exam 2 Flashcards
Rate
Rhythm
Presence of ischemic changes
Chamber enlargement
Conduction blocks
12-lead EKG
Good to give you a baseline
Cardiac, mediastinal, aortic silhouette
Pulm effusion, pulm congestion, PTX
Evidence of implantation/previous surgical marks
chest x-ray
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.)
echo
SCREENING test
performance summary including:
EF
EKG or uptake abnormalities
Failure criteria
Regional perfusion distribution
stress test
DIAGNOSIS test
CO measurement
Specific vessel findings and severity
EF estimate
heart cath
aortic stenosis:
the higher the gradient, the _______ the disease
worse
forced air warmer should especially be used for
OFF pump cases
____________ changes temp first*
esophageal
represents CORE temp
bladder temp
closer to the great vessels
esophageal
what is the best representation of TISSUE temperature
best option
bladder
looking at blood flow to the brain
cerebral ox
looking at awareness, better choice
BIS
CO monitoring is by what
arterial line
or
PA catheter
iSTAT, TEG monitors = 4 things
ACT, ABGs, lytes, blood count
3 labs needed
ABG
ACT
Hct
6 drugs required for induction
versed
fentanyl
etomidate
Sch (anectine)
non-depolarizer
lidocaine
key reason heparin is used in heart surgery
prevent blood clotting in the bypass machine
true or false
inadvertant administration of protamine can be FATAL
do NOT pre-prepare protamine
true
true or false
IV drips AND syringes should be primed and ready
true
beta agonist
epi
alpha agonist
neo
arterial/venous dilator
nitroglycerin
a coronary patient who has IHD is hypotensive, the best drug to improve BP
neo
(alpha agonist)
6 drugs to have IV push
neo
CaCl
nitro
epi
ephedrine
norepi
true or false
antibiotics are facility specific
true
most used antibiotic
cephalosporin
best antibiotic for implant/valve
vancomycin
4 types of pacemakers
esophageal
PA cath
transcutaneous
epicardial
When in close proximity to the heart it creates a stimuli
esophageal
Generally not done, external pads sometimes in case they need to be defibrillated
transcutaneous
Goes directly on the heart, conducting tool
epicardial
what is doppler used for
Making sure there is flow through bypass graft
what 2 tests for blood should be done
Type and screen, type and cross
Choice of agent to use depends on
Availability
Comfort level of the clinician
Side effects
To select the best drug for the specific clinical scenario, must know
o Class
o MOA
o Side effects
o Clinical use
o Dose
only drug that provides phosphodiesterase inhibition
milrinone
indirect beta (2 drugs)
dopamine
ephedrine
epi
low dose=
high dose=
low dose = beta
high dose = beta + alpha
epi:
avoid for ____
SVR
chronotropy
HR
inotropy
EF
contractility
dromotropy
conduction
(good for HB to SR)
3 components of BP
(think of triangle)
HR
SV
SVR
SV is influenced by _________ + ____________
preload + contractility
contractility:
regional issues =
regional = ischemia/poor blood flow
contractility:
global issues =
global = beta blocker, excess agent, hypoxia, acidosis
LAD supplies the
_______ +________ wall
septal + anterior wall
How do you determine which parameter is at fault (the cause) to choose the correct drug
TEE
Best determinant of the SV end of the equation
Choice of therapy should address the ___________ factor
causative
reason the SV may be high in these cases of low SVR
such little resistance (afterload) may cause the heart to eject slightly more than normal
Reserve minimum of ___ PRBCs for the patient
2
with cell saver, it is just PRBCs, you may need ________ + _____
plasma + PLTs
true or false
you can have a normal Hct but still need FFP
true
For each 2.5-3 liters of blood loss, __ liter of red cells are returned
1
with blood loss:
you get __/__ of it back
1/3
heparin pontentiates (increases) the action of the endogenous _____________ ____
antithrombin III
it increases this
antithrombin III increases __________ 1000x
thrombin
dose of heparin
300 units/kg
generally 30ml
target ACT
> or = 400
if ACT does NOT increase, what should you consider
heparin resistance (additional dosing provided)
deficiency of ATIII
deficiency of ATIII
what is the treatment
more heparin
or
FFP + then heparin
or
synthetic ATIII + then heparin
heparin induced thrombocytopenia
true or false
do NOT have heparin anywhere near them (remove from supply area)
true
when is protamine given
when CPB is completely disengaged
dose for protamine
1mg for every 100 units
example: 30,000 units of heparin = 300mg protamine
where and how should protamine be given
central line or PIV
give SLOW
MOA of protamine
electrostatic binding/inactivation of heparin
what does Amicar do
helps prevent clot breakdown
(keeps clots; stops bleeding)
ANTI-fibrinolytic agents
2 drugs
Amicar
TXA
what does ANTI fibrinolytic do
helps prevent clot breakdown (keeps clots)
stops excess bleeding
true or false
TXA does NOTTT effect ACT
true
when should TXA be given
AFTER therapeutic ACT has been achieved
(to avoid heparin interference)
SVR = (_____ -_____) / ____ x 80
(MAP-CVP) / CO x 80
CO = ____ x ____
HR x SV
EF = (_____-____) /____ x100
(EDV-ESV) / EDV x100
CARDIAC Perfusion Pressure (CPP) = _____ -_______
CPP = DBP - LVEDP
CARDIAC perfusion pressure (CPP)
Pressure in the coronaries (DBP) – the pressure that remains inside the LV during rest (LVEDP)
CVP range
5-10
PAP range
___-___ / ___-___
15-30 / 5-10
SVR range
700-1600 DYNES
CI range
2-4
L / min / m2
3 factors that contribute to myocardial oxygen DEMAND
1) wall stress
2) HR
3) contractility
4 factors that contribute to myocardial oxygen SUPPLY
1) coronary blood flow (PRIMARY FOCUS)
2) O2 content of perfusing blood
3) Oxyhemoglobin dissociation curve
4) O2 extraction
What is the most vulnerable section of the heart muscle
SUB-endocardium of LV
why is sub-endocardium LV considered most vulnerable
do NOT result in the classic ST elevation that most clinicians monitor for
for coronary disease, what are the 5 main guidelines for supply + demand
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)
what is Sanford’s preference for starting vascular access
induction followed by line placement
what is the best option for vascular access
aline PRIOR to induction, then all the others AFTER
what is best technique for induction
amnesia =
pain/analgesia =
ongoing amnesia =
muscle relaxant
balanced!
amnesia = benzo
pain/analgesia = fentanyl
ongoing amnesia =
inhalational agent
muscle relaxant
etomidate risk
adrenal suppression/exhaustion
ketamine risk
CAD
(increases HR + SV)
AVOID in large doses
propofol risk
myocardial depression
AVOID in critical patients
most important thing to understand about induction
make it SMOOTH (no coughing/bucking) AND QUICK
2 indications for RSI
full stomach
TEE
7 things that affect metabolism of muscle relaxants
temp
pH
organ perfusion
renal output
Vd, rewarming, circulatory arrest
2 major times that redosing may be needed
sternotomy
re-warming
on bypass(?) Vd is greater
aline
what is an issue with optimum/fluctuating scale
keeps the wave screen full no matter the pressure
(can be deceiving)
radial artery site
when is it FALSELY LOW
(2 times)
cold
vasopressors
radial artery site can be FALSELY LOW by ___-___ points
10-30 points
true or false
when on NO pressors + being rewarmed, radial artery site will correlate with other arterial sites
true
___-sided alines are preferred
L-sided
best place for CVL
R IJ
true or false
cerebral oximetry and BIS have NO specific established guidelines regarding usage
true
what demonstrates tissue perfusion
cerebral ox
body is < ____C following bypass
< 34C
What is the primary means of cooling and warming
CPB
What patients can the BLADDER temp read a false/inaccurate number?
oliguric patients
(dialysis, systemic hypovolemia, decreased renal flow)
what kind of temp monitoring should be used for oliguric patients
RECTAL temp is the best
best device
TEE
(transesophageal echocardiogram)
2 primary assessments of TEE
1) volume
2) contractility
specified area is pumping less than normal
hypokinesis
specified area is NOT pumping
akinesis
specified area is moving in the opposite direction of normal
dyskinesis
pulm artery catheter is placed into ___-sided circulation
R-sided
PAC assesses ___+___ heart function
BOTH R+L
things PAC does
volume status
CO
initiates pacing
pulm function
withdraw ____ catheter PRIORRRRR to bypass by ___-___ cm
withdraw PA catheter PRIOR by 3-5cm
(As patients heart collapses during CPB, the swan can further advance, this can result in pulm infarction)
patients with ___BBB can get a complete heart block!
L
3 keys to success with cardiac patients
vigilance
understanding of supply/demand
drug proficiency
size ETT (use larger!!)
male
female
male= 8-8.5
female = 7.5-8
Vt range
6-8 ml/kg
3 ways to “stay ahead” respiratory system
1) alveolar recruitment maneuver
2) PEEP
3) mild HYPOcapnia
AVOID ______carbia
(it causes systemic acidosis)
hypercarbia
once the lungs are deflated, periodic _____ should be given, especially ________ seperating from bypass
ARM should be given
BEFORE sepating from bypass
______ sedation is required during sternotomy
deep
APL valve should be _____ turned to ___ during sternotomy (to deflate)
OPEN (0)
which mammary artery is most commonly used
L
________ Vt during dissection to remain free of surgical field
decrease
___ arterial line may be dampened if retractor for IMA compresses the subclavian artery
L
CONTRAindication for IMA
subclavian stenosis
(since the origin of IMA is the subclavian artery)
3 most common grafting vessels
internal mammary artery (IMA)
saphenous vein
radial artery
most common grafting site
saphenous vein
which arm is used for HARVESTING
non-dominant
which arm is used for aline placement and MONITORING
dominant
________ infusion will be started post bypass
cardizem
(helps to avoid spasm of radial artery)
ACT is obtained ___-___ min after heparin administration
3-5 min
during cannulation
NO MORE THAN < ___-___ SBP
90-100 SBP
arterial cannula
______-luminal within the ___________ ______
intra-luminal
within ascending aorta
what 3 things can result in inability to deliver blood back to the patient
dissection
false lumen
improper placement
venous cannula
located in the
R atrial appendage/RA/IVC
improper placement of a venous cannula results in
venous engorgement
obstructive compartments (SVC syndrome)
risk of stroke/tissue damage
when the patient is placed on bypass, ventilation is _____________
discontinued
who manages hemodynamics during bypass period
perfusion/perfusionist
true or false
all infusions are D/C for bypass
true
why is the patient cooled
to reduce brain and body metabolism
what does the aortic cross clamp do
isolates coronary blood flow (not perfused)
what area is filled with cardioplegia
aortic root
where is aortic root located
between aortic valve + aortic cross clamp
what is the cardioplegia fluid
cold solution
high potassium (makes the heart stop beating)
what is the treatment if cardioplegia cannot be distributed to all the tissue
retrograde route
where is retrograde route catheter placed
coronary sinus
3 types of way to cool patient
1) topical ice slush
2) cardioplegia
3) systemic cooling (cold blood)
distal temp during CABG
___-___ C
10-15 C
as cardioplegia is washed away and heart is warmed, the heart _______ _______
heart starts itself
true or false
NO blood is yet moving through heart it via automaticity
true
3 drugs for hyperkalemia and reperfusion dysrhythmias
lidocaine
calcium
magnesium
when heart is beating slow, give
chronotrope
when heart is beating bad, give
inotrope
when heart is fine + BP is low, give
alpha agonist
true or false
you must MANUALLY reinflate the lungs following bypass
true
true or false
use careful recruitment withOUT over-pressurizing to avoid damage to lungs
true
bypass pump is ____________ clamped to allow flow into the heart
partially
with bypass pump being gradually weaned, TEE monitoring should include
absence of intracardiac air
cardiac volume
contractility
valve evaluation
when are cannulas removed
when heart is pumping well
+
re-initiation of bypass is NOT a threat
after giving protamine, ACT should be
120
where are chest tubes placed (2)
pleural
+
mediastinal
during closure of sternum, lungs should be ____________ reinflated
MANUALLY
while in the ICU, be able to
pacing (epicardial)
ventilation settings
lab values + CXR
vital signs
documentation/handoff
extubation goal of __-__ hours
6-8 hours
what does a short intubation time help with
shorter hospital stay
reduced cost
reduced infection
less complications
extubation > ___ hours was considered prolonged/abnormal
> 24 hours
how can you facilitate < 8 hour extubation
avoid postop NMBs
reverse NMBs
use short-acting narcotics and sedatives
average pump prime volume
1500 ml
reduce viscocity means
thinner
why do we AVOID reducing viscosity
1) anemia
2) reduced O2 carrying
true or false
arresting the heart allows surgical access, however, may NOT decrease O2 demand
true
3 techniques to reduce O2 consumption
stopping the heart
cooling the heart
systemic cooling
cardioplegia temp ___-___C
10-15 C
systemic temp ___C
28 C
antegrade =
aortic root
to myocardial tissue
retrograde =
coronary sinus
to aortic root
benefit retrograde prime
prevents 1500ml extra fluid
allows patient’s blood volume to backfill
true or false
retrograde prime does NOT drop the Hct
true
PRIOR to bypass, limit crystalloid to < __ L
< 1 L
regurgitation GOAL
“fast, full, forward”
what are 3 things important with STENOSIS
full preload
AVOID tachycardia
SVR/afterload CONTROL
what are 3 things important for REGURGITATION
full preload
maintain HR
DECREASE afterload
“fast, full, forward”
off-pump CABG
does NOT arrest the heart
does NOT go on cardiac bypass
true or false
you MUST have an aline for offpump CABG
true
true or false
off-pump CABG:
EKG and TEE may be INaccurate
(due to mechanical displacement of heart)
true
OFF-pump CABG
2 treatments for stress of heart
1) fluid bolus
2) trendelenburg
(fills the heart)
when is OFF-pump CABG indicated
single bypass cases
(IMA to LAD)
OFF-pump CABG
ACT ____-____
300-400
true or false
OFF PUMP CABG
there is NO CPB utility for rewarming
true
true or false
stablization device is designed to facilitate a MOTIONLESS surgical site, withOUT arresting the heart
true
what vessel is best choice for OFF-pump CABG
mammary artery (IMA)
why is IMA a good choice for off-pump
does NOT require anastomosis (it has a native blood supply)
advantages of off-pump
NO dilution, LESS capillary permeability, LESS renal, LESS inflammatory
disadvantages of off-pump
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
3 indications for balloon pump (IABP)
ischemia
potential ischemia
poor CO
3 CONTRAindications for balloon pump (IABP)
aortic disease
aortic valve disease
surgery on the aorta (surgical insult)
balloon INflating =
diastole
balloon DEflating =
just PRIOR to systole
balloon inflating helps with what*
improves SUPPLY
improving oxygenation
balloon deflating helps with what*
reduces DEMAND
less SVR, ejects easier
balloon tip should be DISTAL to the ___ ___________ ________
L subclavian artery
what is goal of IABP
improve CPP
reduce workload
IABP
augmented ___________ pressure should exceed > UNASSISTED ________ pressure
DIASTOLIC > SYSTOLIC
How would we improve CPP with drugs
neo (this is finite)
what part of the body sees the boost in pressure
only PROXIMAL/ABOVE the balloon
highest number for IABP
diastole/inflation
the larger the gradient, the _____ you need the balloon
larger gradient =need it MORE
impella is a _____
VAD (ventricular assistive device)
3 indications for impella
acute MI
cardiogenic shock
post-bypass period
true or false
an IMPELLA would keep the patient alive if the heart stopped
(you could maintain CO)
true
where does an IMPELLA reside
LV
why is epi used (3)
1) chronotropic (HR)
2) inotropic/contractility (EF)
3) dromotropic (conduction)
what is cell saver
PRBCs only
similar to a VAD
tandem heart
When cardiac bypass fails, use this!
tandem heart
Device can function simply as a pump or with the aid of an oxygenator as ECMO
tandem heart
best option to view awareness
BIS monitor
true or false
TAVR
native valve STAYS in place
true
1 indication for TAVR
severe aortic STENOSIS
cerebral ox tells us what
FLOW
trans-_______ (of the LV)
distal aortic route (femoral route)
TAVR
trans-apical
TAVR
once the valve is positioned inside the native valve, _______ _____________ __________ is initiated to MINIMALIZE CO
rapid ventricular pacing
true or false
MAC and GA can both be used for TAVR
(NO difference in outcomes)
true
true or false
TAVR is HIGH risk
true
calcium buildup
balloon over/underinflation
1 reason for retrograde*
presence of CAD
L heart cath monitors __________
pressure
what is the primary substrate of metabolism in the brain*
glucose
_______glycemia WORSENS hypoxic injury
HYPOglycemia
adult human brain weighs ______-______ grams
1300-1400
_____-_____ml of blood flow per MINUTE
650-700 ml
____% total CO = brain
14%
the BRAIN ITSELF can increase blood flow to as much as ____-____% CO
15-20%
Cerebral blood flow AVERAGE
____ml/_____grams/min
50ml
/100gm/min
Cerebral blood flow SLOWING of EEG
____ml/_____grams/min
25ml
/100gm/min
Cerebral blood flow ISOELECTRIC EEG
____ml/_____grams/min
15-20ml
/100gm/min
Cerebral blood flow IRREVERIBLE INJURY
____ml/_____grams/min
<10 ml
/100gm/min
_____________ + ___________ = more sensitive to hypoxic brain injury than other parts of the brain
Hippocampus + cerebellum
CEREBRAL perfusion pressure = _____-_____ or _____
MAP - ICP or CVP,
whichever is HIGHER
CEREBRAL perfusion pressure =
MAP
CEREBRAL perfusion pressure (CPP)
< ____ torr = EEG changes, autoregulation diminished
< 50 torr
CEREBRAL perfusion pressure (CPP)
< ____ torr = irreversible injury
< 25 torr
autoregulation occurs at MAP 50-150 _____
torr
*when Vm (minute ventilation) DOUBLES,
_____ DECREASES by 1/2
CBF
CBF increases ___-___% for every 1 C temp
5-7%
volatile anesthetics have uncoupling > ___-___ MAC
> 1-1.5 MAC
luxury perfusion
_____ > _______
CBF > CMRO2
__________ can be neuroprotective at high doses
volatiles
(they decrease CMRO2)
____ anesthetics PRESERVE coupling
IV
reduced CMRO2
decrease CBF (vasoconstrict)
what 2 drugs INCREASE CMRO2
and ICP + CBF
nitrous
Sch
what drug INCREASES ICP + CBF only
ketamine
propofol is isoelectric EEG at ____mcg/kg/min
500
what drug can cause seizures in patients with seizure history
etomidate
what drug has a metabolite that can cause seizures
Demerol (normeperidine)
CONTRAindication for benzos
patients with increased ICP,
due to RESPIRATORY DEPRESSION (leads to rise in CO2)
ketamine increases ICP
> ___%
> 80%
CONTRAindications to Sch (3)
denervated muscle
CVA
motor neuron lesion
**____________ drugs, such as __________, cause an INCREASE in dose requirements for NON-depolarizers
anticonvulsant drugs, such as dilantin
NON-expandable “closed box”
1) Brain tissue (___%)
2) Blood (___%)
3) CSF (__%)
1) Brain tissue (80%)
2) Blood (12%)
3) CSF (8%)
true or false
brain tissue has almost NO nociceptive (pain) nerve tissue
true
*Cushing’s REFLEX (not triad)
INCREASING ICP =
HTN
bradycardia
true or false
increase in ICP CAN damage brain
true
what type of epi effects are prominent for neuro
beta 2
goal is a “________” brain
relaxed
_______ventilation
and
_______carbia
should be used for brain surgery
HYPERventilate
HYPOcarbia
normal brain surgery, maintain Hct ____-____%
30-35%
keep brain patients ______volemic
NORMO
______ volume expansion helps reduce vasospasm
mild
AVOID ________ and ____ fluids
limit __________ to 1-1.5 L
dextrose + LR
limit hetastarch
true or false
it is MORE important to accomplish a SMOOTH induction rather than any particular drug combo
true
keep patient ________tensive during neuro surgery
NORMOtensive
HTN = increased ICP/CBF
HoTN = ischemia, decreased CPP
maximize venous drainage
avoid excessive neck ________
avoid flexion
keep HOB > ___
> 15**-30
*when should neuro function/spontaneous breathing be intact?
PRIOR to skin closure, pin removal
otherwise, the removal of the noxious stimuli (pins) will lead to delay of return of spontaneous respirations
what type of awakening should be used
rapid
(promotes neuro assessment)
CPP
level of the _____________
external auditory meatus
+
tragus
CPP has a ________ pressure than the heart
lower pressure
- 1 mmHg for every _____cm
1.25 cm
CPP: avoid < ____
< 50
4 types of intracranial mass lesions
1) congenital
2) neoplastic
3) inflammatory/infectious
4) vascular
2 types of neoplastic lesions
benign
malignant
2 types of inflammatory/infectious lesions
cyst
abcess
2 types of vascular lesions
AVM
hematoma
***when you suspect neuro insult to the brain, give ________
it prevents brain swelling!
steroids/decadron
why are anticonvulsants metabolized fast
CP450
mass lesions symptoms
headache
seizures
reduction in cognitive/neuro
focal neuro deficits
for mass lesions, you want to AVOID _______ benzos/opioids
PREOP
elevated ICP symptoms (5)
headache
N/V
papilledema
focal neuro deficits
AMS
poor outcome after ischemic events (AVOID)
____________ blood glucose
____________ brain temp
avoid
increased blood glucose
increased brain temp (avoid warmers)
where are majority of masses
_______tentorial
__________ fossa surgery
SUPRAtentorial
ANTERIOR fossa surgery
4 common symptoms of SUPRAtentorial
headache
seizures
hemiplegia
aphasia
“HSHA”
2 symptoms of INFRAtentorial
cerebella dysfunction
-ataxia, nystagmus
brain stem compression
-altered mental status, altered respirations
slow growing lesions are
usually Asymptomatic
fast growing lesions
acute neuro deficits
what would be affected by altered respirations/mental status
INFRAtentorial
POSTERIOR fossa surgery
RAS, ANS, some cranial nerves
circulatory/respiratory centers
POSTERIOR fossa surgery
how can we monitor damage to respiratory center during posterior fossa surgery
spontaneous ventilation
VAE can occur when
wound is _______ heart
ABOVE
highest incidence of VAE
sitting craniotomy
symptoms of VAE (5)
decreased/flat ETCO2
decreased O2
sudden HYPOtension
circulatory arrest
ET nitrogen absorption
*most sensitive NON-invasive monitor
precordial DOPPLER
mill-wheel roaring sound
*most sensitive INVASIVE monitor
TEE
transesophageal echo
0.25 ml air detected
treatment for VAE (2)
wax+saline
L LATERAL DOWN/DECUBITUS position
what is a PARADOXICAL air embolism
air entering SYSTEMIC circulation
3 types of defects that can cause paradoxical air embolism
PFO
atrial
ventricular septal
What is the leading cause of subarachnoid non-traumatic hemorrhage
sacular aneurysm rupture
2 risk factors for CEREBRAL ANEURYSM
age 55-60
female
Where are majority of aneurysms (2)
Internal carotid bifurcation
+
ANTERIOR cerebral artery
subarachnoid bleed symptoms (2)
intense headache (85%)
transient LOC with N/V
avoid ______tension with cerebral aneurysm
AVOID HYPOtension
(we want perfusion!)
true or false
cerebral aneurysm
EKG changes are NON-ischemic, NON-cardiac in origin, with NO adverse outcome
true
cerebral aneurysm
what is the major cause of mortality and morbidity
vasospasm
cerebral aneurysm
surgical intervention with
> ___ mm
> 7 mm
clipping
vasospasm
keep Hct < ___
< 32
vasospasm
true or false
will need to correct the HYPOnatremia (due to the hemodilution)
true
treatment for vasospasm
“Triple H”
HEMOdilution
HTN
HYPERvolemia
vasospasm
2 drugs for treatment
inotropes
calcium channel blockers
(nimodipine, nicardipine)
subdural hematoma
where does blood collect
between dura and arachnoid
what kind of bleeding causes subdural hematoma
venous
subdural hematoma
symptoms
headache, drowsiness, cognitive decline, obtunded
subdural hematoma
treatment
craniotomy
burr holes
subdural hematoma
______capnia is desired
NORMOcapnia
AV malformation
_______cerebral hemorrhage
INTRAcerebral
risk factor (1) for AV malformation
age 10-30
“little AV”
AV Malformation
treatment (2)
1st neuroradiology treatment
2nd surgical resection
HYPERventilation + mannitol
what surgery can have extensive blood loss
AV malformation
hypersecretory tumors can cause
acromegaly (growth hormone) and hyperglycemia
this can lead to possible
difficult intubation
pituitary surgery
types of resections
1) trans-phenoidal (MAJORITY)
2) intracranial
pituitary surgery
ETT should be placed to the ___ side
L side
pituitary surgery
**opposite of the other surgeries
use ______ventilation
________carbia
HYPOventilation
HYPERcarbia
you want a bulging/tight brain
malformation where MEDULLA protrudes through foramen magnum
arnold-chiari malformation
arnold-chiari
risk factor (1)
females
Infratentorial masses can obstruct CSF at __th ventricle and lead to obstructive hydrocephalus
4th
arnold-chiari
anesthesia implications
same as those for posterior fossa surgery
head trauma
symptom: _____tension
HYPOtension
true or false
head trauma
RSI is NOT best option
(due to cricoid pressure)
true
head trauma
maintain CPP at ____-____
70-110
head trauma
treatment
robinul (for enhanced vagal tone)
AVOID peep until AFTER dura is opened
leave intubated/paralyzed
true or false
ortho patients have more positioning challenges than any other surgery
true
ortho
best positions
supine
sitting lateral decubitus
prone
ortho
Excellent advantages, but can be UNreliable
Used more for UPPER extremity surgery
regional
Rheumatoid Arthritis
Immune related, ___________ inflammation of synovial joints
progressive
rheumatoid arthritis
Atlantoaxial subluxation:
C-spine films to evaluate + determine if awake fiberoptic intubation is indicated = > ___mm = instability
> 5mm
true or false
it is OKAY to use LMA with lateral positioning (shoulder surgery)
true
shoulder surgery
we want _____tension
HYPOtension is good!
arthroscopic surgery
keep BP _____
irrigation fluid ___-___ mmHg
BP should be LOW
irrigation fluid 60-80 mmHg
TMJ dysfunction can lead to
limited jaw opening
Atlantoaxial instability can lead to
limited neck ROM
which surgery should you check distal pulses
CERVICAL spine
(use ear probe oximeter)
CERVICAL spine surgery
true or false
coughing or bucking MUST be PREVENTED
true
what is a risk with LUMBAR spine surgery
brachial plexus
arms/shoulders should be LESS THAN < 90
LUMBAR spinal surgery
diaphragm has moved __________/________
decreases FRC + Vt
CEPHALAD/upward
ortho
long procedure,
greater blood loss,
use cell saver and type/crossmatch
spinal fusion
scoliosis have __________ lung disease
restrictive
anterior/posterior approach
Neuromuscular monitoring is indicated, due to artery of _____________
adamkiewicz
hip fracture
____________ arm is placed on chest
IPSI-lateral
hip FRACTURE
_________ position
supine
hip REPLACEMENT
_______ __________ position allows for greater ROM
lateral decubitus
**Bilateral hip surgery is CONTRAindicated if declining pulm function occurs after ___ hip surgery (O2 sat drops 94ish)
1st
ortho
what surgery has high incidence of DVT
knee replacement
more distal = higher risk
knee replacement
regional:
femoral 3-in-1
LFC, obturator, femoral
true or false
knee surgery is MORE painful
true
Very short procedures
“popping” back into place
short-acting paralysis + propofol
closed reduction
Used to bind prosthetic to bone
Exothermic reaction occurs
-Hardens cement and expands
-Lysis of blood cells and marrow
Methylmethacrylate Cement
Embolization of air, fat, marrow, cement
intermedullary HTN
Systemic absorption of cement
leads to
decreased SVR (HYPOtension, vasoDILATION)
release of tissue thromboplastin,
platelet aggregation, microemboli formation
hammering
Bone Cement Implantation Syndrome
(migration to pulm system)
HYPOtension
Hypoxia
Reduced CO
Dysrhythmias
Shunt
Pulm HTN
treatment for Bone Cement Implantation Syndrome (2)
increase FiO2
adequate hydration
exsanguination
cuff should overlap ____º from nerve bundle
180 degrees
____ torr over SBP = LOWER extremity
100 torr
____ torr over SBP = UPPER extremity
50
tourniquet
neuro damage may occur if >___ hrs or if over nerve bundle
> 2 hours
Pneumatic Tourniquet
physiologic effects
INFLATION
INCREASE in SVR, CVP, PVR
displaced/added blood volume (300-500ml)
treatment for “tourniquet pain”
opioids added to LA
deflation (10-15 min)
Pneumatic Tourniquet
physiologic effects
DEFLATION
metabolic acidosis
tachycardia
HYPOthermia
HYPOtension (most common)
why does HYPOtension occur with deflation
sudden reduction of SVR/PVR
washout of ischemic metabolites (thromboxane)
when does tourniquet pain occur
after 1 hour
DVT, PE, VAE common
long bone fractures
(especially hip + knee)
___________ anesthesia REDUCES risk of DVT
regional
(epidural/spinal)
why does regional technique reduce risk of DVT
Higher levels of plasminogen + plasminogen activators
HYPERkinetic blood flow
**Fat Embolism Syndrome/Triad
1) petachaie (axillary/subconjuctival)
2) dyspnea
3) confusion, mental changes
**Fat Embolism Syndrome/Triad
occurs ___-___ hours later
12-24 hours
other symptoms with fat embolism
tachycardia (ST segment changes)
fat in urine, sputum, conjuctiva
risk factor for PULMONARY fat embolism
lung disease
treatment for fat embolism (4)
O2
fluids
steroids
aggresive ventilation!
ortho postop pain management
best option
multimodal + regional
(NSAIDs + opioids + regional)
VAE
large air bubbles can lead to INCREASED ___ afterload and decreased ___
INCREASED RV
decreased CO
true or false
pituitary is RARELY metastatic
20-50% are NON-secretory
true
shoulder surgery
VAE is possible with
beach chair position
shoulder surgery
what type of block
interscalene
how can you avoid airway swelling
steroids
*what is most common with deflation of tourniquet
hypotension
pinprick tingling
A-delta
dull aching pain
C
