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Basics in Anesthesia > Fluids & Monitoring > Flashcards

Fluids & Monitoring Flashcards

1
Q

Extracellular ⅓ 20%

A

sodium, ca, chloride, hco3

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2
Q

Intracellular ⅔ 40%

A

potassium phosphate and magnesium

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3
Q

Extracellular compartments are composed of

A

80% interstitial fluid 11L
20% plasma 3L

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4
Q

Hormone system that regulates blood pressure & fluid balance

A

RAAS

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5
Q

effect of aldosterone from adrenals in RAAS

A

causes kidneys to reabsorb Na and H2O

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6
Q

how RAAS regulates BP

A

Hypotension
Increased tubular chloride
Sympathetic stimulation

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7
Q

posterior pituitary releases

A

ADH

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8
Q

ADH effect on V1 and V2

A

V1: vasoconstriction
V2: decrease UO by causing reabsorption in distal tubules.

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9
Q

PH of 3 cryalloids

A

NS: 5.5
LR: 6.5
Plasmalyte: 7.5

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10
Q

The oSMolality of 3 crystalloids
Standard: 280-295

A

NaCl: 310

LR: 275

Plasmalyte: 298

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11
Q

benefits of LR

A

helps maintain electrical neutrality

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12
Q

Contraindications of LR (mildly hypotonic)

A

TBI, neurovascular insult (cerebral edema), blood transfusion,

Theoretical insult to renal patients due to lactate to bicarb

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13
Q

Plamalyte effect on renal function

A

the most isotonic. preserve pH and renal perfusion best.

compatible with blood

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14
Q

What is a colloid

A

High MW molecules in electrolytes solution. doesn’t pass intact glycocalyx (hyperglycemia)

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15
Q

Dextrans side effects

A

1 renal failure
2 impairs vWF and plt aggregation
3 no longer used in clinical practice.

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16
Q

Albumin in endothelial injuries

A

Pulmonary edema in patients with hyperglycemia/diabetics

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17
Q

How does anesthesia impact MV flow and organ perfusion?

A
  1. Opioid and dex decrease HPA stress response
  2. Neuralaxia anesthesia decreases SNS stim
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18
Q

3 Goal-directed fluid therapy (GDFT)

A
  1. supports O2 balance
  2. suports neuroendocrine response
  3. euvolemia preserves glycocalyx and MV flow
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19
Q

What activates HPA

A

autonomic and somatic stimulation

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20
Q

CNS activation causes the release of hormones

A

corticotropin-releasing hormone –>
anterior pituitary releases ACTH –>
cortisol from adrenals –> increase energy

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21
Q

sympathetic stimulation release of catecholamines from adrenals

A

increase SVR, HR, MV vasoconstriction = increased metabolic rate and O2 consumption

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22
Q

Tissue injury causes the endothelium to release

A

cytokines and inflammatory cells = hyperthermia, increase O2 demand, alters MV circulation

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23
Q

Prolonged tissue injury may cause

A

vasodilation, endothelial damage, edema, insulin resistance, vascular loss, hypotension, DECREASED ORGAN PERFUSION

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24
Q

angiotensin 2 causes:

A
  1. vessel vasoconstriction
  2. kidneys reabsorb NaCl and H2O
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25
Q

ANP pathway

A

atrial stretch –>
ANP release by cardiac myocytes –>
increase GFR –>
drop renin and ADH release –>
increase UO

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26
Q

Hydrostatic vs oNCotic pressure

A

Starling Forces –> dilute blood stops Na reabsoption

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27
Q

blood flow through capillaries depends on 4 things

A

1 BP in capillaries
2 hydrostatic pressure in interstitium
3 oncotic pressure
4 subglycocalyx

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28
Q

Atrial Natriuretic Peptide

A

Released by atrium in response to increased stretch

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29
Q

advantages of crystalloid

A

replacement ratio 3:1
Expands the ECF
Restores 3rd space loss

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30
Q

disadvantages of crystalloid

A

–>Limited ability to expand plasma volume (lasts 20-30min)
–>edema
–> Large volume of NaCL –> hyperchloremic metabbolic acidosis
–>dilutes albumin (decrease cap onc pressure)
–>dilutes coags

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31
Q

Colloid Advanatges

A

replacement 1:1
increases plasma vol 3-6 hours
small vol
less edema
anti-inflammatory
dextran 40 decreases blood viscosity & improves microcirculatory flow in vascular surgery

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32
Q

Dextran

A

no longer used in clinical practice due to renal failure, impairing vWF and platelet aggregation

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33
Q

females

A

45 % solids, 55% fluids

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34
Q

males

A

40% solids 60% fluids

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35
Q

Fluid exchange between extracellular compartments is dependent on

A

Starling Forces

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36
Q

daily fluid volume required to maintain TBW

A

25-35 ml/kg per day

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37
Q

intravasuclar blood pressure driven by CO and impacted by vascular tone

A

capaillary hydrostatic pressure Pc

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38
Q

hydrostatic pressure of the interstitial space

A

interstital fluid pressure Pif

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39
Q

osmotic force of
colloidal proteins within the vascular space

A

plasma oncotic pressure

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40
Q

3 effects of RAAS system

A

1 ADH release from posterior pituitary
2 Aldosterone release adrenal cortex
3 Renal efferent arteriolar vasoconstriction increases GFR

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41
Q

Atrial Natriuretic Peptide

A

Released by atrium in response to increased stretch

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42
Q

5 effects of ANP

A

1 Increase GFR (Kidneys release Na and Water)

2 Systemic vasodilation

3 Inhibit renin release
4 Opposed production & action of angiotensin 2
5 Decreases aldosterone secretion

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43
Q

Historical Fluid Management 4 Steps

A
  1. 4 2 1 rule
  2. NPO time hours x maintenance rate
  3. surgical loss
  4. Blood Loss
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44
Q

HPA –> cortiocoreleasing hormone –>

A

–> ant pit releases ACTH –> cortisol from adrenals

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45
Q

4 effects of cortisol from adrenals

A
  1. protein breakdown
  2. hepatic release of glucose
  3. Glycogenolysis
  4. anti-inflammatory

ultimately increase energy levels and preserve intravascular volume

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46
Q

Increase catecholamine from adrenal medulla –>

A

Increased HR, SVR, and microcirculatory vasoconstriction (bad). Causes increased metabolic rate and O2 consumption

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47
Q

Anesthetic Considerations of GDFT

A

dex/opiods/neuralaxia supports O2 balance, neuroendocrine response, and euvolemia preserves glycocalyx and MV flow

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48
Q

CI <2.5 after 250cc bolus

A

inotrope

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49
Q

MAP <65 after 250cc bolus

A

vasopressor

50
Q

what relationship does the frank starling law describe

A

LVEDP and SV. Increase in preload will increase contractility until a point that it cannot generate more force.

51
Q

CVP a wave

A

atrial contraction

52
Q

CVP c wave

A

tricuspid closure; buldging

53
Q

CVP v wave

A

RV systole/ RA passive filling

54
Q

2 reasons for the loss of CVP a waveform

A

a fib
v pace

no RA contraction

55
Q

Giant a wave or cannon wave

Teddys heart disease challenge

A

Junctional rhythm
Complete AV block
V pace
T or M stenosis
MIschemia
Ventricular hypertrophy

56
Q

large v waves on CVP

A

tricuspid mitral regurg
acute increase in intravascular volume

57
Q

High CVP

A

fluid volume overload
tricuspid stenosis/regurg
tamponade
R heart failure
L heart failure
pulmonary hypertension
constrictive pericarditis

58
Q

distance from IJ to RA

A

15 cm

59
Q

distance from IJ to RV

A

25-35cm

60
Q

distance from IJ to PA

A

35-45cm

61
Q

distance from IJ to PAOP

A

40-50cm

62
Q

subclavian to RA length

A

10cm

63
Q

L IJ to RA

A

20 cm

64
Q

femoral vein to RA

A

40 cm

65
Q

Allen test 3 steps

A

1 depress ulna and radial open and close fist
2 release the ulnar artery
3 blood should return

–> positive fallen test

66
Q

PA catheter dicrotic notch

A

closure of pulmonic valve

67
Q

High PAP

A

pulmonary hypertension
LV failure
mitral stenosis/regurg
volume overload
ASD/VSD L to R shunt
catheter whip

68
Q

High PAOP

A

ischemia
LV failure
mitral stenosis or regurg
volume overload
cardiac tamponade
constrictive pericarditis

69
Q

PVRI Pulmonary Vascular Resistance Index

A

(mPAP - PAOP)/CI x 80
45-225 dynes * sec/cm5 * m2

70
Q

SVRI Systemic Vascular Resistance Index

A

(MAP-RAP)/CI x 80
1760-2600 dynes * sec/cm5 * m2

71
Q

CI

A

CO / BSA
CI = 2.8-3.6 L/min * m2

72
Q

area under time temperature curve

A

inversely proportional to CO

73
Q

thermodilution

A

d5w in proximal swan port –> thermistor at trip of swam

74
Q

Thermodilution and CO overestimated: 4

A

Falsly high CO

low injection volume
injection too warm
thrombus on thermistor
partial wedge

Small warm wedged thrombus

75
Q

Thermodilution and CO underestimated 2

A

Falsely low CO

excess injection volume
too cold injection

76
Q

unpredictable thermodilution readings

A

shunts (L–>R & R–>L)
tricuspid regurg

77
Q

normal MVO2

A

60-80

78
Q

what is mvo2

A

o2 left after delivering to tissues, indirect monitor of O2 delivery (decreasing CO)

79
Q

increased O2 Need

A

fever, shivering, pain, stress, anxiety

80
Q

decreased O2 Need

A

analgesia
sedation
mechanical ventilation
hypothermia

81
Q

decreased O2 supply

A

decrease CO
hemodilution
hypoxia
anemia
heart disease

82
Q

increase O2 supply

A

increase CO
early sepsis
cyanide poisoning
AV shunt

83
Q

ET CO2 compared to ABG

A

2-5 torr lower than ABG with cardiopulmonary abnormalities and larger with dead space

84
Q

ET CO2 (infared analysis) diverting monitor

A

Most common (the ones we use) . it measures gas from a sample tube, NOT the breathing system

85
Q

CO2 end of inspiration, begins expiration

A

first phase of capnography

86
Q

CO2 capno expiratory upstoke

A

second phase

87
Q

CO2 capno plateau & alveolar emptying

A

third phase

88
Q

co2 capno rapid decrease of CO2 due to inspiration

A

fourth phase

89
Q

increased dead space (increased VQ mismatch) on ETCO2

A

decreases ETCO2

90
Q

LOW co2 production

A

Decreased CO2 production/delivery
Hyperventilation
Equipment problems

91
Q

High CO2

A

high CO2 production/delivery
hypoventilation
equipment problems:

92
Q

Flow Volume Loops provide info on

A

pulmonary resistance
Flow vs Volume

93
Q

Pressure-Volume Loop provides info on

A

compliance

v/p = compliance

94
Q

Left Shift Oxyhemo

A

hypothermia
hypocapnia
alkalosis
decreased 2,3 dgp
carboxyhemoglobin
met hemoglobin
hgb f

95
Q

What is the oxyhemoglobin curve telling us

A

relationship between saturation of hemoglobin at a given PO2 in plasma

96
Q

Pulse oximetry deviancy

A

2% when 80-100%
5% when <80%

97
Q

Deoxygenated hbg absorbs light at what wavelength

A

650-750 nm red

98
Q

4 limitations of pulse ox

Smic

A

1 methemoglobin (underestimates SPO2 when > 85%)
2 carboxyhemoglobin
3 sickle cell
4 injected dyes (methyl blue and indigo carmen)

99
Q

6 risks associated with hypothermia

A

1 wound infection
2 increased O2 consumption (shivering)
3 increased r/o CV events
4 sickling in sickle cell
5 decreased drug metabolism
6 coagulation impaired

100
Q

ANNA recommendation

A

temp monitoring for all peds patients recieveing GA and any other time when indicated (using a warmer or case >30m long)

101
Q

ASPN definition of hypothermia

A

<36 c

102
Q

forced air warmer is what kind of warming

A

convective warming

103
Q

1u of blood or 1L crystalloid decreases body temp by how much

A

0.25 c

104
Q

What is the gold standard of temp management?>

A

PA blood temp

105
Q

what 3 other temp sites correlate with PA blood temp?

A

1 tympanic membrane
2 distal esophagus
3 nasopharyngeal

106
Q

how to measure nasopharyngeal temp length

A

nose to ear

107
Q

esophageal monitoring

A

45 cm from nose

yes in GA with ETT
No in LMA

108
Q

thermoregulation afferent nerves a delta vs c

A

c fibers = warm
a delta = cold

109
Q

General anesthesia drops temp by how much

A

0.5 to 1.5 in first 30 m, then slowly declined 0.3 until plateau

110
Q

why does regional anesthesia cause hypothermia

A

blocking ANS causes vasodilation

111
Q

combining GA and regional causes that effect on temperature

A

plateau never comes, temperature will continue to drop

112
Q

4 MOA of heat loss

A

1 radiation - from patient to environment
2 conductive - from patient to OR table
3 convective - moving air currents
4 evaporation - vaporization of liquid from body

113
Q

5 effects of mild hypothermia on the body

A
  1. shivering (increased O2 consumption)
  2. coagulation issues
  3. wound infection
  4. decreased drug metabolism
  5. 3x increase in morbid myocardial outcomes
114
Q

3 reasons for hyperthermia in OR

A

1 iatrogenic over warming
2 MH
3 infection (less common)

115
Q

the device that monitors anesthesia depth

A

BIS Bispectral Index

116
Q

Where do you want your BIS?

A

40-60

117
Q

limitations of BIS

A

Unreliable ketamine and nitrous oxide
hypothermia
cautery
bare bugger
baby <6m

118
Q

<40 BIS?

A

deep hypnotic = oversedated = hemodynamic change

119
Q

the upstroke of pulmonic PA catheter waveform

A

opening of pulmonic valve

120
Q

wedge pressure a wave

A

LA systole

121
Q

wedge pressure c wave

A

mitral closure (hard to see)

122
Q

wedge pressure v wave

A

La filling

Basics in Anesthesia (5 decks)

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