regitine)
  • Droperidol
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39
Q

Alpha-adrenergic blockers effects (both a positive and a negative)

A

positive- vasodilation

negative- increased HR and myocardial oxygen demand due to beta stimulation (makes alpha-blockers not a good choice)

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40
Q

What is the big advantage with the use of beta-blockers for DH

A

decreased HR and CO

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41
Q

How are beta-blockers typically used for DH (with what other drugs?)

A

Used with vasodilators to abolish reflex tachycardia

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42
Q

T/F beta-blockers help prevent wide variations in BP

A

true

43
Q

What are the downsides to the use of labetalol for DH

A
  • not as potent
  • masks the adrenergic response to acute blood loss
  • long duration lasts in postop period
44
Q

propranolol pretreatment has what positive effects?

A

reduced dose of SNP and the rebound HTN upon discontinuation

45
Q

What beta blocker is associated with reducing plasma renin activity? what does that result in?

A
  • Esmolol
  • results in improved stability and greater reduction in CO
46
Q

2 causes for caution with the use of sodium nitroprusside

A
  • increased ICP
  • cyanide toxicity
47
Q

Is sodium nitroprusside good for short periods?

A

Yes

“dial-a-pressure”

48
Q

Are there adverse effects on myocardial contractility with the use of nitroprusside?

A

No

49
Q

What can you pretreat with to reduce the dose of SNP and avoid rebound HTN?

A
  • propranolol
  • captopril
  • enalapril
50
Q

Does nitro have a more or less dramatic decrease in BP compared to Nipride?

A

less dramatic decrease

51
Q

Does nitro decrease systolic or diastolic more?

A

systolic

52
Q

Compared to nipride, does nitro have better or worse coronary artery perfusion?

A

better coronary artery perfusion

53
Q

Does nitro increase ICP?

A

Yes, but not as bad at SNP

54
Q

benefits of 3inch transdermal NTG patch for DH

A
  • moderate hypotension
  • reduced blood loss by 50%
  • reduced need for transfusion
55
Q

Does spinal/epidural anesthesia have vasodilating effects on arterial, venous, or both?

A

both due to sympathectomy

56
Q

What regional block is required to prevent tachycardia during DH

A

T1-T4

57
Q

What plexus is blocked during lower abdominal and pelvic surgery

A

pelvic venous plexus

58
Q

Can you use epi in your spinal/epidural if using it for DH?

A

No, if epi is added to the local it can counteract the hypotensive effect

59
Q

Is it better to reduce Bp by decreasing SVR or CO? why?

A

decreasing SVR so blood flow to tissues is maintined

60
Q

What are the principal hazards of DH

A

Ischemia of the brain and myocardium

61
Q

What is the safest lower limit of BP during DH and why?

A

50-55mmHg in a normotensive patient bc that is the lowest pressure at which autoregulation of CBF is maintained

62
Q

When MAP falls below___, CBF no longer responds to changes in PaCO2

A

50mmHg

63
Q

During normotension, CBF changes linearly with PaCO2 when the PaCO2 is ___?

A

20-70mmHg

64
Q

What should be avoided to maintain the balance of myocardial oxygen supply and demand?

A
  • tachycardia
  • myocardial depression
  • coronary artery perfusion alteration
65
Q

During DH why is there an increase in dead space ventilation and what happens to the PaCO2?

A

Decreased perfusion causes the increased dead space ventilation which results in increased PaCO2

66
Q

Decreased PaO2 due to increased shunt seen with what drug and what type of lungs?

~halp idk how to word this info bc my lil brain does not understand

A
  • Seen with nipride but not with iso
  • Seen in normal lungs, but not with COPD
67
Q

The effects of DH on PaCO2 and PaO2 make what necessary?

A

controlled ventilation and increased oxygenation

68
Q

At what MAP does GFR begin to decrease

A

MAP< 75

69
Q

When MAP drops below 75 and GFR decreases, are the metabolic needs of the kidneys still met? What symptom is seen?

A

Yes metabolic needs still met but oliguria occurs

70
Q

Is a rapid recovery of UOP seen when DH is d/c?

A

rapid recovery only in normovolemic patients

71
Q

T/F strict maintenance of UOP during DH is crucial

A

false, it is not neccessary

72
Q

Renal function is better preserved with a combo of iso and __ than a higher concentration of iso alone

A

labatelol

73
Q

How is liver perfusion affected during DH

A
  • altered d/t limited autoregulation for the hepatic artery and no autoregulation for the portal venous circulation
  • increased sympathetic outflow causes splanchnic vasoconstriction and decreased flow to the liver and intestine
74
Q

decreased blood flow to the eyes during DH leads to what complications

A
  • blurry vision
  • blindness(rare)
75
Q

What 3 interventions are used to help reduce likelihood of eye injury during DH

A
  • careful positioning to avoid increased intraocular pressure (neutral position)
  • maintain Hgb
  • colloid instead of crystalloid to minimize edema
76
Q

What should you look for on EKG that would indicate inadequate myocardial perfusion

A

ST depression and ectopic beats

77
Q

What leads are the best to look at for signs of ischemia

A

Lead 2 and V5

78
Q

How does DH effect temp

A

vasodilation causes rapid loss of body heat

79
Q

Where should your transducer of your artline be leveled during DH

A

the level at internal carotid/circle of Willis to monitor CPP

(tragus of the ear)

80
Q

Is ETCO2 accurate during DH, why or why not?

A

Not accurate d/t increased dead space, decreased CO, and no changes in body metabolism

81
Q

a sudden decrease in ETCO2 during DH case could indicate what?

A

PE

82
Q

In regards to ETCO2 and CBF, what should be avoided to prevent cerebral vasoconstriction and decrease CBF

A

hyperventilation

83
Q

T/F there is an increase in mortality associated with DH compared to other anesthetics

A

false, no difference in mortality

84
Q

complications seen with DH

A
  • dizziness, prolonged awakening, cerebral artery thrombosis
  • renal thrombosis
  • anuria, oliguria
  • postop bleeding
  • inadequate or excessive hypotension
85
Q

What type of DH is desired for plastic, maxilo-facial, and ENT cases

A
  • slow onset
  • sustained moderate hypotension with slow return to normal
86
Q

When massive blood loss is anticipated what type/characteristics of DH are desired

A

moderate sustained hypotension with reduced HR

87
Q

When clipping cerebral aneurysm what type/characteristics of DH are desired?

A

profound hypotension with short period of excessively small pressures

88
Q

What drug should be avoided during DH

A

atropine

89
Q

Is more or less sedation/analgesia required during DH

A

generous sedation or analgesia

90
Q

PACU considerations following DH procedure

A
  • raise HOB
  • avoid CO2 retention
  • avoid hypoxia
91
Q

What position should be avoided unless arterial pressure is being measured at the level of the circle of willis

A

severe head up position

92
Q

don’t know how to ask this but important fact:

Don’t reduce the systolic pressure during the case to less than the pre-op diastolic pressure

A

:)

93
Q

SNP advantages

A
  • potent
  • reliable
  • rapid onset and recovery
  • CO well preserved
94
Q

SNP disadvantages

A
  • reflex tachycardia
  • rebound HTN
  • pulm shunting
  • cyanide toxicity
95
Q

Dexmedetomidine advantages

A
  • dose dependent sedation and analgesia with associated hypotension
  • decreases IV/inhalational anesthetic requirements
  • smooth emergence
96
Q

Dexmedetomidine disadvantages

A
  • bradycardia
  • heart block
97
Q

Esmolol advantages

A

useful to control tachycardia

98
Q

esmolol disadvantages

A

potential for significant cardiac depression

99
Q

advantages of nitroglycerin for deliberate hypotension

A
  • preserves myocardial blood flow
  • reduces preload
  • preserves tissue oxygenation
100
Q

NTG disadvantages

A

increases ICP

highly variable dosage requirements

101
Q

Nicardipine advantages for deliberate hypotension

A

preserves cerebral blood flow

102
Q

Nicardipine disadvantages

A

trick- nothing according to that chart

103
Q

Remi + propofol advantages

A
  • reduces middle ear blood flow (remi)
  • decreased PONV (propofol)
104
Q

remi + propofol disadvantages

A
  • no analgesic effect once remi infusion d/c
  • postop secondary hyperalgesia

S5 - Anesthesia Pharm II - Test 2 (7 decks)

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