Final Exam Flashcards
What conditions cause R ventricular hypertrophy?
COPD, pulmonary stenosis, tricuspid insufficiency, posterior MI
What EKG findings will you see with R ventricular hypertrophy?
Tall R wave in V1, progressive decrease in amplitude in V4, shifting QRS vector to right with increased R precordial waves
What are some causes of secondary T wave abnormalities?
conduction disturbances, ventricular hypertrophy, CNS ischemia
What EKG findings would you see with left ventricular hypertrophy?
deeper right precordial S waves and taller left precordial R waves
How do you calculate MAP?
(SBP + 2 DBP)/3
For every 10 cm change, the BP changes by
7.4 mm Hg
For every inch change, the BP changes by
2 mmHg
What is the calculation for allowable blood loss?
ABL = EBV x [(starting Hct-target Hct)/starting Hct]
What should your Hct be in relation to your Hgb?
3x
How do you calculate EBV?
premies: 90-100 ml/kg, full term neonates: 80-90 mL/kg, infants 80 ml/kg, adults 70 ml/kg
When should you transfuse?
healthy patients 7-8 g/dl and Hct of 21-24%; elderly or CV/pulmonary dz Hgb 10 d/dL or Hct 30%
How much does one unit of pRBCs raise Hgb and Hct?
1 and 2-3%
What is the ideal BP cuff size?
ideal length 80% of extremity circumference, 40% of extremity circumference
Deflation of the IABP should occur at what point?
Before QRS complex
How do you calculate maintenance fluid rate?
4,2,1 rule (or if over 20 kg, just take weight and add 40)
How do you calculate TBW deficit?
(0.6 x kg) x ](Na-140)/140]
What are some causes of decreased SvO2?
hyperthermia, shivering, seizures, reduced pulmonary transport of O2, hemorrhage, decreased CO
What are some causes of increased SVO2?
hyperdynamic conditions, sepsis, L-R shunts, cyanide poisoning increased CO, unintentional PA wedge, L shift in O2Hgb curve
What does hyperkalemia do to your EKG?
narrow peaked T wave, arrhythmia, wide QRS, heart block
How do you calculate NPO status replacement?
hrs NPO x maintenance rate
What is considered a minimally invasive procedure and what is the fluid requirements?
lower abdomen, hernia repair, small plastics - 2 ml/kg
What is considered a moderately invasive procedure and what is the fluid requirements?
upper abdomen, appy, chole, uncomplicated ortho procedures- 4 ml/kg
What is considered a severely invasive procedure and what is the fluid requirements?
upper and lower abdomen, total hip, bowel resection- 8 ml/kg
What is the fluid replacement in the first hour of surgery?
1/2 NPO deficit + 3rd space loss + maintenance
What is the fluid replacement in the 2nd and 3rd hours of surgery, each?
1/4 NPO deficit + 3rd space loss + maintenance
What is the fluid replacement in the 4th hour of surgery and beyond?
3rd space loss + maintenance
What EKG changes will you see with hypercalcemia?
shortened ST and QT interval
What are the goals of ERAS?
decrease LOS and morbidity, faster recovery, decreased readmission rates, decreased cost
What are pre-op considerations for ERAS?
optimize pre-op conditions, educate pt and family to set realistic expectations, and emphasize fasting period
What are the fasting guidelines for ERAS?
2 hours for clear liquids, 2 glasses of water before bed and morning of, carb rich drink 2 hours prior
What are common premedications for ERAS?
acetaminophen, celecoxib, gabapentin, heparin
What medications should you avoid giving routinely preop according to ERAS?
benzos
What does ERAS recommend for induction?
propofol, intermediate acting NMBA (roc) or succs, antibiotic prophylaxis 30-60 min before incision
What are mechanical ventilation optimal parameters for ERAS?
tidal volume 6-8 ml/kg IBW, PEEP 5 (10 for lap procedures), FiO2 50%, 8 RR to maintain ETCO2 40
Describe TRALI
Transfusion related lung injury- caused by transfusion of antibodies that interact with pt’s WBCs- aggregate in pulmonary circulation and damages alveolar capillary membrane
What is TACO?
transfusion associated circulatory overload
What’s the difference between type, screen, and crossmatch?
type- 5 minutes, tests for ABO and Rh antigens; screen- 45 minutes, tests for antibodies; crossmatch- 45 min, tests compatibility between recipient serum and actual blood to be transfused
What should you do for an emergency transfusion?
2 pRBCs of uncrossmatched O- blood and continue until anti a/b titers are determined
What are PAC indicated for?
impaired cardiac function (CAD, valvular dysfunction, HF), evaluation of response to fluids/drugs (shock/sepsis, renal failure, severe burns, cont iontropic support), cross clamping of thoracic aorta, suspected or diagnosed pulmonary emboli, pulmonary disease (acute resp failure, COPD, pulmonary HTN)
What procedures are PAC indicated for?
CABG, valve replacement, pericardectomy, aortic surgery requiring cross clamping, sitting crani, portal systemic shunts, major pulm procedures, high risk OB
What are contraindications to PAC?
absolute- tricuspid or pulmonic valve stenosis, RA or RV masses, tetralogy of Fallot
relative- severe dysrhythmias, coagulopathies, new pacemaker or LBBB
How do PAC monitor CO?
based on Fick principle- measures concentration difference in fluid stream over time using thermodilution technique
Describe thermodilution technique
injection of known quantity and temp bloused through proximal port of PAC at end expiration- average of 3 injections used
CO value is derived from the ? (thermodilution technique)
total area under the waveform
What is CVP?
measures fluid pressure entering R side of heart
What is the a wave on CVP and where is it on EKG?
RA contraction; just after P wave
What is the c wave on CVP and where is it on EKG?
ventricular contraction, tricuspid closing and bulging; just after QRS
What is the v wave on CVP and where is it on EKG?
atrial filling; just after T wave begins
What is the x descent on CVP and where is it on EKG?
atrial relaxation/ventricular systole; ST segment
What is the y descent on CVP and where is it on EKG?
tricuspid opens and blood fills ventricle; after T wave ends
What is the risk when using L IJ approach?
thoracic duct damage
What is the distance from the L IJ insertion site to vena cava- RA junction?
20 cm
Where should the PAC tip be?
zone 3- uninterrupted blood flow
What are s/s of hypermagnesemia?
lethargy and loss of DTRs, decreased BP/HR, decreased RR, increased PR interval, wide QRS, prolonged QT
What are causes of hypernatremia?
loss of water in excess to Na or retention of large quantities of Na- osmotic diuresis, diarrhea, perspiration, DI, nephrogenic diabetes, hypertonic saline, hyperaldosteronism/Cushing’s
What is a significant electrolyte imbalance that can occur from massive transfusion?
hypocalcemia- Ca binding by citrate preservative
What is an acid/base imbalance from massive transfusion?
metabolic alkalosis (citrate and lactate are converted to bicarb by the liver)
What is hetastarch and what can it cause?
colloid; coagulopathy
What is the distance from PAC insertion to RA, and what does the waveform look like?
20-30 cm, small amplitude waveform
What is the distance from PAC insertion to RV, and what does the waveform look like?
30-40 cm, high amplitude waveform
What is the distance from PAC insertion to PA, and what does the waveform look like?
40-50 cm, high amplitude waveform with higher diastolic trough than RV
What is the distance from PAC insertion to PCW, and what does the waveform look like?
45-55 cm; similar waveform to RA but higher pressure
What are the 4 variables of mixed venous oximetry? (What is the equation?)
SvO2 = SaO2 - [VO2/(Q x 1.34 x Hgb x 10)]
What is the purpose of PACU?
critical assessment, stabilization, prevention and detection of complications
What are the benefits of MAC?
Quicker recovery in OR, shorter PACU time, less N/V, less cost, high patient satisfaction
Goals of operative positioning
optimum surgical exposure, access for monitoring, prevent complications and injuries, maintain body integrity and physiological function
Describe brachial plexus nerve injury
prevents muscles of arm and hand from working properly, loss of feeling
Describe ulnar nerve injury
numbness/tingling of 4th and 5th fingers
Describe radial nerve injury
drooping of wrist and fingers
Describe suprascapular nerve injury
pain in shoulder, weakness and loss of shoulder function
Describe sciatic nerve injury
weakness of knee flexion, foot movements, difficulty bending food inward and down
Describe common peroneal nerve injury
inability to dorsiflex toes
Describe posterior tibial nerve injury
flattening of foot, inward rolling of ankle, turning out of toes and foot
Describe saphenous nerve injury
loss of sensation over medial aspect of lower leg
Describe obturator nerve injury
difficulty with ambulation, unstable leg
Describe pudendal nerve injury
phantom pain of lower regions of pelvis
Describe femoral nerve injury
affects ability to walk, problems with sensation of leg and food
What are common nerve injuries in lithotomy?
common peroneal, femoral nerve
What surgical position can cause compartment syndrome from occlusion of the femoral artery?
lithotomy
What are some useful pieces of information from previous anesthesia record?
induction drugs/doses used, tube size used, history of MH, pseudocholinesterase deficiency
What is the purpose of Murphy eye, and should your stylet pass it?
allows for release of pressure; no
How do you perform a Mallampati?
sit upright, extend neck, open mouth wide, stick out tongue, do NOT phonate
What are the components of the preop assessment?
name, DOB, verify procedure, indication for procedure, med history, prior anesthetic history, H&P (airway), lab results, consults, pt eduation, informed consent
What changes flow from laminar to turbulent?
change in direction >20 degrees, increased velocity, corrugated tubing
What are required components of vaporizers?
concentration calibrated, interlock system, liquid level present, keyed filler device, no discharge of liquid anesthetic
Describe variable bypass vaporizer
splits gas into vaporizer above and through liquid agent- uses bimetallic strip
Describe electronic vaporizer
computer calculates volume of gas to get concentration- heated and pressurized
Which way do the vaporizer knobs move?
counter clockwise
What is the Tec 6 heated and pressurized at?
39 C and 2 atm
All the muscles that move the VC (abductors, adductors, tensors) are supplied by the ? except the cricothyroid muscle, which is supplied by the ?
RLN; SLN
For sensory, above the VC, the larynx is supplied by the ? and below the VC by the ?
ILN (branch of SLN); RLN
What does the internal branch of SLN do?
sensory input above VC
What does the external branch of SLN do?
motor to cricothyroid muscle
Where is the R RLN?
branches from vagus, loops around brachiocephalic artery
Where is the L RLN
branches from vagus and recurs around aorta
What is the only motor branch of the glossopharyngeal nerve?
stylopharyngeus
What do the posterior cricoarytenoids do?
abducts cords
What do the lateral cricoarytenoids do?
adducts cords
What muscles close the glottis?
aryepiglottic and oblique arytenoid muscles
What muscles open the glottis?
thyroepiglottic muscles
What is the ideal gas law?
PV=nRT or PV=T
Boyles law
T constant, P and V inversely proportional
Charles law
P constant, T and V directly proportional
Gay Lussac law
V constant, T and P directly proportional
How do you calculate the contents of an O2 cylinder?
2000 psi/660 L, cross multiply with current pressure
when should you change your O2 cylinder?
1000 psi or less
What is Fick’s law?
diffusion is directly proportional to surface area and gradient and inversely proportional to membrane thickness
How do you calculate TV delivered if your machine does NOT decouple and does NOT account for compliance?
(TV+FGF)-compliance
FGF- TV in mL divided by I:E ratio divided by RR
compliance- compliance x PIP
How do you calculate FiO2?
divide actual oxygen by total amount of liters
ex) 1 L of O2 and 1 L of air- 1.21/2= about 60%
What is the purpose of a diaphragm valve and where is it found on the machine?
reduces pressure- first and second stage regulator (decreases pressure from cylinder)
What are some examples of active cardiac conditions?
unstable coronary syndromes (unstable angina, severe angina, recent MI), decompensated HF, significant arrhythmias (high grade AV block- mobitz 2 and 3rd degree, SVT or Afib RVR, symptomatic ventricular arrhythmias or bradycardia, new onset VT), severe valvular disease (AS, MS)
EKG findings with posterior MI
R wave >0.04 seconds in V1 and V2 and R/S >1 posterior, depressed ST
What artery is affected in posterior MI?
posterior descending
What EKG findings would you see in RBBB?
V1- rSR (triphasic, wide QRS, inverted T
V6- small q wave, broad S wave, upright T
What EKG findings would you see in LBBB?
V1- broad negative QRS
V6- positive QRS, broad R wave, no Q wave or S wave
EKG changes with inferior wall infarct
ST elevation in II, III, aVF; ST depressions in I and aVL; abnormal Q waves in II, III, aVF
What are re-entry or circus movements?
re-excitation of cardiac tissue from same cardiac impulse- mechanism of most tachydysrhythmias
What are requirements of re-entry/circus movements?
imbalance between conduction and refractoriness, unidirectional block
What are some causes of re-entry/circus movements?
elongation of conduction pathway (chamber enlargement), decreased velocity of conduction of cardiac impulse (after MI), shortened refractory period (toxic doses of antidysrhythmics)
What lead is best for detecting ischemia?
V5
The ? represents the combination of all the instantaneous vectors during ? into a single vector that we call ?
mean cardiac vector; systole; axis
Limb leads determine the axis in the ? plane and provide information about the position of the electrical activity of the heart as it rotates around an ? axis. This is the axis we will deal with as it is the most commonly reported on EKGs
frontal; anteroposterior
Intersection of leads ? and ? divide the precordium into 4 quadrants
I and aVF
What is a normal axis?
0 to 90 between positive poles of leads I and aVF- QRS is upright in both
What is R axis deviation?
90 to 180- QRS is negative in I and positive in aVF
What is L axis deviation?
0 to -90- QRS is positive in I and negative in aVF
What is indeterminate axis deviation?
-90 to -180 QRS is negative in both leads
What leads monitor the lateral wall of the LV?
V5-6
What leads monitor the anterior LAD?
V1-V6
In lead I, left arm is ? and right arm is ?
positive; negative
In lead II, right arm is ? and foot is ?
negative; positive
In lead III, left arm is ? and foot is ?
negative; positive
Name the 9 cartilages of the larynx
single- cricoid, thyroid, epiglottic
paired- arytenoid, corniculate, cuneiform
