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NUNA 681 Pharm II > Exam II: Deliberate Hypotension > Flashcards

Exam II: Deliberate Hypotension Flashcards

1
Q

Deliberate Hypotension (DH): controlled, _____, _____

A

controlled, induced, elective

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2
Q

Deliberate Hypotension (DH): A reduction of _____ blood pressure to 80 to 90 mm Hg

A

systolic

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3
Q

Deliberate Hypotension (DH): A decrease in ____ to 50 to 65 mm Hg in normotensive patients

A

MAP

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4
Q

Deliberate Hypotension (DH): A ____ reduction of baseline MAP

A

30%

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5
Q

Benefits of DH:
Reduced blood ____
Conserve blood _____
Avoidance of _____ reactions
Decreased transmission of ____-____ _____

A

loss
supply
transfusion
blood-borne disease

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6
Q

Benefits of DH:
Facilitation of surgical dissection -
Microscopic surgical (___, intracranial ___ ______)
Identification of _____ vs. non______ tissue, vital structures

A

(ENT, intracranial AV malformation)
malignant vs nonmalignant

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7
Q

Benefits of DH:
Facilitation of surgical dissection -
Reduction of amount of _______ tissue, debris and wound infection
Reduction in _____ time

A

cauterized
operative

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8
Q

Benefits of DH:
Reduction of _____ beneath skin flaps
Better _____ outcome, improved ____ _____

A

oozing
plastics
wound healing

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9
Q

Benefits of DH:
Prevention of ______ rupture (i_____, a_____)

A

aneurysmal
intracranial, aortic

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10
Q

Benefits of DH:
Reduction in intravascular _____
_____ of the aorta

A

tension
coarctation

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11
Q

Indications for DH:
_____surgery - _____vascular

A

neurosurgery - cerebrovascular

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12
Q

Indications for DH:
Large _____ procedures – total ___ _____, spinal fusions

A

orthopedic
hip arthroplasty

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13
Q

Indications for DH:
Surgery on large ____ – pelvic

A

tumors

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14
Q

Indications for DH:
Surgery on the head and neck – ____-____, middle ____

A

maxillo-facial
ear

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15
Q

Indications for DH:
_____ surgery

A

plastic

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16
Q

Indications for DH:
Patients in whom _____ is undesirable

A

transfusion

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17
Q

Contraindications:
Improved ____ and ______ have allowed patients who previously would have been excluded to be eligible for DH

A

drugs and monitoring

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18
Q

Contraindications:
Relative – H/O _____ disease, r____ dysfunction, l____ dysfunction, severe peripheral c______, myocardial infarction or angina

A

cerebrovascular
renal
liver
claudication

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19
Q

Contraindications:
Hypo____

A

Hypovolemia

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20
Q

Contraindications:
severe _____

A

anemia

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21
Q

Contraindications:
Untreated _____ – increased risk of death and morbidity during DH (Treatment of hypertension returns cerebral ______ toward normal – DH safe for ______-controlled hypertension.)

A

HTN
autoregulation
medically

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22
Q

Influences of bleeding perioperatively:
Arterial – related to ____ – abolished by tourniquet, reduced by decreased ____, ____

A

MAP
MAP, HR

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23
Q

Influences of bleeding perioperatively:
_____ – dependent on local flow in the _____ _____ – reduced by decreased BP and local vaso______ (infiltration)

A

capillary
capillary bed
vasoconstriction

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24
Q

Influences of bleeding perioperatively:
Venous – related to venous ____, venous ____ and dependent on _____ – abolished by spinal or epidural and direct acting vasodilators

A

return
tone
posture

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25
Q

Methods to achieve hypotension (physiologic):
Body positioning – operative site above the level of the ____(for each ___ cm of vertical height above the heart, the local arterial pressure is reduced by ___ mm Hg)
Aiding the ____ _____ in vasodilated capacitance vessels
___-___ position

A

heart
2.5 cm
2 mmHg
venous pooling
head-up

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26
Q

Methods to achieve hypotension (physiologic):
____ ____ _____ – decreased venous return, and thus CO

A

positive pressure ventilation

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27
Q

Methods to achieve hypotension (physiologic):
PEEP – decreased ____ ____

A

venous return

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28
Q

Methods to achieve hypotension (physiologic):
Decreased ____ and ____

A

SV and HR

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29
Q

Methods to achieve hypotension (physiologic):
Other ways you may have heard this:
Invasive and Non-Invasive BP Monitoring -
(2) ___ cm of height = 0.75 mmHg; and later…
(3) ___ cmH20 = 7.5 mmHg
Neurosurgical Anesthesia - (4) ___ mmHg for each 1.25 cmH20

A

1 cm
10 cmH2O
1 mmHg

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30
Q

Methods to achieve hypotension (mechanical):
Tourniquets –
Monitor duration - __ min upper limb and ___ min for lower limb – ischemia can occur in ___ time than this

A

60 min
90 min
less

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31
Q

Methods to achieve hypotension (mechanical):
Tourniquet -
Monitor pressure – ___ mm Hg in arm; ___ mm Hg in leg

A

250
300

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32
Q

Methods to achieve hypotension (mechanical):
Tourniquet -
Don’t use on ___ ___ patients

A

sickle cell

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33
Q

Methods to achieve hypotension (mechanical):
Local infiltration with _____

A

epinephrine

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34
Q

Methods to achieve hypotension (mechanical):
Local infiltration with epinephrine -
local ______

A

vasoconstriction

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35
Q

Methods to achieve hypotension (mechanical):
Local infiltration with epinephrine -
concentrations 1:_____ to 1:______

A

1:200,000
1:400,000

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36
Q

Methods to achieve hypotension (pharmacologic):
____ anesthetic agents

A

volatile

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37
Q

Methods to achieve hypotension (pharmacologic):
_____ ganglionic blockers

A

sympathetic

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38
Q

Methods to achieve hypotension (pharmacologic):
____-adrenergic blockers

A

alpha

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39
Q

Methods to achieve hypotension (pharmacologic):
____-adrenergic blockers

A

beta

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40
Q

Methods to achieve hypotension (pharmacologic):
_____dilators

A

vasodilators

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41
Q

Methods to achieve hypotension (pharmacologic):
_____ and ____ anesthesia

A

spinal and epidural

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42
Q

Isoflurane: Minimal effect on myocardial _____ at low concentrations

A

contractility

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43
Q

Iso: Vasodilation effect is readily ____

A

adjusted

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44
Q

Iso: Great for _____reduction in BP

A

moderate

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45
Q

Iso: Less of an effect on ___ than halothane

A

ICP

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46
Q

Iso: Depresses cerebral _____ (_____)

A

metabolism (CMRO2)

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47
Q

Iso: Minimizes reflex _____ or ______ (CNS depressant)

A

vasoconstriction or tachycardia

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48
Q

Sevo: Shown to minimize the heart rate fluctuations that occur with use of n_____, n_____, or a_____ (PGE) to achieve hypotension. Decreased _____ activity. Study looked at combination with N2O

A

nitroglycerin, nicardipine, or alprostadil
sympathetic

49
Q

Sympathetic ganglionic blocker - Trimethaphan (Arfonad):
Interruption of _____ outflow, vaso_____

A

sympathetic
vasodilation

50
Q

Sympathetic ganglionic blocker - Trimethaphan (Arfonad):
Urinary ____, m_____ (mistaken for cerebral ischemia), _____ due to parasympathetic block (bleeding)

A

retention
mydriasis
tachycardia

51
Q

Sympathetic ganglionic blocker - Trimethaphan (Arfonad):
T_____

A

Tachyphylaxis

52
Q

Pretreatment with ____ po reduces the required infusion of PGE 1 needed to maintain DH and reduces the blood loss by ___%.

A

clonidine
45%

53
Q

Use of _____ combined with ______ to provide controlled hypotension during posterior spinal fusion

A

dexmedetomidine
remifentanil

54
Q

Patients with gynecologic cancer to undergo radical hysterectomy. Doses of ____ of 75 mcg and 150 mcg were given 60 minutes before induction of anes. Blood loss was _____.

A

clonidine
reduced (from 1461 to 805 and 931.)

55
Q

Additional benefits of dexmedetomidine for max-face cases:
-a_____ – reduced opioids post-op
-a_____
-___ stability
-h_____
-minimal vent depression on emergence

A

analgesia
anxiolytic
CV
hypotension

56
Q

Alpha adrenergic blockers - Phentolamine (Regitine), droperidol
Vaso____
Increased ___ and myocardial oxygen ____ due to beta stimulation

A

vasodilation
HR
demand

57
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Big advantage is decreased ___ and ___

A

HR
CO

58
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Used along with _____

A

vasodilators

59
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Prevents ____ ____ in BP (vasospasm re: subarachnoid hemorrhage)

A

wide variations

60
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
_____ not as potent, no increase in ICP

A

labetolol

61
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Labetalol masks the _____ response to acute ___ ____ (long duration lasts in postop period)

A

adrenergic
blood loss

62
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Propranolol _____ reduced the dose of SNP and the ____ _____ upon discontinuation

A

pretreatment
rebound HTN

63
Q

Beta-adrenergic blockers - Propranolol, atenolol, esmolol, (labetalol*):
Esmolol reduced ___ ____ ___ – improved stability; greater reduction in CO

A

plasma renin activity

64
Q
A

All three reduced MAP. Esmolol was the only one to decrease HR and CO. Significant decrease in SVR for iso and nipride; esmolol does not block alpha, should not block beta2 either. Change in CO impacts CVP, PCWP. Increased plasma-renin activity for both iso and nipride which will result in increased Na and water retention; not seen with esmolol.

65
Q

Vasodilators - Sodium nitroprusside:
“dial-a-___”
Good for ___ periods

A

pressure
short

66
Q

Vasodilators - Sodium nitroprusside:
Increased ____ - caution

A

ICP

67
Q

Vasodilators - Sodium nitroprusside:
____ ____ – monitor acid/base balance

A

Cyanide toxicity

68
Q

Vasodilators - Sodium nitroprusside:
No adverse effect on ____ ____

A

myocardial contractility

69
Q

Vasodilators - Sodium nitroprusside:
Pretreat with ____ or _____ to reduce dose of SNP and avoid rebound ____tension (or enalapril 2.5 mg 60 min p)

A

propranolol or captopril
hypertension

70
Q

Vasodilators - Nitroglycerin:
Less dramatic decrease in ___

A

BP

71
Q

Vasodilators - Nitroglycerin:
Decreases ____ more than _____ (maintains flow)

A

systolic
diastolic

72
Q

Vasodilators - Nitroglycerin:
less ____ recovery

A

rapid

73
Q

Vasodilators - Nitroglycerin:
____ _____ perfusion better

A

coronary artery

74
Q

Vasodilators - Nitroglycerin:
___ ____ in some patients

A

less effective

75
Q

Vasodilators - Nitroglycerin:
increase in ____ - Caution

A

ICP

76
Q

3-inch NTG transdermal – reduced blood loss by almost ___% and reduced the need for _____ of patients having ORIF of femur fractures
“induction of _____ hypotension”

A

50%
moderate

(Blood loss was reduced from 950 ml to 443 ml in placebo group to nitro group.)

77
Q

Spinal and epidural anesthesia:
Vasodilation of both arterial and venous due to _____

A

sympathectomy

78
Q

Spinal and epidural anesthesia:
If __-__ are blocked, tachycardia is prevented

A

T1-4

79
Q

Spinal and epidural anesthesia:
Used in lower abdominal and pelvic surgery – ___ ____ ____

A

pelvic venous plexuses

80
Q

Spinal and epidural anesthesia:
If _____ is added to the local, the hypotensive effect of the block might be ______.
Consider intermittent ____ or continuous epidural _____.

A

epinephrine
counteracted
bolus
infusion

81
Q

Hypotension - organ function:
It is best to reduce BP by decreasing ___ rather than ___ so blood flow to tissues can be maintained.

A

SVR
CO

82
Q

Hypotension - organ function: Ischemia of the ___ & ____ are the principal hazards of deliberate hypotension.

A

brain and myocardium

83
Q

Hypotension - organ function: CNS - Principle of _____ is key.

A

autoregulation

84
Q

Hypotension - organ function: “Safe” lower limit is __ to __ mm Hg in normotensive patient because that is the lowest pressure at which autoregulation of ____ is maintained.

A

50 to 55
CBF

85
Q

During normotension, CBF changes linearly with PaCO2 when PaCO2 is __-__ mm Hg. When the MAP falls below __ mm HG, CBF ______ responds to changes in PaCO2.

A

20-70
50
no longer

86
Q

Heart – maintain balance between myocardial ___ ____ and ____. AVOID– t____, myocardial d____, coronary artery perfusion alteration

A

oxygen supply and demand
tachycardia
depression

87
Q

Lungs – with hypotension: Increased PaCO2 due to increased _____. Must maintain ___ with ____ replacement

A

deadspace
CO
fluid

88
Q

Lungs – with hypotension: Decreased PaO2 due to increased ____. Seen with use of ____, but not with ____. Seen with normal lungs, but not with ____.

A

shunt
Nipride
isoflurane
COPD

89
Q

Lungs – with hypotension: Necessitates _____ ventilation, increased ______

A

controlled
oxygenation

90
Q

Lungs – with hypotension: Dead space – ventilation of alveoli where the blood doesn’t reach – decreased pressure causes decreased perfusion through pulmonary capillaries. Seen especially with increased mean _____ pressure, ____-_____, and hypo_____. To minimize, maintain CO with fluid replacement.

A

airway
reverse-trendelenburg
hypovolemia

91
Q

Kidneys - Glomerular filtration rate is _____ when MAP falls below ____ mm Hg

A

reduced
75

92
Q

Kidneys - Metabolic needs of kidneys still met, but _____ occurs

A

oliguria

93
Q

Kidneys - Normovolemic patients have rapid ____ of urine production when hypotension is dc’d. Strict maintenance of ___ ____ during deliberate hypotension is ____ necessary

A

recovery
urine output
not

94
Q

Kidneys - Renal function was better preserved with combination of ____ and _____ than with higher concentrations of ____ alone.

A

isoflurane and labetalol
isoflurane

95
Q

Splanchnic Circulation - Liver perfusion is altered due to limited autoregulation for the ___ ____ and no autoregulation for the ___ ____ _____

A

hepatic artery
portal venous circulation

96
Q

Splanchnic Circulation - Increased ____ outflow (baroreceptor mediated in response to decrease BP) causes splanchnic ______ and decreased blood flow to the ____ and the _____.

A

sympathetic
vasoconstriction
liver and the intestine

97
Q

Eye - Decreased blood flow to the eyes causes ___ ___ ____ and rarely _____

A

blurring of vision
blindness

98
Q

Eye - Position carefully to avoid increased intraocular pressure which would oppose blood flow even further.
Factors for this include ____ _____ and ___ ____ - neutral position

A

external pressure and venous congestion

99
Q

Eye - Maintain ____

A

Hgb

100
Q

Eye - _____ v. _____ – minimize edema

A

Colloid v. crystalloid

101
Q

Monitoring - ____ – signs of inadequate myocardial perfusion like ST depression and ectopic beats

A

ECG

102
Q

Monitoring - Pulse oximetry – signs of decreased _____ and peripheral _____

A

oxygenation
perfusion

103
Q

Monitoring - Temperature - body heat lost more rapidly from ______

A

vasodilation

104
Q

Monitoring - ___ ___ – beat to beat measurement of BP
allows sampling of ____s
place transducer at level of ___ ____ (CPP)

A

arterial line
ABGs
internal carotid

105
Q

Monitoring -
ETCO2 – not completely accurate due to increased _____, decreased ____, and changes in body ______
Sudden decrease may indicate ____
Use as guide to avoid hyperventilation which would further decrease ____.

A

deadspace
CO
metabolism
PE
CBF

106
Q

Monitoring - Central venous line – ____ replacement and monitor ____

A

fluid
CVP

107
Q

Monitoring - UOP – especially ___ cases

A

long

108
Q

Monitoring - e____ ____, EEG, serum ______, ABGs, h_____

A

evoked potentials
electrolytes
hematocrit

109
Q

Complications - Mortality is ___ ____ from that of all anesthetics

A

not different (0.01 to 0.007%)

110
Q

Complications - Nonfatal complications

A

CNS related – dizziness, prolonged awakening, cerebral artery thrombosis
Retinal thrombosis
Anuria, oliguria
Postoperative bleeding

111
Q

Complications - Inadequate hypotension – use ___ ___

A

second agent

112
Q

Complications - ____ hypotension

A

excessive

113
Q

Complications - Many patients have underlying ___ ____ that is undiagnosed by routine examine; these patients are at risk for complications due to hypotension / hypoperfusion. Patients should be thoroughly evaluated prior to using deliberate hypotension; the decision should not be one that is made ___ ___ ___, but well in _____.

A

organ dysfunction
in the OR
advance

114
Q

Types - Slow onset, ___ ____ hypotension with ____ return to normal - Plastic, maxillo-facial, ear, nose, throat

A

sustained moderate
slow

115
Q

Types - Moderate sustained hypotension with ___ ____ - when massive ___ ___ is anticipated

A

reduced HR
blood loss

116
Q

Types - Profound hypotension with ___ ____ of excessively small pressures. Clipping ___ ____.

A

short periods
cerebral aneurysm

117
Q

Background anesthesia -
B____ anesthetic
Omit a____
Use generous sedation or analgesia
Neuromuscular blocker
During hypotension, increase ____
Continue in PACU – avoid CO2 retention, hypoxia, use patient’s position

A

balanced
atropine
FiO2

118
Q

Important guidelines -
Don’t reduce the systolic pressure during the _____ to less than the ____ ____ ____.

A

operation
pre-op diastolic pressure

NUNA 681 Pharm II (12 decks)

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