Final Exam Flashcards
1
Q
What does the left brain reflect?
A
Logical Sequential Rational Analytical Objective Look at parts
2
Q
What does the right brain reflect?
A
Random Intuitive Holistic Synthesizing Subjective Looks at wholes
3
Q
Frontal Lobe used in…
A
Word Production Problem Solving Planning Behavioral Control Emotion
4
Q
Temporal Lobe used in…
A
Memory
Emotion
Word Understanding
5
Q
Occipital Lobe used in….
A
vision
6
Q
Hypoxia
A
Inadequate oxygen in body tissue
7
Q
Ischemia
A
inadequate blood supply in body tissue
8
Q
Seizures
A
sudden attack of an illness or condition, synonyms: attack, fit, spasm, convulsion
9
Q
Hypoglycemia
A
the medical condition of having an unusually low level of sugar in the blood (maybe more with kids)
10
Q
Hyperglycemia
A
the medical condition of having an unusually high level of sugar in the blood (maybe more with adults)
11
Q
Neurological Injury
A
Results from the combination of a patient chronically at risk with a variety of surgically related insults or stresses for which the vascular system is unable to compensate
12
Q
What are the two types of morbid neurological outcomes?
A
Type I
Type II
13
Q
Type I: Morbid Neurological Outcome
A
Cerebral Death
Non-fatal Strokes
New TIA’s
14
Q
Type II: Morbid Neurological Outcome
A
New intellectual deterioration
New seizures upon discharge
15
Q
Type I Predictors
A
Advanced Age (predispose to stroke) 70: 4 to 9% risk
Aortic Atherosclerosis
Hx of prior neurologic events- 15%
Carotid Stenosis
16
Q
Type II Predictors
A
Low cardiac output states Atrial arrhythmias Systolic Hypertension Diabetes Pulmonary Disease Excessive Alcoholism
17
Q
What is the prevalence of neurological impairment?
A
6.1 %
18
Q
What are some examples of neurological impairment?
A
Stroke, stupor, coma, deterioration in intellectual function, memory deficit or seizures
19
Q
What is the prevalence of Post-Op Delirium?
A
10-60% (depends on age and type of surgery)
20
Q
What is the LOS of patients with Post-Op Delirium?
A
These patients have LOS of 20-25 days vs. 10 days for patients with no adverse outcomes
21
Q
Incidence of Transient Neurologic Dysfunction
A
7-44%
22
Q
Incidence of Permanent Complications of neurologic dysfunction
A
1.6 to 23%
23
Q
What type of vent placement reduces neurological risk?
A
RSPV (LA to MV to LV); direct
24
Q
What part of cardiac surgery has the highest neurological risk?
A
Short filling of beating heart after XC
Filling again after taking out vent
25
Surgical Technique addressing Atheroembolism
Epiaortic ultrasound
Single Cross Clamp
No touch techniques
Paying attention
26
How to perfusionists contribute to neurological dysfunction?
Hypoperfusion
Inflammation
Focal (Embolism)
Global (Complete/Incomplete)
27
Types of Embolism
```
Air
Plaque
Microemboli
LV thrombus
Fat
Debris
```
28
Global Examples (Complete and Incomplete)
Complete: cardiac arrest, DHCA
Incomplete: hypotension, inadequate CPB flow
29
3 Examples of Inflammation
Ischemia Reperfusion Injury
Vascular Integrity
Exposure to Blood
30
Ischemia Reperfusion Injury
Potent triggers for: activation of leukocyte, leukocyte-endothelial or leukocyte endothelial platelet binding
31
Vascular Integrity
Foreign Surface
Capillary Plugging
Liberation of free radicals
32
Exposure to Blood
Activates platelets, monocytes and neutrophils
33
Factors Affecting Blood Oxygenation
Tailoring Oxygen Delivery
| Tailoring Oxygen Consumption
34
How do you tailor oxygen delivery?
```
MAP
CO2
CI and Pump Flow
Hematocrit
Mechanical Issues
```
35
How do you tailor oxygen consumption?
Anesthetic Agent and Depth
| Temperature
36
What could you do if you want to cool a kid quickly?
Increase CO2. CO2 is huge in changing co2 metabolic delivery
37
Types of Brain Monitoring
```
Neurological exam
Blood Pressure monitoring
EEG- electroencephalogram
BIS- Bispectral Index
TCD- Transcranial Doppler
ICP- Intra-cranial pressure monitoring
SjVO2- Saturation of Jugular Venous Oxygen
SvO2- Saturation of Venous O2 (global)
rSO2-Regional Saturation of oxygen
```
38
rSO2
Regional Saturation of Oxygen
39
What tools can we use to help prevent brain injury?
```
EEG
BIS Monitoring (Bispectral Index)
INVOS Somanetics Cerebral Oximetry/Invivo Optical Spectroscopy
```
40
What is an EEG?
Recording from scalp of electrical activity in underlying cerebral cortex
Signal by amplifying voltage differences between pairs of electrodes (each pair constitutes a lead attached to the scalp)
Reflects correlated synaptic activity caused by post-synaptic potentials of cortical neurons
Each lead covers a surface area of 2.5 cm
41
Number of EEG Electrodes
21 International 10-20 electrodes are standard
OR: 2-4 lead monitoring (placed over the cerebral artery)
42
What hemisphere are odd numbers? (EEG)
1,3,5,7
| Left Hemisphere
43
What hemisphere are even numbers? (EEG)
2,4,6,8
| Right hemisphere
44
What percent of the population show abnormalities due to old injuries?
15%
45
How are EEG signals defined?
Frequencies
46
What do alpha and beta activity indicate
patient awake
47
What do theta and delta activity indicate
patinet asleep
48
Alpha Wave
8-13 Hz
Medium amplitude
Predominant location: Occiput
Relaxed, awake
49
Beta Wave
13-30 Hz
Low predominant amplitude
predominant location: frontal
Alert, awake
50
Theta Wave
4-8 Hz
High predominant amplitude
predominant location: diffuse
Sleeping infant, child
51
Delta Wave
0-4 Hz
High predominant amplitude
Predominant location: diffuse
Metabolic coma, cerebral ischemia, normal deep sleep, deep anesthesia
52
Main Reason for using EEGs Clinically
Epilepsy
Brain TUmors
Stroke
Focal Brain disorders
53
Secondary Reason for using EEGs Clinically
Diagnosis of coma
Encephalopathies
Brain death
54
EEGs in monitoring depth of perfusion
indirect indicator of cerebral perfusion in carotid endarterectomy
55
Disadvantages of the EEG in the OR
```
Analysis is complex
distract anesthesia from patient care
Electrode impedances
Electrical devises in OR
Electrical activity in skeletal and cardiac myofibrils (pt moving or shivering)
Electromechanical devices (H/L machine)
```
56
What voltages does EEG use?
50-100 micro volts (low voltages)
57
Types of Electrode Impedances
Equal- interference eliminated
| Different- appear as artifact
58
Types of Electrical devices in the OR
Pacemakers
ECG
Electrocaudary units
59
Increase Frequency associated with:
```
Hyperoxia
Hypercarbia: mild
Hypoxia: initial
Seizure
Barbiturates: small dose
Diazepam: ambulatory dose
N2O: 30-70%
Inhalation Agents < MAC
Ketamine
```
60
Decreased Frequency, increased amplitude associate with:
```
Hypoxia: mild
Hypocarbia: moderate to extreme
Hypothermia
Barbiturates: moderate dose
Etomidate
Narcotics
Inhalation agents > 1 MAC
```
61
Decreased frequency, decreased amplitude associated with:
Hypoxia: marked
Hypercarbia: severe
Barbiturates: large dose
62
Electrical silence associated with:
```
Brain death
Hypoxia: severe
Hypothermia: profound
Barbiturates: coma dose
Isoflurane:2 MAC
```
63
Bispectral Index (BIS)
- Processed EEG information as a measure of sedative effects of anesthesia meds
- Monitor was approved for use in 1996
- Information displayed every 10-15 seconds
- Most validated measure of consciousness available
- Graphical trend and numerical value
- Non-invasive, continuous, direct and real time
- Allows anesthesia the ability to access the complicated EEG information during the case
- During the signal analysis, multiple characteristics from the EEG are determined and converted to an algorithm
- Uses easy numbering system to identify depth of anesthesia
64
What does BIS assess?
Relationships among signal components and captures synchronization within signals like the EEG. THen it converts it to a digital number for easy interpretation
65
The BIS Index
The index is a number between 1 and 100
Correlates to important clinical endpoints and EEG states during anesthesia induction
100 is a fully awake patient
66
What does a BIS value of 100 mean?
Awake
| Responds to normal voice
67
What does BIS value of 80 mean?
Light/Moderate Sedation
| May respond to loud commands or mild prodding/shaking
68
What does BIS value of 60 mean?
General Anesthesia
Low probability of explicit recall
Unresponsive to verbal stimulus
69
What does BIS Value of 40 mean?
Deep Hypnotic State
70
What does BIS value of 20 mean?
Burst Suppression
71
What does BIS value of 10 mean?
Flat Line EEG
72
Significant correlation seen between decreasing brain metabolic rate (BMR) and increasing __________.
Anesthesia Effect
73
Target BIS Values
Tailored to each individual
74
Target BIS Value using opoid anesthesia
40 to 60
75
Target BIS Value using opoid anesthesia with supplementation with volatile gas on pump
Normally 25 to 35
| Target to titrate to 45-55
76
Benefits of BIS?
Reduction in primary anesthetic use
Decrease incidence of intraoperative awareness and recall
Reduction in emergence and recovery time
Improved patient satisfaction
77
Disadvantages of BIS
It is a trending device
We can't be responsible to treat the level of sedation
Often monitor only faces anesthesia
78
Two types of Cerebral Oximetry
NIRS (near infra red spectroscopy)
| INVOS (invivo optical spectroscopy)
79
Transcranial Cerebral Oximetry
Non-invasive technique monitoring changes in cerebral oxygen metabolism, which presents additive information when the conventional key variables (as peripheral oxygenation and/or systemic hemodynamics) would not be predictive
80
Benefits of INVOS
Non-invasive, continuous, direct, real time
Site specific (regional) measure vs systemic; often signals earlier warning of reversible ischemia
Detect and correct oxygenation issues that can lead to complications and poor outcomes
Immediately reflects pt reactions
Not pulse, pressure, or temp dependent
Monitor vascular beds
Identifies patient unique rSO2 baselines for customized care
Enhances clinical assessment and decision making
Objective data vs subjective assessment
81
MOMM
Major Organ Morbidity or Mortality
82
What is the MOMM value?
13.4%
83
What is the MOMM with INVOS?
3%
84
MOMM is a cumulative score of:
```
Death within 30 days
Permanent stroke
>48 hours ventilation
Mediastinitis/deep sternal infection
Renal failure requiring dialysis
Re-operation
```
85
Prevalence of Cognitive Decline
24-53%
86
Prevalence of Prolonged Ventilation
5.96%
87
What detects O2 supply issues associated with inflow obstructions?
Cerebral rSO2
88
What are some causes of inflow issues?
Head Position
Heart Position
Arterial Obstruction (Carotid Disease, clamp, hand)
Sponge (cannula malposition)
