exam 1 Flashcards
ENT goal:
Balance ______ relaxation with _______ recovery
DEEP relaxation
RAPID recovery
painful/very stimulation (deep)
short cases (rapid)
ENT
muscle relaxation ___________ paralytics
withOUT
Goals of ENT
preventing fire
minimize blood loss (highly vascular)
specialized techniques
relax the muscle withOUT paralytics
deep but rapid
maintain CV stability
preventing postop airway obstruction
3 types of ET tubes for ENT surgery
RAE
anode
laser tube
ENT
ET tube
Cuffed, uncuffed (rare)
Sometimes difficult to fit, due to BEND
Helps make it less obstructed for the surgeon
The bigger the tube, the further out from the mouth
Nasal tube is good for dentists
RAE (oral or nasal)
ENT
ET tube
Flexible, good at bending, can create knots, resists kinking
However, can be occluded easily with biting (without mouth block)
anode (armored, reinforced)
ENT
ET tube
Metal impregnated tube, reduces risk of fire
However, markings are covered if you wrap it, so need to line it up with another tube; use breath sounds
laser tubes
Most LAs are _______-based
amide
3 drugs used for ENT
LAs
anticholinergics (secretions)
steroids (prolong LA, reduce edema + PONV)
ENT have a high risk of _______
PONV
which ENT case has the highest risk of PONV
middle ear procedures
8th cranial nerve
to decrease blood loss by reducing MAP, while STILL MAINTAINING cerebral and systemic autoregulation
deliberate hypotension
deliberate hypotension
Maintain MAP ≥ greater than or equal to ___
60
true or false
deliberate hypotension
patients with HTN may need HIGHER MAP
true
could need 65 or 75
true or false
deliberate hypotension can be done without aline, unless using nipride
true
2 surgeries for deliberate hypotension
o Extensive dissections
o Functional endoscopic sinus surgery (FESS)
drugs used for deliberate hypotension
Nipride (always use an a-line)
o Dexmedetomidine
o Esmolol
o Nitroglycerin (NTG)
o Nicardipine
o Remifentanil
o Propofol
risk of deliberate hypotension
postop vision loss (irreversible)
laser surgery types (4)
CO2
Nd: YAG
Ho: YAG, KTP
argon
laser surgery drawback
most surgical fires are related to this
What are the 3 biggest concerns with laser surgery)
1) Eye protection (patient + staff)
2) Plume dispersion (viral papillomas); can cause ETT to be dislodged
3) Fires
which ETT is best for fires
laser tube, metal impregnated
safety with laser surgery
matte finish
inflate cuff with methylene blue
shield tissue with wet gauze
suction plume
if patient needs O2 AND needs to respond to verbal commands, do this for O2
deliver minimum amount of O2 (30% or less)
if needed above 30%, deliver 5-10L/min of air under drapes to washout excess O2
stop O2 >1 min before laser use
use adherent incise drape
keep towel edges far away
coat facial hair with jelly
use bipolar
do not use electrocautery to cut into trachea
complications of endoscopy
Eye trauma
o Epistaxis
o Laryngospasm
o Bronchospasm
o Adverse effects to LAs from epi, etc. (LAST)
bronchs require vocal cord ___________*
relaxation
avoid paralytics!
true or false
ONLY use AWAKE extubation with someone who has bleeding in their airway*
true
No ETT involved! It is from an independent source
unprotected airway
High Frequency Jet Ventilation
HFJV, always use lowest ____ possible
O2
<30%
CONTRAindication to HFJV
full stomach
obese
pulm disease (difficult to maintain O2)
difficulties of HFJV
air trapping
SQ emphysema
PTX
type of anesthesia to use for HFJV
TIVA
what bronchus is most common with children for aspiration
Right
gold standard for foreign body aspiration
rigid bronch with GA
foreign body:
inhalational induction with ______________ ventilation
spontaneous
avoid ______ with foreign body
PEEP
postop foreign body
steroids
breathing treatment
mask on face, chin lift
Avoid ETT unless necessary
what 2 drug classes are CONTRAindicated for nerve monitoring/preservation/stimulation
NMBs
LAs
nitrous (avoid >15 min before closing)
2 indications for nerve preservation
parotid glands
mastoidectomies
how long should nitrous be turned off for
> 15 min before closing
myringotomy
ear procedure
usually does NOT require IV access
nitrous is okay to use (short procedure)
nasal fentanyl/dex for calmness
most common ped surgery
tonsillectomy and adenoidectomy (T+A)
true or false
LMAs are NOT recommended for tonsil surgery
true
contraindicated drug for tonsils
NSAIDS (however, studies have not proven they cause worse bleeding)
when are the ONLY times you can use DEEP extubation for ENT cases
“dry field” or VERY NORMAL cases
otherwise, always WAKE them
2 risk factors of bleeding tonsil complication
> 15 years old
within 6 hours (SLOW onset, swallowing blood)
true or false
bleeding tonsils extubate fully AWAKE*
true
true or false
ALL bleeding tonsils are “full stomachs”: MUST HAVE TRUE RSI*
true
thyroid procedures
Increased incidence of myasthenia gravis (increased ____________ to muscle relaxants!)
sensitivity
- Vocal Cords Motor Innervation (2)
o Recurrent laryngeal
o EXTERNAL branch of SUPERIOR laryngeal
gold standard thyroid surgery monitoring
intraop nerve monitoring
ETT with 4 electrodes
NIM tube (neuro inegral monitoring)
NIM electrodes
red: _______
blue: _____
red: RIGHT
blue: LEFT
electrodes should be in contact with vocal cords
thyroid surgery
treat hypotension with _______-________
direct-acting
(phenylephrine)
what can occur following thyroid surgery
HYPOcalcemia
(numb/tingling, laryngospasm, seizures, CV arrest)
treatment for HYPOcalcemia (2)
calcium gluconate or chloride
thyroid hematoma
Post-op hematoma
leads to
ER airway obstruction
leads to
emergent to the OR
true or false
cleft LIP is more difficult
true
difficult to mask and to intubate
done first
facial trauma
assume ___________ injury
cervical spine
use c-collar, F/O
Le Fort fracture
Horizontal, nose/palate, septum, posterior pterygoids
Usually, no issues
Oral or nasal ETT GOOD TO USE
I
Le Fort fracture
Triangular, nose, orbit, below zygoma, lateral maxilla + pterygoids
II
Le Fort fracture
Complete separation of midface from the cranial base across nose, ethmoid, orbit, sphenopalatine fossa
AVOID NASAL ETT without F/O guidance if basilar skull fracture suspected
III
basilar skull fracture signs (4)
o CSF from nose or ears
o Blood behind tympanic membrane (ears)
o “Raccoon eyes”: ALWAYS BILATERAL
o Bruising behind ears: “battle signs”
basilar skull fracture signs are delayed ___-___ days
2-3 days
facial fractures
true or false
ALL are full stomachs
Wire cutters must be available and stay at the bedside throughout the postop course
usually, not an emergency procedure
extubate AWAKE (need to be able to clear the airway)*
true
with any nerve thing, what do we avoid
NMBs or muscle relaxants
radical neck dissection (3)
difficult intubation (due to radiation, movement issues)
LONG procedure
AVOID fluid overload
risk of VAE (due to head-up position
opthalmic surgery
anesthesia type
LAs “epidural”
a little propofol
EXCEPT young children
they cause less PONV
most common + effective for profound analgesia/akinesia (no movement) of eye and eyelids (2)
RETROBULBAR LA*
peribulbar LA
Sub-tenon, infraorbital, supraorbital
which nerves are anesthetized with opthalmic
III, IV, V, VI, VII (3-7)
young children opthalmic surgery anesthesia type
GA
true or false
okay to use anticoags with eye surgery
true
opthalmic surgery
Sch causes transient ____________ IOP
increased
still considered safe
opthalmic surgery
decreases IOP + maintains akinesis
NON-depolarizers
opthalmic surgery
extubate ______
DEEP
2 risks from eye muscles
MH
PONV
opthalmic surgery
Prolonged PONV may be sign of increased ____!
IOP
For FULL stomach, OPEN-EYE INJURY patient
easy airway =
difficult airway =
easy = roc
difficult = Sch
(if sugg is available, use roc, less risk of increased IOP)
Oculocardiac Reflex
Afferent/towards = *
trigeminal (V)
five and dime
Oculocardiac Reflex
Efferent/away = *
Vagus (X)
five and dime
stimulus (4) of Oculocardiac Reflex
Globe pressure
optic nerve pressure conjunctival pressure
muscle traction
true or false
oculocardiac reflex occurs in children more
true
o Sudden, profound bradycardia, asystole, etc
Oculocardiac Reflex
treatment for Oculocardiac Reflex
stop stimulus
Oculocardiac Reflex
If unresolved (the second time it happens) = use ________ (2)
atropine or glycopyrrolate
- CN ____ nerve block = Bell’s Palsy
VII (facial)
Max SQ lidocaine
35 mg/kg
Max SQ epi
70 mCg/kg
1L SQ of tumescent solution
700ml absorbed
max amount of SQ tumescent solution
5L
tumesecent solution (3)
saline + epi + lidocaine
risks with liposuction
VTE*
abd wall perf
sepsis
fluid overload; pulm edema (from tumescent)
hypothermia
LA toxicity
o Highest incidence of death is d/t VTE
abdominoplasty “tummy tuck”
GREATEST risk of VTE
combined procedures
abdominoplasty + liposuction
biggest cause of VTE
smoking
VTE increased risk
long procedures
>__ hr GA
>__hr sedation
> 1 hr GA
2 hr sedation
facial cosmetic surgery
cocaine increases SNS
avoid ____, _________/_________
avoid HTN, swelling/bleeding
fiO2 <30% is =
150-200ml
safety checklist for office based surgery is from
ISOBS (institute for safety in office based surgery)
most common cause of death from OFFICE/PLASTICS based anesthesia
PE
(abdominoplasty)
Only ___ states have guidelines, policies, or position statements regarding office-based surgery and anesthesia (OBA)
33
true or false
standardization of safe practice with adequate safety protocols and practice standards are NOT legal guidelines*
true
true or false
Only 24 states have at least one law that regulated OBA
true
true or false
Heavy/deep or moderate MAC or deep sedation techniques require ETCO2*
however, this is NOT state/legal regulation, this is a standard of practice*
true
- DECREASED cost
- Increased patient and surgeon convenience and satisfaction
- Consistent staffing
- Efficiency
- Patient privacy
- Increased autonomy of practice
- DECREASED risk of infection
- Aging population + drive for cosmetic surgery
advantages of OBA
- Absent or inconsistent state regulations (someone who is not credentialed can perform)
- Lack of peer review and credentialing
- Logistical limitations
- Lack personnel support (solo provider)
- Possible poor quality/amount of equipment
- Lack organizational resources and human infrastructure
disadvantages of OBA
OBA facilities must have
positive pressure ventilation device (bag valve mask)
2 H tanks of oxygen
monitor/defibrilator
- What is the most common cause of death in OBA
inadequate ventilation and oxygenation
what should you keep in mind when monitoring fluids for liposuction
70% of tumesecent is absorbed (so calculate that into the number!)
do not overhydrate
true or false
If a bad trauma event happens, get them to a Level 1 trauma center; it does NOT matter how far it is!
true
modern trauma system has replaced the ________________ _____ ________
community care model
ATLS PRIMARY Survey:
ABCDE’s of trauma care
Vitals
Making sure the patient is stable
o ATLS Secondary Survey
Resuscitation and stabilization in progress
Complete head-to-toe assessment, including neuro exam!
Example: turning on the side, pupils, breath sounds, neuro assessment
Most common type of blunt trauma
MVAs and falls
blunt trauma
Always assume ___________, until confirmed otherwise
unstable C-spine
o What is the worst blunt trauma
thoracic (MVA/steering wheel)
most common symptom of blunt trauma
PTX (40%)
many times, it does NOT show up on x-ray
Tension PTX signs (6)
- HYPOtension
- SQ emphysema
- Unilateral ↓ BS
- ↓ chest wall motion
- Distended neck veins
- Tracheal shift to opposite side
treatment for tension PTX
- Emergent needle aspiration
2nd ICS (above 3rd rib, MCL)
- Beck’s Triad is associated with
pericardial tamponade
Beck’s Triad (3)
PERICARDIAL TAMPONADE
“beck was heart sick”
1) HYPOtension
2) increased CVP
3) jugular distention/muffled heart tones
what is NOT included in becks triad, but IS a symptom of pericardial tamponade
pulsus paradoxus (decreased SBP on inspiration)
what 2 drugs can be given for pericardial tamponade during INDUCTION
ketamine*
etomidate
AVOID PROPOFOL
hemothorax treatment (2)
1st fluid resuscitation
2nd chest tubes
What are common signs of tracheal injury
SQ emphysema
crepitus
most airway injuries occur _______ the carina
below
FAST stands for
Focused Assessment with Sonography in Trauma
great, highly sensitive, 4 views
lethal triad is for what
penetrating trauma, death
lethal triad**
PENETRATING TRAUMA
“lethal trauma”
1) acidosis
2) HYPOthermia
3) coagulopathy
Damage control surgery (DCS) with Damage Control Resuscitation (DCR)
prevent ________ triad
lethal
DCS and DCR
trauma
Limit/decrease _____________, but increase blood products
crystalloids
- DCS examples (2)
abd packing
external fixator
3 things used in Damage control resuscitation (DCR)
POC testing (TEG + ROTEM)
RAPTOR
REBOA
what is RAPTOR
resuscitation with angiography, percutaneous techniques and operative repair
(IR)
what is REBOA
Resuscitative endovascular balloon occlusion of the aorta
3 major assumptions with AIRWAY trauma
1) full stomach
2) c-spine issue
3) hypotensive + hypoxic
what NMBs for patients with AIRWAY trauma
Sch or Roc for RSI
Manual in-line stabilization (MILS)
after front of C-collar removed
* Many people helping!
true or false
AIRWAY trauma
NO outcome difference between DL (miller), VL, and FOB (provider dependent)!
true
you can use any!
what is the LAST resort (avoid it!) for airway trauma
front of neck access (FONA) with crichotomy
what is a dilemma for BREATHING trauma
↓ Decreased compliance (and need for ↑ increased PIP)
vs
barotrauma (with worsening disease)
protected lung ventilation (6)
1) LOW Vt
2) PEEP
3) Permissive HYPERcapnia (hypoventilating) ***
4) Limited fluids
5) Prone positioning
6) NMBs (can help with ventilating)
3 GOALS for breathing trauma
LOW Vt
LOW PIP (<32 cmH2O)
SpO2 90-94% (avoid O2 toxicity!)
excessive oxygen leads to
atelectasis
free radicals, ROS
cellular necrosis/apoptosis
however, ROS is also caused by oxygen toxicity
Current theory: “Golden Hour” is __________ _____ that is age and health status dependent
nonspecific time
Stages of Hemorrhagic Shock
- Blood volume normalized by shifting fluids
Stage I
NONprogressive or compensated
Stages of Hemorrhagic Shock
CV depression due to ISCHEMIA thrombosis, toxins, cellular damage
Stage II
Progressive
Stages of Hemorrhagic Shock
ATP depleted, cellular death with toxins released
o 1) Acute Irreversible: massive hemorrhage death FAST
o 2) SUB-Acute Irreversible: significant shock and cellular ischemia multi-organ failure/death over time/SLOW
Stage III
Irreversible
will die!
treatment of hemorrhagic shock
minimal bleeding:
<2 L crystalloid
(too much fluid can worsen it)
“Hypotensive Resuscitation”
when bleeding is UNCONTROLLED, minimize bleeding by maintaining SBP of ____-____ mmHg
- Controversial; primarily for penetrating trauma
SBP of 85-90
what is the exception to “Hypotensive Resuscitation”
TBI
“Hypotensive Resuscitation”
when bleeding is CONTROLLED, maintain SBP of >____ mmHg and HR <____
> 100 SBP
<100 HR
for CVLs, access ______ the diaphragm when possible
ABOVE
replace EBL with __:__:__
1:1:1 (PRBCs, FFP, PLTs)
IV fluids resuscitation
________ cause rapid restoration but ↑ increased risk of pulmonary edema and bleeding
colloids
IV fluids resuscitation
Avoid ________, except for documented hypoglycemia + peds
glucose
Evidence: BG >____ mg/dL lead to adverse neuro outcomes
> 170
trauma
maintain glucose at ____-____
140-180
trauma
majority of initial injury survivors are _______________ at death
coagulopathic
trauma
elevated ___ on admission = massive injury, hemorrhage, poor perfusion state
PT
prothrombin
(4) Trauma-Induced Coagulopathy (TIC) *
Dilution (too many fluids)
HYPOthermia*
Acidosis
TBI + Shock (coagulopathy)
When labs ARE available/have resulted, transfuse accordingly*
INR <____
PLT >_______
until then, use targeted transfusion (1:1:1)
1.5
PLT >50,000
hypothermia can result in _______
dysfunctional CLOTS
during resuscitation, ______ everything
WARM
acidosis with pH of <____ + hypothermia can result in significant clots
<7.1
true or false
bicarb is NOT effective for clotting issues
true
theory:
TBI + shock releases tissue factor, leading to __-__ complex
T-T complex
T-T complex leads to
activated protein C (APC) pathway
APC pathway inhibits ___ and ____,
+
promotes fibrinolysis
V and VIII
net result of T-T complex and APC pathway
systemic ANTI**coagulation
treatment for TBI and shock
EARLY FFP
assessment of blood consumption score (ABC)
and
trauma-associated severe hemorrhage score
(4)
penetrating injury
SBP <90
HR >120
positive FAST
ABC score of > or = ___
increased RISK of needing massive transfusion (may not be necessary)
2
keep PT level ____
low
TXA
> 12 years = ___ gm bolus over 10 min, then ___ gm over 8 hrs
1 gm over 10 min, then 1 gm over 8 hr
TXA
< 12 years = ___mg/kg bolus, then ___ mg/kg/hr over 8 hours
15 mg/kg
2mg/kg
- TXA should be administered less than < ___ hours post-injury
< 3
what is the up-to-date coagulation pathway
initiation, propagation
intubate with a GCS < __
8
for patients with low GCS score (neuro injury), use ______ IN*tubation
DEEP
diagnosis of ICP
> 10 mmHg
when do you treat ICP
> 25 mmHg
until ICP monitoring is available,
maintain MAP >____ to maintain CPP >____
maintain PaCO2 ___-___
MAP >80
CPP >60
PaCO2 30-35 (HYPO**carbic)
o ACS 3-Tiered Approach
(neuro)
ICP 10 – 20 mmHg
Tier 1
o ACS 3-Tiered Approach
(neuro)
ICP > 20 - 25 mmHg
Tier 2
o ACS 3-Tiered Approach
(neuro)
UNRESOLVED
ICP > 20 – 25 mmHg
Tier 3
o ACS 3-Tiered Approach
(neuro)
- Surgical evacuation, med-induced coma, HYPO**thermia
Tier 3
o ACS 3-Tiered Approach
(neuro)
EVD, mannitol or hypertonic saline, neuromonitoring, CT, NMBs
Tier 2
o ACS 3-Tiered Approach
(neuro)
Elevate HOB 30 deg, short acting sedation/analgesia, monitor ventricular drainage, repeat diagnostics
Tier 1
cushing’s triad is for what
impending herniation
cushing triad (3)
BRAIN HERNIATION
“you want some cushion for your brain”
1) HTN**
2) BRADYcardia
3) irregular respirations
what 2 drugs should you AVOID with increased ICP
nitrous
ketamine
increased ICP, BEST choice for neuro protection, unless myocardial depression is a risk
propofol
drug treatment for ICP (3)
propofol
mannitol (0.25-1gm/kg)
lasix
true or false
Steroids are NOT effective for ↑ ICP
true
Signs of spinal cord injury (6)
1) Paralysis
* 2) Pain
* 3) Position
* 4) Parasthesias
* 5) Ptosis
* 6) Priapism (erection)
Sch
fasciculations can _______ spinal cord injuries
worsen
> ____ hours until forever, AVOID Sch with spinal cord injury
> 24 hours
UP-regulation, hyperkalemia
Be aware of spinal cord injury withOUT radiographic abnormality (_________) and vertebral artery injury (VAI)
this can occur in up to 88% of patients
CIWORA
what is needed for c-spine injury intubation
MILS, c-collar, halos
what 2 drugs do you avoid for spinal injury
Sch
nitrous
spinal cord injury
intra op evoked potentials
maintain _____ anesthetic
LOW
spinal cord perfusion
have MAP at ____-____
85-90
spinal shock triad (3)
1) HYPOtension (dilation)
2) BRADYcardia
3) HYPOthermia (heat loss)
“warm shock”
spinal cord
___ and above leads to major CNS impairment
T6
spinal cord SHOCK
true or false
aline is required to avoid pulm edema and guide pressors
true
Massive SNS response due to stimulus BELOW the spinal INJURY
autonomic dysreflexia
autonomic dysreflexia is most common with injuries above ___
T6
causes of autonomic dysreflexia (3)
bladder distention
fecal impaction (constipation)
nitrous/opioid GA or regional anesthesia (NOT with VOLATILES)
symptoms of autonomic dysreflexia (6)
- HTN*
- Seizures
- Pulm edema
- MI
- Acute renal injury
- Cerebral hemorrhage
treatment for autonomic dysreflexia (5)
- Nitrates
- Nifedipine
- Hydralazine
- Labetalol
- Foley*
what surgery is a major risk for fat emboli, PE emboli, hemorrhage, shock
orthopedics
symptoms of bone fractures (3)
Hypoxic respiratory failure due to continuous fat emboli syndrome (FES)
ARDS
HIGH morbidity and mortality (with pelvic fractures)
treatment for bone fractures (4)
REBOA (occlusion of aortic artery)
repair it early
treat as FULL stomach, RSI
regional? depends
what is the cause of death for junctional trauma
life-treatening hemorrhage
they are NON-compressible**
treatment: junctional tourniquets
what are most INTRAop deaths for trauma patients from (3)
HYPERkalemia
HYPOcalcemia
acidosis
NOT hemorrhage/exsanguination
what are POSTop deaths for trauma patients
multiorgan failure
early:
later:
early: CV failure*
later: PIICS (persistent inflammatory, immunosuppressed catabolic syndrome)
peds burns are mostly due to
scalding (NAT? possible abuse)
burns
main causes of EARLY death < 48 hours (2)
shock or inhalational injury
burns
main causes of LATE death
> 48 hours (2)
multiorgan failure + sepsis
true or false
rule of nines
The difference in % for the head in children is MORE severe*
true
head is 18%
adults it is only 9%
major burn:
> 10% TBSA (adult) or 20% (age extremes): ___degree
> 10% TBSA (adult: ___ degree
2nd degree
3rd degree
true or false
electrical burn or inhalational injury
are considered major burns, regardless of degree
true
burn**
If
patient age + % TBSA
is >____,
that means the patient has a
> 80% mortality
> 115
mortality ________ with added inhalation injury
doubles
burns
Suspect ____________ injury until ruled out
inhalation
burns
true or false
heat in UPPER airway is dissipated, reflex laryngospasm occurs, which CLOSES the airway, so the LOWER airway damage is uncommon
true
burns
what is LOWER airway damage due to
toxins
NOT the hot air/steam
gold standard for airway exam for burn
fiberoptic
true or false
with upper airway damage, EARLY intubation is required, even if asymptomatic
true
burns
if swelling/obstruction is present, ________ intubation is the best choice
AWAKE
burns
Progressive air leak around ETT indicates airway swelling is ___________
subsiding
burn AIRWAY
treatment (3)
topicals, ketamine, dex
burn AIRWAY
avoid this class of drug
avoid NMBs (we want spontaneous ventilation)
CO binds to Hgb with 200x the affinity of O2 (______ shift), decreased SaO2 & metabolic acidosis
LEFT shift
true or false
pulse ox does NOT detect carbon monoxide
true
it will be falsely high
treatment for carbon monoxide poisoning
100% O2 until CoHgb <___% for ___ hours
100% O2 until CoHgb <5% for 6 hours
cyanide (HCN) causes metabolic __________
acidosis
symptoms of cyanide (HCN) toxicity
o Changes in LOC
o Seizures
o DILATED pupils
o HYPOtension
o Apnea
o High lactate levels
treatment for cyanide (HCN) toxicity
Hydroxocobalamin (vitamin B12a)
burns
fluid loss is greatest in the FIRST ___ HOURS
12 hrs
burns
HYPERmetabolism
highest stress response is 1st ___ days after injury
3 days
burns
HYPERmetabolism
plasma catecholamines are ___-___x higher than usual
10-50x higher
burns
when does the PRONOUNCED hypermetabolic phase set in
___ hrs post injury
48 hours post-injury
lasts up to 2 years following
burns
treatment for hypermetabolic phase
abx
beta-blockers
warming devices
anti-hyperglycemia
nutrition
fluid resuscitation
Parkland***
__ ml LR fluid x TBSA % x kg
over the first ___ hours
4ml
example: 70 kg pt with 30% TBSA burn = 8,400 mL
over 1st 24 hours = average of 350 mL/hr
(a lot of fluid!)
2 types of fluid resuscitation
parkland
modified brooke
what type of fluid for parkland resuscitation
heavy isotonic crystalloid (LR)
parkland resuscitation
children require ________ additionally
glucose
burns
CV
hypovolemia
hypotension
decreased CO
then, hypermetabolic
HTN
tachycardiac
burns
pulm
decreased function (even with no inhalational injury)
acute lung injury
decreased FRC
decreased compliance
increased capillary permeability, pulm edema, ARDS
burns
pulm treatment
use low Vt
use low PIP
burns
renal
myoglobinuria
hemoglobinuria
AKI
burns
AKI categorized by RIFLE
Risk
Injury
Failure
Loss
End-stage kidney disease
burns
immune
sepsis
pneumonia
what is the leading cause of death for burns
sepsis
burns
GI/nutrition
metabolic rate 2x normal
insuline RESISTANCE (hyperglycemia)
ileus
use RSI
burns
true or false
if intubated, do NOT stop enteral feedings (transpyloric)/TPN
continue them intraop*
use RSI
true!
otherwise, patient will get hypoglycemic fast
burns
common guidelines for when to stop debridement (3)
1) no more than 20% body surface at a time
2) core temp < 35 C
3) 10 units PRBCs given (approx 3500ml)
burns
true or false
even if Hct is normal (30), the patient could be dehydrated, so the Hct would be FALSELY HIGH
a number is just a number, until you put it into perspective of the patient; it doesn’t matter if their Hct is 35 or 45*
true
burns
anesthesia implications
thorough assessment
MINIMALLY safe NPO orders
2 large IVs/CVLs
labs/blood available
INCREASED opioids/NMBs due to hypermetabolic state
warm everything
postop ventilation
burns
absolute CONTRAindication
Sch
burns
fluid/blood replacement
start blood _________
as SOON as blood loss begins
KEEP UP AND STAY AHEAD OF THE GAME
burns
true or false
they require INCREASED amount of NMB
true
due to up-regulation
burns
true or false
anesthetic effects may be EXAGGERATED if hypovolemic
true
burns
true or false
regional should be AVOIDED
true
(sympathetic blockade, needle through burned tissue, coagulopathy)
burns
when is regional the ONLY good choice (otherwise, avoid it!)
children with caudal (lower extremity) burns
burns
utilize _______ extubation*
AWAKE
burns
avoid _________ due to oozing
NSAIDS
burns
which drug might be a good choice for postop/emergence
dex
what is the majority of MH from gene ______
chromosome _________
RyR1 gene
chromosome 19q13.1
MH
true or false
you can have the RyR1 variation, but not have MH
true
MH
true or false
Up to 50% have had 2 or more UNEVENTFUL GAs in the past!
true
MH
only < __% have positive family history
< 7%
causes of MH
volatiles (NOT nitrous)
Sch
explain MOA of MH
depolarization,
opens RyR1,
SUSTAINED calcium release,
cannot be re-uptake into SR fast enough,
sustained muscle contraction,
anaerobic metabolism,
acidosis, hyperthermia,
ATP is depleted
hypoxia, cell death, rhabdo
massive hyperkalemia (cause of death)
what is the cause of death for MH
massive hyperkalemia
MH peak age of incidence
3 years old
true or false
black box warning for Sch with children
true
what is the 1st sign of MH
hypercarbia
what are the EARLY signs of MH
hypercarbia (first)
hyperthermia
tachycardia
MH
hyperthermia occurs __ degree C every 10 minutes
1 degree every 10 min
when does MH occur
intraop (98%) of the time
or
1st hour postop
dantrolene MOA
BINDS to RyR1 receptor
promotes closing state
and
calcium reuptake
MH
skeletal muscle relaxant properties of dantrolene occur at the ______________ level
INTRAcellular (not the NMJ)
dantrolene pH
9.5
dantrolene reduces mortality of MH from >40% to ___%
1.4%
dantrium
____mg per vial
____ml per vial sterile water
20mg per vial
60ml per vial
contains mannitol
ryanodex
____mg per vial
____ml per vial sterile water
250mg per vial
5 ml per vial
small amount of mannitol (drawback)
MH
what 2 types of patients do you use non-triggering anesthetic*
For patients with blood relative with known MH
or
a myopathy with high association to MH
what are the 3 core myopathies for MH*
1) central core
2) multi-minicore
3) king-denborough
MH
flush machine with ___ L/min O2
10 L/min
MH
some machines need up to ____ min of flush time!
120
anesthesia type for MH patients
TIVA
propofol, opioids, non-depolarizer, nitrous
what type of thermometer is needed for MH risk patients
esophageal
axillary
nasopharyngeal
NOT skin temp
1st thing to do when MH is suspected
discontinue the agent
treatment for MH*
discontinue agent
hyperventilate 100% O2 or 10 L/min flow
get help
dantrolene
cooling measures
propofol/benzos
foley
lab tests
bicarb, hyperventilate, insulin (for hyperkalemia)
dantrolene BOLUS/LOADING dose
_____ mg/kg
repeat every ___-___ min
2.5 mg/kg
5-10 min until symptoms abate
dantrolene
dose to prevent reoccurence
___ mg/kg
repeat every ___ hours
for ____-____ hours
1 mg/kg
every 6 hours
24-48 hours
MH
true or false
NO direct ice on skin
true
MH
for NON-RESPONSIVE hyperthermia:
invasive/internal cooling (chilled NS)
MH
stop cooling measures at ___C*
38C
MH
INSERT FOLEY
keep UOP >__ml/kg/hr*
> 2
what is CONTRAindicated with dantrolene
calcium channel blockers
-pine
MH
bicarb dose for acidosis
___-___mg/kg
1-2mg/kg
MH
gold standard diagnostic test (ONLY ONE)
Caffeine Halothane Contracture Test (CHCT)
post-pubescent
MH
For a pregnant patient not believed to be at risk for MH, but whose partner is susceptible to MH, which of the following is “Best Practice” *
Treat as MHS until delivery of fetus (OKAY TO GIVE Sch** for RSI)
Dantrolene ___ mg/kg should be accessible within ___ minutes of the first MH signs*
10mg/kg
within
10 min
true or false
masseter muscle rigidity after Sch administration could be a sign of MH
true
true or false
MH can still occur in neonates
and
starting symptoms for children may be different (such as hyperkalemic cardiac arrest)!
true
later findings of neonate with MH
anasarca
mottling
anuria
creatinine kinase 2,900
DIC
symptoms of muscular dystrophy
muscle weakness
contractures
resp/CV weakness
possible:
learning disabilities
deafness
vision deficits
true or false
MH is NOT necessarily linked to musclar dystrophy
true
however, AVOID triggers and use TIVA to avoid hyperkalemia, etc
most common type of muscular dystrophy
myotonic
2nd most common type of muscular dystrophy
dystrophinopathy
(x-linked recessive)
what is the MOST severe phenotype of dystrophinopathy muscular dystrophy*
Duchenne Muscular Dystrophy (DMD)
what is the less severe phenotype of dystrophinopathy muscular dystrophy
becker MD
___% of muscular dystrophy has NO family history
30%
for muscular dystrophy, preop ___ should be drawn
CPK, it can be 100x normal
(however, always use TIVA, no matter the results)
wheelchair bound before adolescence
Duchenne Muscular Dystrophy (DMD)
if duchenne muscular dystrophy patient gets triggers, that can cause severe ______________ and _____________, leading to cardiac arrest (30% mortality!!)
rhabdomyolysis
hyperkalemia
What is a frequent 1st sign of DMD
cardiac arrest during inhalational induction
for DMD patients,
by ___ years old, serial ______ MUST BE DONE to evaluate cardiomyopathy*
8 years old, serial ECHOs
treatment for DMD (1)
glucocorticoid (prednisone)
with down syndrome, up to ___% have CARDIAC DEFECTS
50%
VSD, TOF, PDA, AV
what can occur upon induction with down syndrome*
BRADYCARDIA
true or false
downs syndrome
you MUST know cardiac status (ECHO) if non-emergency case
true
what are the 2 issues with patients with congenital defects*
intubation/mask difficulty
cardiac issues (have ECHO)
often have pacemakers, may need a magnet!!
what is the MOST DIFFICULT intubation for congenital defects
pierre robin
cystic fibrosis
symptoms
chronic inflammation/infection
hepatic dysfunction/clotting disorders*
OBSTRUCTIVE disease
INCREASED FRC
decreased FEV1
decreased expiratory flow
decreased VC
malnutrition
cystic fibrosis
true or false
do NOT dry the patient out
use humidity in the circuit
use SHORT acting agents (des, sevo, remi, prop, atracurium, nimbex)
true
cystic fibrosis
CONTRAindications (2) *
anticholinergics (glyco)
antagonists of NMBs (neostigmine)
cystic fibrosis
extubate ______*
AWAKE
sickle cell anemia
mutant Hgb ___
A
(recessive)
true or false
sickle cell TRAIT doesnt matter!
we only care about sickle cell DISEASE
true
sickle cell
acute chest syndrome (ACS) (1)
throwing clots/pulm emboli
more likely to occur after surgery, pregnancy, increased age
sickle cell
transfuse ONLY to Hct of ___%
avoid over transfusing
30%
sickle cell
WARM
WET
GREEN***
warm: keep them warm
wet: keep them hydrated
CANNOT BE NPO
green: keep them oxygenated
for craniofacial abnormalities, what is the best type of airway
LMA
when you dont know what you are dealing with, _________ the case
cancel
what are the 4 POTENTIALLY difficult airways for congenital disease***
turner’s/noonan’s
apert’s
arthrogryposis
goldenhar
“TAAG”
what are the 6 KNOWN difficult airways for congenital disease***
pierre robin**
treacher collins*
down’s syndrome
crouzon’s
beckwith/gigantism
which 3 congenital diseases do NOT have heart issues
pierre robin
crouzon’s
goldenhar
“PCG”
VSD heart issue
arthrogryposis
coarctation of AORTA=females
coarctation of PULM ARTERY=males
noonan’s turner’s
NORA
ambu bag must be able to inflate >___% O2
> 90%
what is an important thing for NORA
dependable communication devices
NORA has _________ incidence of death compared to the OR
(conventional belief)
HIGHER death
however, the NACOR thinks NORA has a lower mortality rate!!!
> 50% of NORA deaths are _______________
preventable, sub-standard care
what are most NORA claims related to
inadequate oxygenation/ventilation
OVER-sedation, resp depression
what is the most common anesthetic technique for NORA
MAC
for NORA claims related to over-sedation, what is the issue
limited ETCO2 monitoring or none at all
moderate and deep require ETCO2!
mean age of NORA patients is 3.5 years _________ than OR patients
OLDER
NORA patients are _______ medically complex than OR
more
(there are more ASA III-V)
NORA patients are _______ likely to be discharged earlier than OR patients
MORE likely to be discharged
MRI challenge:
distance between patient and anesthesia machine
> 1 person needed for airway management
what is a difference in NORA and OR staff
uncertainty how to delegate during a crisis
MRI
Radiofrequency radiation emitted by MRI scanners is absorbed by the patient as heat energy, which can cause _____
burns
magnet strength is measured in ________
teslas (T)
most common teslas
1.5 and 3 T
true or false
teslas
the larger the number (T), the stronger the MRI, the clearer the pictures, but the higher the risks
true
MRI
4 zones: ____T - ___T
0.5T-4T
most common NORA adverse outcomes (minor) (3)
PONV
pain
hemodynamic instability
Highest NORA mortality categories (2)
cardiology and radiology
highest NORA adverse outcomes
GI endoscopy (might be related to sheer volume of cases though!)
NORA has a ________ amount of emergency procedures
greater
NORA
true or false
preop evaluation must occur
+
must check for proper equipment
true
NORA
prone or lateral positions (2)
GI procedures
ERCP
primary process leading to CAD, stroke, extremity ischemia, and aneurysms
atherosclerosis
where does atherosclerosis form
o Coronary arteries
o Carotid bifurcation (laminar flow changes to turbulent flow)
o Infrarenal abdominal aorta
o Iliac arteries
o Superficial femoral artery
atherosclerosis
What are the reasons for the ultimate injury (3)
plaque enlargement (reduced blood flow)
embolism of plaque (thrombi)
advanced plaque (occlusion)
risk factors for atherosclerosis
o Smoking (8x more likely)
o Hyperlipidemia
o Diabetes
o HTN (60%)
o Family history
o Male
o Advanced age
o Insulin resistance
o Physical inactivity
o Elevated C-reactive protein, elevated lipoprotein
3 types of Arteriosclerosis
infrarenal
thoracoabdominal
descending thoracic
1 type of cystic medial necrosis
degeneration of aortic media
(ascending aorta)
ELECTIVE AAA repair mortality rate ___%
5%
1-11%
surgery is recommended for AAA diameter
4 to >5.0!!! cm
RUPTURED AAA mortality rate ___%
75%
35-94%
PREhospital mortality rate of ruptured AAA
80-90%
AAA grow ___mm a year
4 mm
even with treatment
untreated mortality rate AAA
5 year
81%
untreated mortality rate AAA
10 year
100%
law of LAPLACE*
T = P x r
tension = pressure x radius
<4 cm rupture risk
0%
4-5cm rupture risk
0.5-15%
5-6cm rupture risk
3-15%
6-7cm rupture risk
10-20%
7-8cm rupture risk
20-40%
> 8cm rupture risk
30-50%
Originates in the proximal ascending aorta and usually involves the ascending aorta, arch, and can go to abdominal aorta
DEBAKEY
Type 1
o Confined to the ASCENDING aorta
DEBAKEY
Type 2
o Confined to the DESCENDING thoracic aorta
DEBAKEY
Type 3a
DESCENDING thoracic aorta
May extend into the abdominal aorta and iliac arteries
DEBAKEY
Type 3b
o The ASCENDING aorta is involved, with or without the ARCH or the DESCENDING aorta
STANFORD
Type A
o The DESCENDING thoracic aorta is involved, with or without PROXIMAL or DISTAL extension
STANFORD
Type B
Where do aneurysms occur most commonly (2)
ascending thoracic aorta (close to aortic valve)
descending thoracic aorta (distal to L subclavian artery)
AAA major causes of death (4)
MI* (40-70%)
resp failure
renal failure
stroke
cross-clamping
hemodynamics depend on (3)
site of clamp
preop cardiac reserve (LV)
intravascular volume
during cross-clamping
cardiac
INCREASED
afterload
wall tension
MAP
SVR
preload
coronary flow
LVEDP (wedge): poor patients only
during cross-clamping
cardiac
UNCHANGED
HR
CO (good LV function)
LVEDP (wedge): good patients
during cross-clamping
cardiac
DECREASED
CO (lousy/bad LV!)
LVEDP
HTN occurs ______ the cross-clamp, hypotension occurs _________
HTN=above
hypotension=below
the longer the __________ of the cross clamp, the GREATER the INCREASE in SVR and DECREASE in CO
duration
time matters!
the ________/_________ the cross-clamp is placed, the GREATER the hemodynamic effect
HIGHER/MORE PROXIMAL
“the closer to the heart, the bigger the impact”
infrarenal __________ effect
suprarenal/infraceliac ____________ effect
supraceliac ___________ effect
infrarenal=LOWEST effect
suprarenal/infraceliac= MODERATE effect
supraceliac= GREATEST effect
proximal = ________ the cross-clamp
ABOVE
if splanchnic venous tone is HIGH, preload will _________
increase
if splanchnic venous tone is LOW, preload will _________
decrease
cross-clamp
increased pulm HTN/wedge + increased permeability =
pulm edema
cross-clamp
pulm damage related to (4)
hypervolemia
metabolites: prostaglandins, free radicals (bronchoconstriction)
activation of renin-angiotensin (BP rises)
complement cascade (inflammation)
INFRArenal cross-clamp:
renal blood decreased ____%
40%
INFRArenal cross-clamp:
renal vascular resistance increased ____%
75%
SUPRArenal and JUXTArenal:
renal blood flow is decreased ___%
80%
cross-clamp
renal failure is due to
reperfusion injury (acute tubular necrosis)
cross-clamp
where does damage occur for spinal cord
artery of adamkiewicz occlusion
cross-clamp
spinal cord: no collateral flow to _________ portion of spinal cord (_________)
ANTERIOR, MOTOR is injured
true or false
somatosensory evoked potential (SSEP) does NOT provide info about anterior spinal cord/motor
true
it is sensory/posterior ONLY
o Anterior Spinal Syndrome
Elective infrarenal ___%
0.2%
o Anterior Spinal Syndrome
Ruptures of the descending aorta ____%
40%
artery of adamkiewicz is found where
T5-L2
origin is unknown
spinal cord perfusion = _____ - _____**
MAP - CSF pressure
to help perfusion, you want to either:
INCREASE MAP
or
DECREASE CSF
how to prevent spinal cord injury
limit cross clamp time to ____ min
30 min
spinal cord injury
prevention:
drains (best option)
30 min or less
shunt (retrograde flow)
HTN
methylprednisone
HYPOthermia
AVOID hyperglycemia
mannitol
what temp do you want patient for reduced spinal cord injury
30-32 C
signs of spinal cord injury
(2)
motor function loss
pinprick sensation loss
preserved: vibration and proprioception
DURING the cross-clamp ______________ ALKALOSIS
central/proximal portion
RESPIRATORY
distal
DURING the cross-clamp ______________ ACIDOSIS
DISTAL/periphery portion
metabolic
cross-clamp
__________ total body O2 extraction
decreased
cross-clamp
___________ SvO2*
INCREASED
cross-clamp
____________ catecholamines
INCREASED
NTG (nitroglycerin) reduces __________ *
preload/venous
effects O2 consumption (improves supply/demand)
Nipride reduces ___________*
afterload
potentially improve CO
DURING cross-clamp, keep them _______volemic
normo (goal directed)
DURING cross-clamp, ___________ mV
DECREASE (due to ETCO2 being lower)
Milrinone decreases ___________*
afterload
DURING cross-clamp, you want the patient _____thermic
hypo
AFTER/RELEASE of cross-clamping
DECREASED:
afterload/SVR
MAP
preload
wedge (PCWP)
pH
temp
AFTER/RELEASE of cross-clamping
what can increase, have no change, or decrease?
CO
dependent on LV
AFTER/RELEASE of cross-clamping
INCREASED
ETCO2
after unclamping, hypotension shock syndrome can involve myocardial ____________ factors
depressant
decreased myocardial contractility
what can happen to the lungs AFTER cross-clamp
pulm edema
(increased permeability, mediator washout)
Wedge (PCWP) should be ____________ by ___-___ mmHg from PRECLAMP values
INCREASED by 3-4 above PRE-clamp values
this is to help with hypotension
AFTER release of cross-clamp
intraop interventions:
Increase Mv
use bair hugger
decrease anesthesia/vasodilation
increase fluids
consider mannitol
bicarb
what is a big challenge with cross-clamp release
fluid management
potential for blood loss
cross-clamp AFTER
maintain UOP ___ml/kg/hr*
1
goal-directed
what is the best prevention of renal failure
preventing hypovolemia
___-___ min PRIORRRRR to cross-clamp, give mannitol ____GM/kg
20-30 PRIOR
0.5*** gm/kg
dopamine for cross-clamp dose
___-___ mCg/kg/min
3-5 mCg/kg/min
use ________-sided aline for DESCENDING THORACIC
RIGHT=descending
PA cath looks at the _____ side
LEFT
best leads for EKG
II, V5
which congenital disorder has “no chin” or micrognathia
pierre robin (most difficult intubation)
what is the best type of anesthesia for AAA
combined! general + regional
regional for AAA requires ______-______ml MORE IV FLUID
1600-2000ml more
what are the 3 high risk AAA
they will need ventilation/intubation postop!
1) ascending aorta
2) aortic arch
3) thoracic aorta
who is more at risk for RUPTURED AAA
older
women
non-white
comorbidities (CHF, renal failure, valve disease)
insurance status
what is the best fluid (to get volume in fast) for RUPTURED AAA
crystalloids
what 2 vascular repairs require CPB (cardiopulm bypass)
ascending aorta
aortic arch
use ______sided aline for ASCENDING aorta
innonminate (brachiocephalic artery) clamped
LEFT=ascending
avoid ________cardia with aortic regurgitation
bradycardia
we dont want it!
due to the slow diastolic time
aortic arch repair: use hypothermia ___-___ C
15-18 C
protects brain
true or false
DESCENDING thoracic surgery does NOT use CPB
true
true or false
DESCENDING thoracic has GREATERRR risk/effects of cross-clamp, ischemia, renal insufficiency
compared to abdominal (AAA)
true
____________ thoracic requires ONE LUNG ventilation (double-lumen tube)
descending
mesenteric traction syndrome
high concentrations of ____
symptoms (4)
F1a (prostaglandin)
decreased BP/SVR
tachy
increased CO
facial flushing
peripheral vascular disease
what is the best anesthesia option
regional (sympathectomy allows for better perfusion)
- What is the most significant factor predicting postop stroke incidence
PREop neuro dysfunction
CEA
PERIoperative strokes
___% in asymptomatic patients
___% in symptomatic patients (TIAs)
___% in existing strokes
3% in asymptomatic patients
5% in symptomatic patients (TIAs)
10% in existing strokes
CEA
OR mortality
___-___%
0.5-2.5%
what is mortality for CEA patients due to
myocardial infarction
increased risks CEA (6)
o Age >75
o Symptomatic lesions
o Uncontrolled HTN
o Angina
o Carotid thrombus
o Occlusions near the CAROTID SIPHON
you want _____tension for patients who are getting a CEA intraop
HTN! (for perfusion)
neo
cerebral protection for CEA drugs (3)
barbiturates
propofol
dex
passive HYPOthermia!
HTN shifts autoregulation to the _______
RIGHT (higher)
CPP =
MAP - ICP
gold standard monitoring for CEA
awake
EEG
indicator of neuro dysfunction:
loss of ____ wave activity
emergence of _____ wave
loss of BETA
emergence of SLOW
loss of amplitude
carotid stump pressure
< ___ needs a shunt!
< 50 mmHg
inhalational agents at >___ MAC interfere with assessment of EEG/SSEP
> 1 MAC avoid this
best anesthetic choice for CEA
there is no difference in outcome!
CEA
carotid sinus _______________ causes HYPOtension
baroreceptor
CEA
drugs for HYPOtension (3)
LA
ephedrine
neo
CEA
carotid sinus _______________ causes HTN
(and decreased response to hypoxemia)
denervation
often, postop
CEA
while cross-clamp is ON, KEEP SBP >____
> 150
CEA
after cross-clamp is OFF, KEEP SBP <____
<140
CEA
postop, SBP >____ is associated with higher incidence of stroke or MI
> 180
EVAR is most beneficial for _____-risk patients*
HIGH
where is EVAR performed
IR
OR
EVAR 1
criteria
____cm
>___years old
5.5cm
> 60 years old
DREAM
for EVAR
criteria
___cm
5cm
EVAR
patient criteria
renal arteries should be >___cm away from TOP of aneurysm
> 1.5 cm
EVAR
patient criteria
aortic bifurcation should be >___cm away from DISTAL end of aneurysm
> 1 cm
EVAR
femoral artery should be able to handle introducer or at least ___ Mm diameter
withOUT tortuosity
8 Mm
EVAR
ACT >____ seconds
Heparin ___-___ units/kg
___fr sheath
> 300 seconds
50-100 units/kg
12 fr sheath
EVAR
PRIOR to graph attachment/balloon expansion, REDUCEEE
the SBP to ____ mmHg and MAP to ___mmHg during balloon inflation
SBP 100
MAP 60
during balloon inflation
EVAR
where is ischemia most likely to occur
distal (check peripheral pulses)
EVAR
Persistence of blood flow outside the graft; or between the graft and the aneurysmic vessel wall
biggest complication*
endoleak
EVAR
endoleak
inadequate seal
Type __
Type 1
EVAR
endoleak
retrograde flow
Type __
Type 2
EVAR
endoleak
tear or defect, leak
Type __
Type 3
EVAR
endoleak
porous graft flow
Type __
Type 4
EVAR
you want normothermia, normotensive except when
inflating balloon (then reduce it)
EVAR
kidney damage is due to
contrast
(it is NOT a perfusion issue)
EVAR
_____ is CONTRAindicated with pulm comorbidities
GA
EVAR
what is the ONLY difference between GA and regional outcomes
length of hospital stay
longer for GA
parkland, how do you split up the fluid in 1st 24 hours
1/2 in the first 8 hours
1/2 in the last 16 hours
parkland
2nd 24 hours, what do you do
D5W at maintenance rate with colloid 0.5 mL/% TBSA/kg
avoid _________________ with CF
glycopyrollate
LOUSY LV = decreased CO =
decreased coronary flow, decreased heart contractility
cross-clamp = GOOD LV = increased CO =
increased coronary flow, increased heart contractility
cross clamp = ____________ venous capacitance
DECREASED
Pulm vascular resistance goes ____ when UNclamping
goes UP
CROSS CLAMP: ABG
respiratory ALKAlosis
AFTER cross clamp: ABG
metabolic acidosis
