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principles 3 > exam 2 > Flashcards

exam 2 Flashcards

1
Q

Rate
Rhythm
Presence of ischemic changes
Chamber enlargement
Conduction blocks

A

12-lead EKG

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2
Q

Good to give you a baseline
Cardiac, mediastinal, aortic silhouette
Pulm effusion, pulm congestion, PTX
Evidence of implantation/previous surgical marks

A

chest x-ray

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3
Q

4 valves: stenosis and regurgitation

Systolic function: graded EF and presence of any regional wall motion abnormalities (RWMA)

Presence of effusions, air, thrombus, vegetation, or anatomical abnormalities (i.e., PFO/ASD, etc.)

A

echo

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4
Q

SCREENING test

performance summary including:
EF

EKG or uptake abnormalities

Failure criteria

Regional perfusion distribution

A

stress test

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5
Q

DIAGNOSIS test

CO measurement

Specific vessel findings and severity

EF estimate

A

heart cath

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6
Q

aortic stenosis:

the higher the gradient, the _______ the disease

A

worse

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7
Q

forced air warmer should especially be used for

A

OFF pump cases

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8
Q

____________ changes temp first*

A

esophageal

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9
Q

represents CORE temp

A

bladder temp

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10
Q

closer to the great vessels

A

esophageal

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11
Q

what is the best representation of TISSUE temperature

best option

A

bladder

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12
Q

looking at blood flow to the brain

A

cerebral ox

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13
Q

looking at awareness, better choice

A

BIS

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14
Q

CO monitoring is by what

A

arterial line
or
PA catheter

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15
Q

iSTAT, TEG monitors = 4 things

A

ACT, ABGs, lytes, blood count

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16
Q

3 labs needed

A

ABG
ACT
Hct

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17
Q

6 drugs required for induction

A

versed
fentanyl
etomidate
Sch (anectine)
non-depolarizer
lidocaine

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18
Q

key reason heparin is used in heart surgery

A

prevent blood clotting in the bypass machine

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19
Q

true or false

inadvertant administration of protamine can be FATAL

do NOT pre-prepare protamine

A

true

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20
Q

true or false

IV drips AND syringes should be primed and ready

A

true

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21
Q

beta agonist

A

epi

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22
Q

alpha agonist

A

neo

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23
Q

arterial/venous dilator

A

nitroglycerin

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24
Q

a coronary patient who has IHD is hypotensive, the best drug to improve BP

A

neo
(alpha agonist)

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25
Q

6 drugs to have IV push

A

neo
CaCl
nitro
epi
ephedrine
norepi

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26
Q

true or false

antibiotics are facility specific

A

true

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27
Q

most used antibiotic

A

cephalosporin

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28
Q

best antibiotic for implant/valve

A

vancomycin

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29
Q

4 types of pacemakers

A

esophageal

PA cath

transcutaneous

epicardial

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30
Q

When in close proximity to the heart it creates a stimuli

A

esophageal

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31
Q

Generally not done, external pads sometimes in case they need to be defibrillated

A

transcutaneous

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32
Q

Goes directly on the heart, conducting tool

A

epicardial

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33
Q

what is doppler used for

A

Making sure there is flow through bypass graft

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34
Q

what 2 tests for blood should be done

A

Type and screen, type and cross

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35
Q

Choice of agent to use depends on

A

Availability

Comfort level of the clinician

Side effects

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36
Q

To select the best drug for the specific clinical scenario, must know

A

o Class
o MOA
o Side effects
o Clinical use
o Dose

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37
Q

only drug that provides phosphodiesterase inhibition

A

milrinone

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38
Q

indirect beta (2 drugs)

A

dopamine

ephedrine

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39
Q

epi

low dose=

high dose=

A

low dose = beta

high dose = beta + alpha

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40
Q

epi:
avoid for ____

A

SVR

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41
Q

chronotropy

A

HR

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42
Q

inotropy

A

EF

contractility

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43
Q

dromotropy

A

conduction

(good for HB to SR)

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44
Q

3 components of BP
(think of triangle)

A

HR
SV
SVR

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45
Q

SV is influenced by _________ + ____________

A

preload + contractility

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46
Q

contractility:

regional issues =

A

regional = ischemia/poor blood flow

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47
Q

contractility:

global issues =

A

global = beta blocker, excess agent, hypoxia, acidosis

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48
Q

LAD supplies the
_______ +________ wall

A

septal + anterior wall

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49
Q

How do you determine which parameter is at fault (the cause) to choose the correct drug

A

TEE
Best determinant of the SV end of the equation

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50
Q

Choice of therapy should address the ___________ factor

A

causative

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51
Q

reason the SV may be high in these cases of low SVR

A

such little resistance (afterload) may cause the heart to eject slightly more than normal

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52
Q

Reserve minimum of ___ PRBCs for the patient

A

2

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53
Q

with cell saver, it is just PRBCs, you may need ________ + _____

A

plasma + PLTs

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54
Q

true or false

you can have a normal Hct but still need FFP

A

true

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55
Q

For each 2.5-3 liters of blood loss, __ liter of red cells are returned

A

1

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56
Q

with blood loss:
you get __/__ of it back

A

1/3

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57
Q

heparin pontentiates (increases) the action of the endogenous _____________ ____

A

antithrombin III

it increases this

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58
Q

antithrombin III increases __________ 1000x

A

thrombin

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59
Q

dose of heparin

A

300 units/kg

generally 30ml

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60
Q

target ACT

A

> or = 400

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61
Q

if ACT does NOT increase, what should you consider

A

heparin resistance (additional dosing provided)

deficiency of ATIII

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62
Q

deficiency of ATIII

what is the treatment

A

more heparin
or
FFP + then heparin
or
synthetic ATIII + then heparin

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63
Q

heparin induced thrombocytopenia

true or false

do NOT have heparin anywhere near them (remove from supply area)

A

true

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64
Q

when is protamine given

A

when CPB is completely disengaged

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65
Q

dose for protamine

A

1mg for every 100 units

example: 30,000 units of heparin = 300mg protamine

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66
Q

where and how should protamine be given

A

central line or PIV

give SLOW

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67
Q

MOA of protamine

A

electrostatic binding/inactivation of heparin

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68
Q

what does Amicar do

A

helps prevent clot breakdown

(keeps clots; stops bleeding)

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69
Q

ANTI-fibrinolytic agents
2 drugs

A

Amicar

TXA

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70
Q

what does ANTI fibrinolytic do

A

helps prevent clot breakdown (keeps clots)

stops excess bleeding

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71
Q

true or false

TXA does NOTTT effect ACT

A

true

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72
Q

when should TXA be given

A

AFTER therapeutic ACT has been achieved
(to avoid heparin interference)

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73
Q

SVR = (_____ -_____) / ____ x 80

A

(MAP-CVP) / CO x 80

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74
Q

CO = ____ x ____

A

HR x SV

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75
Q

EF = (_____-____) /____ x100

A

(EDV-ESV) / EDV x100

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76
Q

CARDIAC Perfusion Pressure (CPP) = _____ -_______

A

CPP = DBP - LVEDP

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77
Q

CARDIAC perfusion pressure (CPP)

A

Pressure in the coronaries (DBP) – the pressure that remains inside the LV during rest (LVEDP)

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78
Q

CVP range

A

5-10

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79
Q

PAP range
___-___ / ___-___

A

15-30 / 5-10

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80
Q

SVR range

A

700-1600 DYNES

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81
Q

CI range

A

2-4
L / min / m2

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82
Q

3 factors that contribute to myocardial oxygen DEMAND

A

1) wall stress
2) HR
3) contractility

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83
Q

4 factors that contribute to myocardial oxygen SUPPLY

A

1) coronary blood flow (PRIMARY FOCUS)

2) O2 content of perfusing blood

3) Oxyhemoglobin dissociation curve

4) O2 extraction

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84
Q

What is the most vulnerable section of the heart muscle

A

SUB-endocardium of LV

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85
Q

why is sub-endocardium LV considered most vulnerable

A

do NOT result in the classic ST elevation that most clinicians monitor for

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86
Q

for coronary disease, what are the 5 main guidelines for supply + demand

A

1) keep the heart “unloaded” (DECREASE preload)

2) MAINTAIN afterload to ensure CPP

3) DECREASE contractility (beta blocker)

4) DECREASE/minimize HR (beta blocker)

5) maintain adequate blood O2 (Hct and FiO2)

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87
Q

what is Sanford’s preference for starting vascular access

A

induction followed by line placement

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88
Q

what is the best option for vascular access

A

aline PRIOR to induction, then all the others AFTER

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89
Q

what is best technique for induction

amnesia =
pain/analgesia =
ongoing amnesia =
muscle relaxant

A

balanced!

amnesia = benzo

pain/analgesia = fentanyl

ongoing amnesia =
inhalational agent

muscle relaxant

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90
Q

etomidate risk

A

adrenal suppression/exhaustion

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91
Q

ketamine risk

A

CAD

(increases HR + SV)
AVOID in large doses

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92
Q

propofol risk

A

myocardial depression

AVOID in critical patients

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93
Q

most important thing to understand about induction

A

make it SMOOTH (no coughing/bucking) AND QUICK

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94
Q

2 indications for RSI

A

full stomach

TEE

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95
Q

7 things that affect metabolism of muscle relaxants

A

temp
pH
organ perfusion
renal output

Vd, rewarming, circulatory arrest

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96
Q

2 major times that redosing may be needed

A

sternotomy

re-warming

on bypass(?) Vd is greater

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97
Q

aline

what is an issue with optimum/fluctuating scale

A

keeps the wave screen full no matter the pressure
(can be deceiving)

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98
Q

radial artery site

when is it FALSELY LOW
(2 times)

A

cold

vasopressors

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99
Q

radial artery site can be FALSELY LOW by ___-___ points

A

10-30 points

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100
Q

true or false

when on NO pressors + being rewarmed, radial artery site will correlate with other arterial sites

A

true

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101
Q

___-sided alines are preferred

A

L-sided

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102
Q

best place for CVL

A

R IJ

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103
Q

true or false

cerebral oximetry and BIS have NO specific established guidelines regarding usage

A

true

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104
Q

what demonstrates tissue perfusion

A

cerebral ox

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105
Q

body is < ____C following bypass

A

< 34C

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106
Q

What is the primary means of cooling and warming

A

CPB

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107
Q

What patients can the BLADDER temp read a false/inaccurate number?

A

oliguric patients

(dialysis, systemic hypovolemia, decreased renal flow)

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108
Q

what kind of temp monitoring should be used for oliguric patients

A

RECTAL temp is the best

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109
Q

best device

A

TEE
(transesophageal echocardiogram)

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110
Q

2 primary assessments of TEE

A

1) volume
2) contractility

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111
Q

specified area is pumping less than normal

A

hypokinesis

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112
Q

specified area is NOT pumping

A

akinesis

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113
Q

specified area is moving in the opposite direction of normal

A

dyskinesis

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114
Q

pulm artery catheter is placed into ___-sided circulation

A

R-sided

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115
Q

PAC assesses ___+___ heart function

A

BOTH R+L

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116
Q

things PAC does

A

volume status
CO
initiates pacing
pulm function

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117
Q

withdraw ____ catheter PRIORRRRR to bypass by ___-___ cm

A

withdraw PA catheter PRIOR by 3-5cm

(As patients heart collapses during CPB, the swan can further advance, this can result in pulm infarction)

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118
Q

patients with ___BBB can get a complete heart block!

A

L

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119
Q

3 keys to success with cardiac patients

A

vigilance

understanding of supply/demand

drug proficiency

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120
Q

size ETT (use larger!!)
male
female

A

male= 8-8.5
female = 7.5-8

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121
Q

Vt range

A

6-8 ml/kg

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122
Q

3 ways to “stay ahead” respiratory system

A

1) alveolar recruitment maneuver

2) PEEP

3) mild HYPOcapnia

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123
Q

AVOID ______carbia
(it causes systemic acidosis)

A

hypercarbia

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124
Q

once the lungs are deflated, periodic _____ should be given, especially ________ seperating from bypass

A

ARM should be given

BEFORE sepating from bypass

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125
Q

______ sedation is required during sternotomy

A

deep

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126
Q

APL valve should be _____ turned to ___ during sternotomy (to deflate)

A

OPEN (0)

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127
Q

which mammary artery is most commonly used

A

L

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128
Q

________ Vt during dissection to remain free of surgical field

A

decrease

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129
Q

___ arterial line may be dampened if retractor for IMA compresses the subclavian artery

A

L

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130
Q

CONTRAindication for IMA

A

subclavian stenosis

(since the origin of IMA is the subclavian artery)

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131
Q

3 most common grafting vessels

A

internal mammary artery (IMA)

saphenous vein

radial artery

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132
Q

most common grafting site

A

saphenous vein

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133
Q

which arm is used for HARVESTING

A

non-dominant

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134
Q

which arm is used for aline placement and MONITORING

A

dominant

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135
Q

________ infusion will be started post bypass

A

cardizem

(helps to avoid spasm of radial artery)

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136
Q

ACT is obtained ___-___ min after heparin administration

A

3-5 min

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137
Q

during cannulation

NO MORE THAN < ___-___ SBP

A

90-100 SBP

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138
Q

arterial cannula

______-luminal within the ___________ ______

A

intra-luminal
within ascending aorta

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139
Q

what 3 things can result in inability to deliver blood back to the patient

A

dissection
false lumen
improper placement

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140
Q

venous cannula

located in the

A

R atrial appendage/RA/IVC

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141
Q

improper placement of a venous cannula results in

A

venous engorgement

obstructive compartments (SVC syndrome)

risk of stroke/tissue damage

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142
Q

when the patient is placed on bypass, ventilation is _____________

A

discontinued

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143
Q

who manages hemodynamics during bypass period

A

perfusion/perfusionist

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144
Q

true or false

all infusions are D/C for bypass

A

true

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145
Q

why is the patient cooled

A

to reduce brain and body metabolism

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146
Q

what does the aortic cross clamp do

A

isolates coronary blood flow (not perfused)

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147
Q

what area is filled with cardioplegia

A

aortic root

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148
Q

where is aortic root located

A

between aortic valve + aortic cross clamp

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149
Q

what is the cardioplegia fluid

A

cold solution
high potassium (makes the heart stop beating)

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150
Q

what is the treatment if cardioplegia cannot be distributed to all the tissue

A

retrograde route

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151
Q

where is retrograde route catheter placed

A

coronary sinus

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152
Q

3 types of way to cool patient

A

1) topical ice slush
2) cardioplegia
3) systemic cooling (cold blood)

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153
Q

distal temp during CABG
___-___ C

A

10-15 C

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154
Q

as cardioplegia is washed away and heart is warmed, the heart _______ _______

A

heart starts itself

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155
Q

true or false

NO blood is yet moving through heart it via automaticity

A

true

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156
Q

3 drugs for hyperkalemia and reperfusion dysrhythmias

A

lidocaine

calcium

magnesium

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157
Q

when heart is beating slow, give

A

chronotrope

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158
Q

when heart is beating bad, give

A

inotrope

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159
Q

when heart is fine + BP is low, give

A

alpha agonist

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160
Q

true or false

you must MANUALLY reinflate the lungs following bypass

A

true

161
Q

true or false

use careful recruitment withOUT over-pressurizing to avoid damage to lungs

A

true

162
Q

bypass pump is ____________ clamped to allow flow into the heart

A

partially

163
Q

with bypass pump being gradually weaned, TEE monitoring should include

A

absence of intracardiac air

cardiac volume

contractility

valve evaluation

164
Q

when are cannulas removed

A

when heart is pumping well
+
re-initiation of bypass is NOT a threat

165
Q

after giving protamine, ACT should be

A

120

166
Q

where are chest tubes placed (2)

A

pleural
+
mediastinal

167
Q

during closure of sternum, lungs should be ____________ reinflated

A

MANUALLY

168
Q

while in the ICU, be able to

A

pacing (epicardial)

ventilation settings

lab values + CXR

vital signs

documentation/handoff

169
Q

extubation goal of __-__ hours

A

6-8 hours

170
Q

what does a short intubation time help with

A

shorter hospital stay

reduced cost

reduced infection

less complications

171
Q

extubation > ___ hours was considered prolonged/abnormal

A

> 24 hours

172
Q

how can you facilitate < 8 hour extubation

A

avoid postop NMBs

reverse NMBs

use short-acting narcotics and sedatives

173
Q

average pump prime volume

A

1500 ml

174
Q

reduce viscocity means

A

thinner

175
Q

why do we AVOID reducing viscosity

A

1) anemia
2) reduced O2 carrying

176
Q

true or false

arresting the heart allows surgical access, however, may NOT decrease O2 demand

A

true

177
Q

3 techniques to reduce O2 consumption

A

stopping the heart

cooling the heart

systemic cooling

178
Q

cardioplegia temp ___-___C

A

10-15 C

179
Q

systemic temp ___C

A

28 C

180
Q

antegrade =

A

aortic root
to myocardial tissue

181
Q

retrograde =

A

coronary sinus
to aortic root

182
Q

benefit retrograde prime

A

prevents 1500ml extra fluid

allows patient’s blood volume to backfill

183
Q

true or false

retrograde prime does NOT drop the Hct

A

true

184
Q

PRIOR to bypass, limit crystalloid to < __ L

A

< 1 L

185
Q

regurgitation GOAL

A

“fast, full, forward”

186
Q

what are 3 things important with STENOSIS

A

full preload

AVOID tachycardia

SVR/afterload CONTROL

187
Q

what are 3 things important for REGURGITATION

A

full preload

maintain HR

DECREASE afterload

“fast, full, forward”

188
Q

off-pump CABG

A

does NOT arrest the heart
does NOT go on cardiac bypass

189
Q

true or false

you MUST have an aline for offpump CABG

A

true

190
Q

true or false

off-pump CABG:
EKG and TEE may be INaccurate
(due to mechanical displacement of heart)

A

true

191
Q

OFF-pump CABG

2 treatments for stress of heart

A

1) fluid bolus
2) trendelenburg

(fills the heart)

192
Q

when is OFF-pump CABG indicated

A

single bypass cases
(IMA to LAD)

193
Q

OFF-pump CABG
ACT ____-____

A

300-400

194
Q

true or false

OFF PUMP CABG

there is NO CPB utility for rewarming

A

true

195
Q

true or false

stablization device is designed to facilitate a MOTIONLESS surgical site, withOUT arresting the heart

A

true

196
Q

what vessel is best choice for OFF-pump CABG

A

mammary artery (IMA)

197
Q

why is IMA a good choice for off-pump

A

does NOT require anastomosis (it has a native blood supply)

198
Q

advantages of off-pump

A

NO dilution, LESS capillary permeability, LESS renal, LESS inflammatory

199
Q

disadvantages of off-pump

A

risk of ischemia from stress (no “rest/relax”)

anesthesia provider must be more vigilant since there is no bypass interval

heart is tilted, so it can kink the SVC (reduces preload), can have tamponade effects

200
Q

3 indications for balloon pump (IABP)

A

ischemia

potential ischemia

poor CO

201
Q

3 CONTRAindications for balloon pump (IABP)

A

aortic disease

aortic valve disease

surgery on the aorta (surgical insult)

202
Q

balloon INflating =

A

diastole

203
Q

balloon DEflating =

A

just PRIOR to systole

204
Q

balloon inflating helps with what*

A

improves SUPPLY
improving oxygenation

205
Q

balloon deflating helps with what*

A

reduces DEMAND
less SVR, ejects easier

206
Q

balloon tip should be DISTAL to the ___ ___________ ________

A

L subclavian artery

207
Q

what is goal of IABP

A

improve CPP
reduce workload

208
Q

IABP

augmented ___________ pressure should exceed > UNASSISTED ________ pressure

A

DIASTOLIC > SYSTOLIC

209
Q

How would we improve CPP with drugs

A

neo (this is finite)

210
Q

what part of the body sees the boost in pressure

A

only PROXIMAL/ABOVE the balloon

211
Q

highest number for IABP

A

diastole/inflation

212
Q

the larger the gradient, the _____ you need the balloon

A

larger gradient =need it MORE

213
Q

impella is a _____

A

VAD (ventricular assistive device)

214
Q

3 indications for impella

A

acute MI

cardiogenic shock

post-bypass period

215
Q

true or false

an IMPELLA would keep the patient alive if the heart stopped

(you could maintain CO)

A

true

216
Q

where does an IMPELLA reside

A

LV

217
Q

why is epi used (3)

A

1) chronotropic (HR)
2) inotropic/contractility (EF)
3) dromotropic (conduction)

218
Q

what is cell saver

A

PRBCs only

219
Q

similar to a VAD

A

tandem heart

220
Q

When cardiac bypass fails, use this!

A

tandem heart

221
Q

Device can function simply as a pump or with the aid of an oxygenator as ECMO

A

tandem heart

222
Q

best option to view awareness

A

BIS monitor

223
Q

true or false

TAVR
native valve STAYS in place

A

true

224
Q

1 indication for TAVR

A

severe aortic STENOSIS

225
Q

cerebral ox tells us what

A

FLOW

226
Q

trans-_______ (of the LV)

distal aortic route (femoral route)

A

TAVR

trans-apical

227
Q

TAVR

once the valve is positioned inside the native valve, _______ _____________ __________ is initiated to MINIMALIZE CO

A

rapid ventricular pacing

228
Q

true or false

MAC and GA can both be used for TAVR
(NO difference in outcomes)

A

true

229
Q

true or false
TAVR is HIGH risk

A

true

calcium buildup
balloon over/underinflation

230
Q

1 reason for retrograde*

A

presence of CAD

231
Q

L heart cath monitors __________

A

pressure

232
Q

what is the primary substrate of metabolism in the brain*

A

glucose

233
Q

_______glycemia WORSENS hypoxic injury

A

HYPOglycemia

234
Q

adult human brain weighs ______-______ grams

A

1300-1400

235
Q

_____-_____ml of blood flow per MINUTE

A

650-700 ml

236
Q

____% total CO = brain

A

14%

237
Q

the BRAIN ITSELF can increase blood flow to as much as ____-____% CO

A

15-20%

238
Q

Cerebral blood flow AVERAGE
____ml/_____grams/min

A

50ml
/100gm/min

239
Q

Cerebral blood flow SLOWING of EEG
____ml/_____grams/min

A

25ml
/100gm/min

240
Q

Cerebral blood flow ISOELECTRIC EEG
____ml/_____grams/min

A

15-20ml
/100gm/min

241
Q

Cerebral blood flow IRREVERIBLE INJURY
____ml/_____grams/min

A

<10 ml
/100gm/min

242
Q

_____________ + ___________ = more sensitive to hypoxic brain injury than other parts of the brain

A

Hippocampus + cerebellum

243
Q

CEREBRAL perfusion pressure = _____-_____ or _____

A

MAP - ICP or CVP,
whichever is HIGHER

244
Q

CEREBRAL perfusion pressure =

A

MAP

245
Q

CEREBRAL perfusion pressure (CPP)
< ____ torr = EEG changes, autoregulation diminished

A

< 50 torr

246
Q

CEREBRAL perfusion pressure (CPP)
< ____ torr = irreversible injury

A

< 25 torr

247
Q

autoregulation occurs at MAP 50-150 _____

A

torr

248
Q

*when Vm (minute ventilation) DOUBLES,

_____ DECREASES by 1/2

A

CBF

249
Q

CBF increases ___-___% for every 1 C temp

A

5-7%

250
Q

volatile anesthetics have uncoupling > ___-___ MAC

A

> 1-1.5 MAC

251
Q

luxury perfusion

_____ > _______

A

CBF > CMRO2

252
Q

__________ can be neuroprotective at high doses

A

volatiles

(they decrease CMRO2)

253
Q

____ anesthetics PRESERVE coupling

A

IV

reduced CMRO2
decrease CBF (vasoconstrict)

254
Q

what 2 drugs INCREASE CMRO2
and ICP + CBF

A

nitrous

Sch

255
Q

what drug INCREASES ICP + CBF only

A

ketamine

256
Q

propofol is isoelectric EEG at ____mcg/kg/min

A

500

257
Q

what drug can cause seizures in patients with seizure history

A

etomidate

258
Q

what drug has a metabolite that can cause seizures

A

Demerol (normeperidine)

259
Q

CONTRAindication for benzos

A

patients with increased ICP,

due to RESPIRATORY DEPRESSION (leads to rise in CO2)

260
Q

ketamine increases ICP
> ___%

A

> 80%

261
Q

CONTRAindications to Sch (3)

A

denervated muscle

CVA

motor neuron lesion

262
Q

**____________ drugs, such as __________, cause an INCREASE in dose requirements for NON-depolarizers

A

anticonvulsant drugs, such as dilantin

263
Q

NON-expandable “closed box”

1) Brain tissue (___%)
2) Blood (___%)
3) CSF (__%)

A

1) Brain tissue (80%)
2) Blood (12%)
3) CSF (8%)

264
Q

true or false

brain tissue has almost NO nociceptive (pain) nerve tissue

A

true

265
Q

*Cushing’s REFLEX (not triad)

A

INCREASING ICP =

HTN

bradycardia

266
Q

true or false

increase in ICP CAN damage brain

A

true

267
Q

what type of epi effects are prominent for neuro

A

beta 2

268
Q

goal is a “________” brain

A

relaxed

269
Q

_______ventilation
and
_______carbia

should be used for brain surgery

A

HYPERventilate

HYPOcarbia

270
Q

normal brain surgery, maintain Hct ____-____%

A

30-35%

271
Q

keep brain patients ______volemic

A

NORMO

272
Q

______ volume expansion helps reduce vasospasm

A

mild

273
Q

AVOID ________ and ____ fluids

limit __________ to 1-1.5 L

A

dextrose + LR

limit hetastarch

274
Q

true or false

it is MORE important to accomplish a SMOOTH induction rather than any particular drug combo

A

true

275
Q

keep patient ________tensive during neuro surgery

A

NORMOtensive

HTN = increased ICP/CBF
HoTN = ischemia, decreased CPP

276
Q

maximize venous drainage

avoid excessive neck ________

A

avoid flexion

277
Q

keep HOB > ___

A

> 15**-30

278
Q

*when should neuro function/spontaneous breathing be intact?

A

PRIOR to skin closure, pin removal

otherwise, the removal of the noxious stimuli (pins) will lead to delay of return of spontaneous respirations

279
Q

what type of awakening should be used

A

rapid

(promotes neuro assessment)

280
Q

CPP

level of the _____________

A

external auditory meatus
+
tragus

281
Q

CPP has a ________ pressure than the heart

A

lower pressure

282
Q
  • 1 mmHg for every _____cm
A

1.25 cm

283
Q

CPP: avoid < ____

A

< 50

284
Q

4 types of intracranial mass lesions

A

1) congenital

2) neoplastic

3) inflammatory/infectious

4) vascular

285
Q

2 types of neoplastic lesions

A

benign

malignant

286
Q

2 types of inflammatory/infectious lesions

A

cyst

abcess

287
Q

2 types of vascular lesions

A

AVM
hematoma

288
Q

***when you suspect neuro insult to the brain, give ________

it prevents brain swelling!

A

steroids/decadron

289
Q

why are anticonvulsants metabolized fast

A

CP450

290
Q

mass lesions symptoms

A

headache
seizures
reduction in cognitive/neuro
focal neuro deficits

291
Q

for mass lesions, you want to AVOID _______ benzos/opioids

A

PREOP

292
Q

elevated ICP symptoms (5)

A

headache
N/V
papilledema
focal neuro deficits
AMS

293
Q

poor outcome after ischemic events (AVOID)

____________ blood glucose
____________ brain temp

A

avoid
increased blood glucose
increased brain temp (avoid warmers)

294
Q

where are majority of masses
_______tentorial

__________ fossa surgery

A

SUPRAtentorial

ANTERIOR fossa surgery

295
Q

4 common symptoms of SUPRAtentorial

A

headache
seizures
hemiplegia
aphasia

“HSHA”

296
Q

2 symptoms of INFRAtentorial

A

cerebella dysfunction
-ataxia, nystagmus

brain stem compression
-altered mental status, altered respirations

297
Q

slow growing lesions are

A

usually Asymptomatic

298
Q

fast growing lesions

A

acute neuro deficits

299
Q

what would be affected by altered respirations/mental status

A

INFRAtentorial
POSTERIOR fossa surgery

300
Q

RAS, ANS, some cranial nerves

circulatory/respiratory centers

A

POSTERIOR fossa surgery

301
Q

how can we monitor damage to respiratory center during posterior fossa surgery

A

spontaneous ventilation

302
Q

VAE can occur when

wound is _______ heart

A

ABOVE

303
Q

highest incidence of VAE

A

sitting craniotomy

304
Q

symptoms of VAE (5)

A

decreased/flat ETCO2

decreased O2

sudden HYPOtension

circulatory arrest

ET nitrogen absorption

305
Q

*most sensitive NON-invasive monitor

A

precordial DOPPLER

mill-wheel roaring sound

306
Q

*most sensitive INVASIVE monitor

A

TEE
transesophageal echo

0.25 ml air detected

307
Q

treatment for VAE (2)

A

wax+saline

L LATERAL DOWN/DECUBITUS position

308
Q

what is a PARADOXICAL air embolism

A

air entering SYSTEMIC circulation

309
Q

3 types of defects that can cause paradoxical air embolism

A

PFO

atrial

ventricular septal

310
Q

What is the leading cause of subarachnoid non-traumatic hemorrhage

A

sacular aneurysm rupture

311
Q

2 risk factors for CEREBRAL ANEURYSM

A

age 55-60
female

312
Q

Where are majority of aneurysms (2)

A

Internal carotid bifurcation
+
ANTERIOR cerebral artery

313
Q

subarachnoid bleed symptoms (2)

A

intense headache (85%)

transient LOC with N/V

314
Q

avoid ______tension with cerebral aneurysm

A

AVOID HYPOtension

(we want perfusion!)

315
Q

true or false

cerebral aneurysm

EKG changes are NON-ischemic, NON-cardiac in origin, with NO adverse outcome

A

true

316
Q

cerebral aneurysm

what is the major cause of mortality and morbidity

A

vasospasm

317
Q

cerebral aneurysm

surgical intervention with
> ___ mm

A

> 7 mm

clipping

318
Q

vasospasm

keep Hct < ___

A

< 32

319
Q

vasospasm

true or false

will need to correct the HYPOnatremia (due to the hemodilution)

A

true

320
Q

treatment for vasospasm

“Triple H”

A

HEMOdilution

HTN

HYPERvolemia

321
Q

vasospasm

2 drugs for treatment

A

inotropes

calcium channel blockers
(nimodipine, nicardipine)

322
Q

subdural hematoma

where does blood collect

A

between dura and arachnoid

323
Q

what kind of bleeding causes subdural hematoma

A

venous

324
Q

subdural hematoma

symptoms

A

headache, drowsiness, cognitive decline, obtunded

325
Q

subdural hematoma

treatment

A

craniotomy

burr holes

326
Q

subdural hematoma

______capnia is desired

A

NORMOcapnia

327
Q

AV malformation

_______cerebral hemorrhage

A

INTRAcerebral

328
Q

risk factor (1) for AV malformation

A

age 10-30
“little AV”

329
Q

AV Malformation
treatment (2)

A

1st neuroradiology treatment

2nd surgical resection
HYPERventilation + mannitol

330
Q

what surgery can have extensive blood loss

A

AV malformation

331
Q

hypersecretory tumors can cause
acromegaly (growth hormone) and hyperglycemia

this can lead to possible

A

difficult intubation

332
Q

pituitary surgery

types of resections

A

1) trans-phenoidal (MAJORITY)

2) intracranial

333
Q

pituitary surgery

ETT should be placed to the ___ side

A

L side

334
Q

pituitary surgery

**opposite of the other surgeries

use ______ventilation

________carbia

A

HYPOventilation

HYPERcarbia

you want a bulging/tight brain

335
Q

malformation where MEDULLA protrudes through foramen magnum

A

arnold-chiari malformation

336
Q

arnold-chiari
risk factor (1)

A

females

337
Q

Infratentorial masses can obstruct CSF at __th ventricle and lead to obstructive hydrocephalus

A

4th

338
Q

arnold-chiari

anesthesia implications

A

same as those for posterior fossa surgery

339
Q

head trauma

symptom: _____tension

A

HYPOtension

340
Q

true or false

head trauma
RSI is NOT best option
(due to cricoid pressure)

A

true

341
Q

head trauma

maintain CPP at ____-____

A

70-110

342
Q

head trauma

treatment

A

robinul (for enhanced vagal tone)

AVOID peep until AFTER dura is opened

leave intubated/paralyzed

343
Q

true or false

ortho patients have more positioning challenges than any other surgery

A

true

344
Q

ortho

best positions

A

supine

sitting lateral decubitus

prone

345
Q

ortho

Excellent advantages, but can be UNreliable

Used more for UPPER extremity surgery

A

regional

346
Q

Rheumatoid Arthritis

Immune related, ___________ inflammation of synovial joints

A

progressive

347
Q

rheumatoid arthritis

Atlantoaxial subluxation:

C-spine films to evaluate + determine if awake fiberoptic intubation is indicated = > ___mm = instability

A

> 5mm

348
Q

true or false

it is OKAY to use LMA with lateral positioning (shoulder surgery)

A

true

349
Q

shoulder surgery

we want _____tension

A

HYPOtension is good!

350
Q

arthroscopic surgery

keep BP _____

irrigation fluid ___-___ mmHg

A

BP should be LOW

irrigation fluid 60-80 mmHg

351
Q

TMJ dysfunction can lead to

A

limited jaw opening

352
Q

Atlantoaxial instability can lead to

A

limited neck ROM

353
Q

which surgery should you check distal pulses

A

CERVICAL spine

(use ear probe oximeter)

354
Q

CERVICAL spine surgery
true or false

coughing or bucking MUST be PREVENTED

A

true

355
Q

what is a risk with LUMBAR spine surgery

A

brachial plexus

arms/shoulders should be LESS THAN < 90

356
Q

LUMBAR spinal surgery

diaphragm has moved __________/________

decreases FRC + Vt

A

CEPHALAD/upward

357
Q

ortho

long procedure,
greater blood loss,
use cell saver and type/crossmatch

A

spinal fusion

358
Q

scoliosis have __________ lung disease

A

restrictive

359
Q

anterior/posterior approach

Neuromuscular monitoring is indicated, due to artery of _____________

A

adamkiewicz

360
Q

hip fracture

____________ arm is placed on chest

A

IPSI-lateral

361
Q

hip FRACTURE

_________ position

A

supine

362
Q

hip REPLACEMENT

_______ __________ position allows for greater ROM

A

lateral decubitus

363
Q

**Bilateral hip surgery is CONTRAindicated if declining pulm function occurs after ___ hip surgery (O2 sat drops 94ish)

A

1st

364
Q

ortho

what surgery has high incidence of DVT

A

knee replacement

more distal = higher risk

365
Q

knee replacement

regional:
femoral 3-in-1

A

LFC, obturator, femoral

366
Q

true or false

knee surgery is MORE painful

A

true

367
Q

Very short procedures
“popping” back into place

short-acting paralysis + propofol

A

closed reduction

368
Q

Used to bind prosthetic to bone

Exothermic reaction occurs
-Hardens cement and expands
-Lysis of blood cells and marrow

A

Methylmethacrylate Cement

369
Q

Embolization of air, fat, marrow, cement

A

intermedullary HTN

370
Q

Systemic absorption of cement
leads to

A

decreased SVR (HYPOtension, vasoDILATION)

371
Q

release of tissue thromboplastin,
platelet aggregation, microemboli formation

A

hammering

372
Q

Bone Cement Implantation Syndrome

(migration to pulm system)

A

HYPOtension
Hypoxia
Reduced CO
Dysrhythmias
Shunt
Pulm HTN

373
Q

treatment for Bone Cement Implantation Syndrome (2)

A

increase FiO2

adequate hydration

374
Q

exsanguination

cuff should overlap ____º from nerve bundle

A

180 degrees

375
Q

____ torr over SBP = LOWER extremity

A

100 torr

376
Q

____ torr over SBP = UPPER extremity

A

50

377
Q

tourniquet

neuro damage may occur if >___ hrs or if over nerve bundle

A

> 2 hours

378
Q

Pneumatic Tourniquet

physiologic effects
INFLATION

A

INCREASE in SVR, CVP, PVR

displaced/added blood volume (300-500ml)

379
Q

treatment for “tourniquet pain”

A

opioids added to LA

deflation (10-15 min)

380
Q

Pneumatic Tourniquet

physiologic effects
DEFLATION

A

metabolic acidosis

tachycardia

HYPOthermia

HYPOtension (most common)

381
Q

why does HYPOtension occur with deflation

A

sudden reduction of SVR/PVR

washout of ischemic metabolites (thromboxane)

382
Q

when does tourniquet pain occur

A

after 1 hour

383
Q

DVT, PE, VAE common

A

long bone fractures
(especially hip + knee)

384
Q

___________ anesthesia REDUCES risk of DVT

A

regional
(epidural/spinal)

385
Q

why does regional technique reduce risk of DVT

A

Higher levels of plasminogen + plasminogen activators

HYPERkinetic blood flow

386
Q

**Fat Embolism Syndrome/Triad

A

1) petachaie (axillary/subconjuctival)

2) dyspnea

3) confusion, mental changes

387
Q

**Fat Embolism Syndrome/Triad

occurs ___-___ hours later

A

12-24 hours

388
Q

other symptoms with fat embolism

A

tachycardia (ST segment changes)

fat in urine, sputum, conjuctiva

389
Q

risk factor for PULMONARY fat embolism

A

lung disease

390
Q

treatment for fat embolism (4)

A

O2
fluids
steroids
aggresive ventilation!

391
Q

ortho postop pain management

best option

A

multimodal + regional

(NSAIDs + opioids + regional)

392
Q

VAE

large air bubbles can lead to INCREASED ___ afterload and decreased ___

A

INCREASED RV
decreased CO

393
Q

true or false

pituitary is RARELY metastatic

20-50% are NON-secretory

A

true

394
Q

shoulder surgery

VAE is possible with

A

beach chair position

395
Q

shoulder surgery

what type of block

A

interscalene

396
Q

how can you avoid airway swelling

A

steroids

397
Q

*what is most common with deflation of tourniquet

A

hypotension

398
Q

pinprick tingling

A

A-delta

399
Q

dull aching pain

A

C

principles 3 (4 decks)

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