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NA 1 > GA: Maintenance - Exam 2 > Flashcards

GA: Maintenance - Exam 2 Flashcards

1
Q

Monitors to use during GA all the time:

A

-EKG, BP, SpO2
-temp (unless GA timing is <30min OR case <1hr)

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2
Q

Monitors used soemtimes for GA:

A

-O2/Agent conc
-NM block PNS checker
-BIS
-EtCO2

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3
Q

Get baseline VS in

A

PREOP

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4
Q

Which VS to get prior to induction:

A

EKG, BP, SpO2, precordial stethoscope?

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5
Q

Which VS ok to get after induction

A

-ArtBP, temp, SOUND ON FOR PLETH

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6
Q

Using senses in OR:

A

Sound: pleth, SUCTION, surgeon, pt
Vision: monitors, pt, skeletal muscle, surg field
Touch: temp, claminess, pulse, twitches

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7
Q

Precordial stethoscope benefits:

A

-immediate detection of circuit disconnect
-changes in lung sounds
-early detection of decreased Vt/RR in TIVA and MAC cases
-cheap, high reliability

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8
Q

Pulse Ox measure what

A

oxygenation

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9
Q

Capnography measures what

A

ventilation

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10
Q

Factors when using invasive monitoring:

A

-pt hx
-surg procedure
-EBL

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11
Q

Pros of permissive low EtCO2 (30-35)

A

-keeps HR + BP low
-no increase in cardiac O2 demand
-dec need muscle relaxants
-decreased hypnotic requirement

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12
Q

Cons of permissive high EtCO2 (45-50)

A

-HTN
-Tachycardia
-increased myocardial demand = ischemia

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13
Q

What is hypoxic pulmonary vasoconstriction?

A

natural response that causes vasoconstriction in alveoli that are hypoxic to avoiding having blood uselessly perfuse unoxygenated alveoli

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14
Q

Cons of permissive low EtCO2 (30-35)

A

-INHIBITS hypoxic pulmonary vasoconstriction which then leads to SHUNTING causing a LEFT shift in O2Hgb curve (O2 hangs onto Hgb more) in already compromised pt

-prolonged QTi, arrhythmia, decreased CO, decreased CBF, increased CMRO2

-DECREASED lung compliance (BC bronchoconstriction)

THIS IS WORSE THAN PERMISSIVE hypercapnia

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15
Q

Pros of permissive high EtCO2 (45-50)

A

-improved tissue oxygenation/perfusion
-quicker healing and less infection rate from more O2 delivered to surg site
-increased CO and vasodilation
-increased CBF
-mild resp acidosis improves lung function and prevents organ injury
BETTER THAN PERMISSIVE HYPOCAPNIA

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16
Q

When to avoid permissive hypercapnia (EtCO2 45-50)

A

-increased ICP -will increase CBF and raise ICP
-if CO2 gets too high can cause acidosis and make reversing muscle relaxants diffucult***

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17
Q

Temp impact on infection rate

A

2 degree difference in core temp can cause 3x higher rate of infection

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18
Q

Methods we control temp:

A

-bair hugger
-fluid warmer
-cover head
-raise OR temp
-headed humidification of gas

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19
Q

GA causes atelectasis by:

A

-paralyzing pt (reducing lung compliance)
-giving higher FiO2
-eliminating sign reflex
-absorption atelectasis (when O2 goes into capillaries faster than waste like nitrogen leaves into alveoli)

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20
Q

ARMs
-sustained inflation

A

-take pt off vent
-close APL a bit
-squeeze bag until peak pressure is 40cmH2O
-hold for 30-90sec
-some AGM can do this

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21
Q

ARMs
-incremental PEEP

A

-start of w/ PEEP you have
-incrementally increase PEEP to 20cmH2O then go back down but don’t turn off PEEP

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22
Q

O2 Hgb curve
-a pO2 of 60 would normally be

A

90%SaO2

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23
Q

O2 Hgb curve
-normal P50 value

A

26-27mmHg PO2
-PO2 in which 50% Hgb saturated (SpO2 =50%)
-loading onto Hgb isn’t affected by R or L shift in P50
-R or L shift DRASTICALLY affects O2 release from Hgb

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24
Q

O2 Hgb curve
-R shift meaning + causes

A

R shift =Higher P50 value so Hgb releases O2 to tissues more readily

Causes:
-acidosis (CO2 or H)
-HYPERcarbia
-HYPERthermia
-HIGH 2,3 DPG (from chronic hypoxemic or anemia)
-HIGH P50
-Hgb S(sickle cell)

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25
Q

O2 Hgb curve
-L shift meaning + causes

A

L shift=Lower P50 value so Hgb hangs on to O2 more

Causes:
-alkalosis
-HYPOthermia
-HYPOcarbia
-LOW 2,3 DPG (can be from older blood sitting in bank)
-Fetal Hgb
-methemoglobin
-CO

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26
Q

Why does pH affect O2 Hgb curve?

A

Bohr Effect

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27
Q

T/F Pt with CO poisoning will have SaO2 reflecting this

A

FALSE
-will appear falsely high

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28
Q

Methemoglobin
-ferric vs ferrous

A

Fe3+ is FERRIC
Fe2+ is FERROUS<- normal
-Hgb in ferrIC state will not bind with O2

29
Q

Methemoglobin
-affect on OxyHgb curve

A

-will shift L, O2 not delivered to tissues
-SpO2 will look NORMAL

30
Q

Methemoglobin
-causes

A

Nitrate poisoning (prolonged nipride gtt)

LA toxicity:
-procaine
-lidocaine
-benzocaine
-phenytoin
-sulfonamides
-METOCLOPRAMIDE

31
Q

Methemoglobin
-s/s

A

clinical cyanosis and NORMAL SpO2
-falsely high Spo2

32
Q

Methemoglobin
-tx

A

If MetHb is >20%:
-Methylene blue 1-2mg/kg over 5 min
-Ascorbic acid 2mg/kg
-Blood tx PRN
-Hyperbaric O2

NADPH METHEMOGLOBIN REDUCTASE causes enzymatic reduction of LEUCOMETHYLENE which reduces methemoglobin

33
Q

Methemoglobin
-Methylene Blue MOA, CI

A

MOA: NADPH METHEMOGLOBIN REDUCTASE causes enzymatic reduction of the DRUG into LEUCOMETHYLENE which reduces methemoglobin

CI: in pts with G6PD deficiency (type of anemia that reacts to many meds causing hemolysis)

34
Q

Methemoglobin
-Methylene Blue dosing

A

1-2mg/kg over 5 min
-if level still high after 1hr can repeat dose (MAX 7-8mg/kg /day)
-works quick and can cause rebound

1-2 or methylene blue
up to 7-8 if not looking great

35
Q

What must be done after each position change?

A

Assess BS

36
Q

When moving OR bed, always _ _

A

disconnect circuit

37
Q

4-2-1 rule for fluid mgmt

A
  1. 4mL/kg for 1st 10kg
  2. 2mL/kg for 2nd 10kg
  3. 1mL/kg for every kg after first 20kg

Ex) 70kg pt= 40mL(4mL/kg) + 20mL(2mL/kg) + 50mL(1mL/kg)= 110mL/hr maintenance

38
Q

Estimated NPO fluid deficit =

A

Maintenance fluid requirement * hours NPO
-give over 3 hr (1/2, 1/4, 1/4)

Ex) 70kg pt who fasted 6hr
70kg =110mL/hr (4-2-1) * 6 = 660mL deficit for 70kg pt after 6hr fast
So, Hr 1) 110 + 330mL=440mL Hr 2) 110+220mL= 330mL Hr3) 330mL <- JUST maintenance and deficit ONLY so far

39
Q

Replacing surgical fluid losses

A

-superficial trauma (orofacial) = 1-2mL/kg/hr
-minimal trauma (herniorrhaphy) = 2-4mL/kg/hr
-moderate trauma (major nonabdominal or lap abdominal surg) = 4-6mL/kg/hr
-severe trauma (major open abdominal surg) = 6-8mL/kg/hr

Ex) pt having lap abdominal case 70kg taking 3 hr:
280-420mL/hr * 3 = 840-1260mL/hr (NOT INCLUDING MAINT + DEFICIT !)

40
Q

Replace Crystalloid in _ ratio for blood loss

A

3:1 (3mL for every 1mL EBL)
(LR, 0.9, D5W)

Ex) Pt EBL was 1 lap sponge (150mL)
so give 450mL or ~500mL crystalloid(not including maint, NPO deficit, and surg losses**)

41
Q

Replace Colloid or blood in _ ratio for blood loss

A

1:1
(albumin)

42
Q

Release of ADH during stress/procedures so expect UO to _

A

decrease

43
Q

Monitor + chart foley UO volume + characteristic Q

A

1hr

44
Q

Measuring blood loss:

A

-ask whats in suction cannister (not all will be blood)

Sponges:
-4x4=10mL
-Raytech = 10-20mL
-Lap sponge 18x18 = 150mL
weighing sponge = 1gm = 1mL

45
Q

Normal blood volume
-Premie

A

90-105mL/kg

46
Q

Normal blood volume
-full term

A

80-90mL/kg

47
Q

Normal blood volume
-infant

A

70-75mL/kg

48
Q

Normal blood volume
-women

A

65mL/kg

49
Q

Normal blood volume
-men

A

70mL/kg

50
Q

Maximum allowable blood loss =

A

[Estimated blood volume * (Starting Hct -target Hct)] / starting Hct

Ex. 85kg woman w/ preop Hct 35%
EBV= 5525mL , starting Hct = 35, target Hct = 30
[5525*(35-30)]= 27625 then /35 = ~789mL allowable blood loss
-can use Hct or Hgb?

OR Linda method

-find EBV
-EBV x current Hct
-EBV x lowest Hct
-subtract those 2 numbers then x 3

51
Q

What can measure how awake pt is?

A

BIS or entropy monitor
-not as reliable with opioids and certain induction drugs (ketamine, precedex)

52
Q

BIS level indicating pt awake

A

95-100

53
Q

BIS level indicating pt in anesthetic depth

A

40-60
-<60 likelihood of awareness/responsiveness to surgery is low

54
Q

What is difference between deep sleep and anesthetic state?

A

differential in stimulus that rouses brain to conscious perception

55
Q

Distinguishing stimuli that could rouse pt:

A

-intubation
-laryngoscopy
-rib retraction
-abdominal exploration
-incision
-closure
-electrical stim(TOF,etc)
-shouting/shaking

56
Q

Suppression of response to different stimulus (easier->harder)

A

-verbal
-forming implicit/explicit memories
-purposeful movement
-ventilation
-pseudomotor responses (tearing, sweating)
-CV responses

comeback in reverse

57
Q

Amnestic period after anesthetic dose (0.1-0.2mg/kg) is - hrs

A

1-2

58
Q

Awareness most often happens during the _ phase and least on _

A

maintenance
emergence

59
Q

T/F Amnesia is always necessary for GA

A

false, pt could ask for no amnesia, med hx could CI it, type of case, etc

60
Q

IA and IV agents produce amnesia at doses significantly _ than those required for unconsciousness and immobility

A

LESS
-so if unconscious and unable to move SHOULD be ok..?

61
Q

Ways to make sure your pt will not get up off the table and streak down the hall:

A

PNS for NMRD
-want ~2twitches
-cont infusion of NMBD?
-DON’T place DIRECTLY on muscle, want to monitor inhibition of NM receptor
-orbicularis recovers before adductor pollicis so use face 1st and elbow to recover
-check Q 15 min

62
Q

Things you want ready when waking pt up:

A

-mask/syringe
-reversal agent
-post op pain med
-anti emetic
-OPA + tongue blade

63
Q

T/F It is not ok to prep for next case while you are caring for another pt

A

false, just DON’T TURN BACK ON THEM
Scan:
-Pt
-Surg area
-VS
-Vent (Vt, pressure ,FiO2, settings)

64
Q

When to NOT take a break:

A

-key moments (intubation/emergence)-leads to error

65
Q

Things to mention in a brief report:

A

-what surg is being done
-PMH
-airway info
-fluids/blood loss
-any complications (airway/ diff mask, etc)
-plan for emergence (if close to end)
-ASK IF THEY NEED MORE INFO

66
Q

Most adverse events are _ related

A

respiratory
-also human error related

67
Q

Common intraop complications:

A

-PVCs on incision
-pt moving
-bronchospasm
-CV changes
-bleeding
-allergy
-POWER OUTAGE

68
Q

Common human error complications

A

-unnoticed circuit disconnect
-drug errors
-airway mismanagement
-anesthesia machine misuse
-fluid mgmt
-IV line disconnect

NA 1 (31 decks)

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