Exam 3- Dan's Jazz Flashcards
Who has higher incidence of awareness under GA?
Children
What are the 9 risk factors for having awareness under GA?
- Routine use of paralytics
- TIVA
- Production pressure
- Hemodynamic instability
- Obstetric/Cardiac/Trauma
- Patient age
- Difficult airway
- Limited cardiac reserve
- Substance abuse
What type of substance abuse is a risk factor (3)
Chronic ETOH
Anxiolytics
Cocaine
Experiences with awareness during GA and percentages (4)
Audio (48%)
Not being able to breath (48%)
Pain (30%)
PTSD (30%)
4 classes of etiologies for patient awareness:
Class 1: pt specific altered increase in anesthetic receptors
Class 2: pt can’t tolerate anesthetic
Class 3: pt hemodynamics mask awareness
Class 4: anesthetic delivery failure
Hemodynamic; 5 typical indicators of physiologic and motor response:
- High BP
- HR
- Movement
- Lacrimation
- Dilated pupils
Major criteria for high risk awareness under GA (7):
- Longer term use of narcotics/ETOH/cocaine
- EF <40%
- H/O anesthesia awareness
- H/O difficult airway
- ASA 4/5
- Aortic stenosis/ open heart surgery
- End stage lung disease
Minor criteria to be high risk of awareness under GA (4)
- Periop use of Beta Blockers
- COPD
- BMI >30
- Tobacco 2 packs/day
Prevention for awareness under GA (5)
- Premed with versed
- Frequent machine checks
- Insure pt is asleep prior to intubation
- Concerned when giving BB or antiHTN
- Avoid paralysis unless needed
Is assist-control ventilation (ACV) desirable for patients who breathe rapidly, why?
NO because may induce both hyperinflation and respiratory alkalosis
Each breath is either an assist or control breath, bu they are all of the same volume
Assist control ventilation (ACV)
Guarantees a certain number of breaths, but pt breaths are partially their own, reducing the risk of hyperinflation or alkalosis
Synchronized intermittent-mandatory ventilation (SIMV)
Disadvantage of SIMV:
Increased work of breathing and tendency to reduce CO (which prolong ventilator dependency)
Which ventilator should be used for pt who has LV dysfunction:
ACV
When is pressure-control ventilator preferred:
Pt with neuromuscular disease
Variation of CPAP that releases pressure temporarily on exhalation that results in high average airway pressures
Airway pressure release ventilation
Does APRV require more or less sedation?
More
Volume target backup is added to a pressure assist-control mode
Pressure regulated volume control (PRVC)
- Clinician sets the percentage of work of breathing
- Positive feedback loop
- Compliance and resistance calculated using intermittent end-inspiratory and end-expiratory Pasteur maneuvers
Proportional assist ventilation
Low levels of PEEP are most dangerous in with pts:
Hypovolemia and cardiac dysfunction
PEEP is indicated clinically for (3):
- Low volume ventilation cycles
- FiO2 requirements >.60 (stiff, diffuse lay injured lungs; ARDS)
- Obstructive lung disease
Who do you NOT use PEEP on?
Pneumonia; affect healthy tissue and worsen oxygenation
How to see effect on PEEP?
Peak inspiratory pressure (PIP)
-if PIP increases less than added PEEP=PEEP improved compliance of lungs
Ways PEEP can be monitored (2)
PIP
PaO2/FiO2 ratio (increase)
Prone ventilation may improve what?
Oxygenation by redistributing pulmonary blood flow
When is prone not good?
Neurosurgery
2 absolute contraindications of prone positioning:
- Unmonitored or increased ICP
2. Unstable vertebral fractures
Respiratory rate greater than 4x the normal value (>150breaths/min) and very small tidal volumes
High frequency oscillatory ventilation
What is high frequency oscillatory ventilation referred to as and why?
Lung protective ventilation
-reduce vent associated lung injury (ARDS and acute lung injury)
Combines conventional cycles with high frequency percussion
-conventional ventilation and HFPV with a high frequency of 400-800 cycles/min
High frequency percussive ventilation
When is high frequency percussive ventilation used?
Burn ICU
Step wise reduction from ventilator in superior to intermittent mandatory ventilation (3)
- Mechanical support
- Pressure support mode
- Multi daily T-piece trails
What is good for trails of unassisted breathing with weaning off vent:
Low levels of pressure support
Successful first trial, followed by discontinuation of mechanical ventilation
Simple transition
3 spontaneous-breathing trials but fewer than 7days between the first unsuccessful trial and successful discontinuation of mechanical ventilation
Difficult transition
At least 3 unsuccessful spontaneous-breathing trial or 7days or more of mechanical ventilation after the initial unsuccessful trial
Prolonged transition
3 reasons why trials of spontaneous breathing do not succeed:
- Respiratory mechanics worsen during spontaneous breathing trial
- Deterioration of respiratory mechanics can result from
- increased respiratory resistance (asthma and obstructive pulmonary)
- decreased lung compliance (pulmonary fibrosis, edema, acute lung injury, ARDS)
- air trapping (COPD) - Challenge the circulation
3 things with respiratory load:
- Lung disease
- Cardiovascular dysfunction
- Chest-wall disease
3 things with respiratory capacity:
- Muscle weakness
- Diminished respiratory drive
- Impaired neuromuscular function
2 big things during weaning from ventilator:
- SBT for 30min
2. Assess airway, cough, airway secretions and mentation
When can respiratory distress develop after extubation?
Up to 48 hrs
What reduce the need for reintubation after discontinuation of mechanical ventilation:
Noninvasive positive pressure ventilation
Risk factors for unsuccessful discontinuation of mechanical ventilation: age
> 65 yr
Risk factors for unsuccessful discontinuation of mechanical ventilation: APACHE II score
> 12 on day of extubation
Risk factors for unsuccessful discontinuation of mechanical ventilation: partial pressure of arterial CO2 after extubation
> 45 mmHg
Hypotension due to peripheral vasodilatation but also by a poor response to a therapy with vasopressors drugs
Vasodilators shock
What is vasodilator shock due to hemorrhage also known as:
‘Irreverisible’ or late phase hemorrhagic shock
4 other things that are characterized by cardiovascular collapse and that are likely to be associated with vasodilatation:
- Lactic acidosis due to metformin intoxication
- Certain mitochondrial diseases
- Cyanide poisoning
- Cardiac arrest with pulse less electrical activity
What is nitric oxide in both septic shock and decompensated hemorrhagic shock:
Increased
Inhibits NO preventing SM relaxation by nitrogen-based vasodilators:
Methylene blue
As shock worsens, the initial very high concentration of vasopressin in plasma does what?
Decreases
Vasodilator shock has no effect with what (4)
Vasopressor
Norepinephrine
Angiotensin II
Endothelin
Vasopressin max dose for post cardiotomy shock
.1untis/min
Vasopressin max does for septic shock:
.07units/min
How long should Sux not be given after burns, trauma, and denervation:
24-72hrs
What should be used to test for TOF
Double burst
What test to use to test for TOF >.7:
Tetanus for 5 seconds of 50Hz
4 twitches:
0-75%
3 twitches?
75%
2 twitches?
80%
1 twitch?
90%
0 twitches?
> 90%
How long does neostigmine take to peak?
10min
Initial dose of neostigmine?
1mg
Shallow medium block vs deep block dosage of sugammadex?
2mg/kg
4mg/kg
Immediate reversal dose of sugammadex 3 min after giving max 1.2 mg/kg of Roc?
16mg/kg
Is there a dose adjustment needed for sugammadex?
Not when pt is >65yr, obese, or gender
Trigger CO2 <35
Pt needs narcotics
Trigger CO2 >50:
Pt do NOT need narcotics
CO2 between 35-50:
Wait and titrate to effect later
When are colloids (volume expanders) used (2):
- Hyperproteinemia
2. Malnourished pts who can’t tolerate large infusions of crystalloids
3 times to use colloid:
- Renal failure
- Large trauma
- Microsurgical
When should crystalloid fluids be used:
Pts with dehydration (loss of ISF and IVF)
When should crystalloid fluids be limited:
Replaced of deficits and ongoing clear-fluid losses
Where are colloid fluids designed to stay?
In IV space
