ITE block 7 Flashcards
Why do infants tolerate dehydration better than adults?
Greater total body water to body weight ratio
infants 70% and adults 60%
-10% fluid deficit would be severe dehydration in adults, mod in infants
Best way to assess dehydration in infants
weight!
the tachycardia, skin turgor, cap refill can change due to other factors
Signs of mild dehydration
Weight loss 5%
fluid deficit 50 cc/kg
normal skin turgor
flat anterior fontanelle
normal eyes
Urine <2 cc/kg/hr
urine specific gravity < 1.02
infant moderate dehydration
weight loss 10%
fluid deficit 100 cc/kg
decreased skin turgor
sunken anterior fontanelle
sunken eyes
dry mucous membranes
<1 cc/kg/hr urine
urine specific gravy 1.02-1.03
infant severe dehydratio
weight loss 15%
fluid deficit 150 cc/kg
greatly decreased skin turgor
markedly sunken anterior fontanelle
very dry mucous membranes
UOP <0.5 cc/kg/hr
urine specific gravy >1.030
Burn resuscitation
4 cc x %TBSA x kg
1st half given in first 8 hours
2nd half given in next 16 hours
Fluid rehydratio in severe dehydration in infants
emergency phase: 20-30 cc/kg isotonic fluid bolus
phase I: first 6-8 hrs: 25-50 cc/kg
phase 2: next 24 hours: remainder of deficit
ABA physical requirements to practice
no age or physical requirements
-if disability and safe workaround it’s okay
-on a case by case basis determined by practitioner and their employer if can be done safely
When to use blood cyanide levels
only as a confirmatory diagnostic
-not helpful acutely due to time it takes to process -> use co-oximetry, ABG/VBG, lactic acidosis, hx of Na nitroprusside use to dx and treat
Tx for cyanide toxicity
hydroxocobalamin
sodium thiosulfate
-b/c it causes inhibition of oxidative phosphorylation
Symp of cyanide toxicity
HA, confusion, dizziness, sz -> coma
HTN and tachycardia -> hypoTN, arrhythmia, AV block
flushing, cherry red appearence
abd pain, N/V
tachypnea -> bradypnea
pulm edema
cyanosis
renal failure
hepatic necrosis
rhabdo
Decelerations in Fetal heart tracing
HR decrease >15 bpm for max of 3 minutes
Variable decelerations when cat II v III?
if >15 bpm for < 3 minutes, for <50% of the contractions category II
if >50% of contractions -> category III -> intrauterine resuscitation -> L lateral position, IVF, maternal O2, or poss intra-amniotic infusion
Types of deceleration
VEAL CHOP
Variable: Cord compression
Early: Head compression
Accelerations: Okay
Late: Placental insuff
Prolonged decelerations
decelerations lasting 2-10 minutes -> severe uteroplacental insuff or umbilical cord compression
Achondroplasia considerations
-short stature
-foramen magnum stenosis -> likely to get brainstem compression dep on position
-avoid inc ICP (likely to have hydrocephalus + foramen magnum stenosis)
-choanal stenosis
-central apnea and OSA -> can lead to pulm HTN
-macroglossia, high arched palate
-spinal stenosis
-macrocephaly
Post ROSC what is the next step
12 lead EKG
-need baseline if doing hypothermia
-need baseline if going to do PCI
Gold standard for dx of MH
halothane and caffeine muscle contracture test
hypothermia causes intraop
Decreased wound healing
Increased myocardial O2 consumption (shivering)
clotting issues
inc infectio
risk of arrhythmia or ischemia
Why hypothermia post neuraxial
Impaired detection of cold
Vasodilation
Decreased threshold for shivering and vasoconstriction (lower temp required to initiate)
worse w/ higher dermatome
GA v GA and neuraxial hypothermia
GA + neuraxial -> worse hypothermia than GA alone
-Get redistribution from both, and lowering vasoconstriction
-Worse central recognition of hypothermia w/ both
Cirrhosis hemodynamic changes
portal HTN -> inc endogenous vasodilators (nitric oxide) -> sensed as volume depleted by kidneys -> inc renin and sodium retention
-vasodilation -> dec SVR -> dec afterload -> inc cardiac output -> inc mixed venous
-inc collaterals produced to avoid portal HTN -> AV collaterals bypass capillary beds -> inc mixed venous
-hyperdynamic cardiac (inc CO and dec SVR)
-inc blood shunted to intestinal system -> inc vasoactive intestinal peptide
Platypnea
hypoxia and dyspnea while sitting up, improved while laying flat
-due to inc shunting of blood through lungs
-assoc w/ hepatopulm syndrome
thromboangiitis obliterans
small blood vessels become inflamed and swollen -> blood vessels narrow and get blocked
-fingers/toes pale, red, blue, and cold w/ sudden severe pain
When to use a sympathetic block
Neuropathic pain (CRPS, DM, herpes zoster)
Visceral pain (cancer pain -> celiac block)
Vaso-occlusive dx -> helps relieve pain and improves circulation (CP from chronic angina, Raynauds, vasospasm, thromboangiitis obliterans)
Where are sympathetic NS cell bodies located?
T1-L2 in lateral horn
Stellate ganglion
C6-7
block used for pain in upper extremity/thorax
complications: Horner syndrome, tracheo/esophageal injury, PTX, RCLN injury
Celiac plexus
located by aorta and IVC at L1
used to block for abd cancers, usually posterior approach below 12th rib
complications: retroperitoneal hematoma, bleeding, chylothorax, PTX
Lumbar sympathetic chain
Anterior to L1-5
posterior approach
tx: neuropathic pain in lower limbs, phantom pain, visceral pain involving intestinal/urinary
compl: genitofemoral n injury, bleeding
ABG for pregnant woman
Ventilation changes occur w/i 1st 12 weeks -> 40% inc MV by 12 weeks
resp alk -> incompletely compensated w/ metabolic acidosis
pH 7.44/ PaCO2 30/ PaO2 105/ HCO3 21
O2 initially inc during 1st and 2nd trimester, by 3rd inc O2 counteracted by the inc O2 demand from fetus
Respiratory quotient
Amount of CO2 per unit O2 consumed to a specific energy substrate
0.8: mix of carbs and proteins
0.7: lipids
0.8: protein
1: Carbs
if pt having trouble weaning off vent -> give more lipids, lower CO2 production
Rapid shallow breathing index
RSBI = RR/ TV
<105: successful weaning predicted
>105: failure predicted
In ICU RSBI > 105, TPN due to ileus
how to improve chances of vent weaning?
Inc lipid concentration in TPN -> less CO2 produced than if more carbs or protein -> easier to wean b/c less inc in RR encouraged
Rf for metformin lactic acidosis
contrast dye
renal impairment
hepatic impairment
65 or older
hypoxic or volume-depleted
excessive alcohol**
tx: supportive, HD
What side ETT fits in a size 4 Unique LMA?
6.0
What size ETT fits in a size 4 Ambu LMA?
7.5
What size ETT fits in a size 4 ProSeal LMA?
5
What size ETT fits in a size 4 iGel LMA?
7
Pulmonary compliance equation
inverse of elastance
complication = Change in volume/ change in pleural pressure
2 most common causes for delay in ambulatory surgery center
pain
PONV
Best way to wean pt off vent if failed initial SBT
Daily SBTs w/ pressure support assistance (pressure support augmentation w/ pt initiation)
-progressive dec in pressure support
10 month old for uro procedure long face, high prominent forehead, wide nose, low-set ears, high arched clef palate, micrognathia, deep palmar creases, developmentl delay, systolic murmur? chromosomal abnormality?
Trisomy 8 w/ mosaicism
-may have renal issues, assoc w/ AML and MDS,
prenatal corpus callosum agenesis and ventriculomegaly are suggestive
-if you survive beyond first few weeks of life, likely have mosaicism
A few day old baby, microcephay, microphthalmia (small eyes), cleft lip, cardiac def, hypoplastic or absent riibs, polydactyly
Patau syndrome (mean surival 7 days)
Trisomy 13
**holoprosencephaly, cleft lip, absent ribs, polydactylyl)
-if you survive beyond first few weeks of life, likely have mosaicism
One week old baby, microcephaly, micrognathia, VSD/ASD, inguinal hernia, renal malformation, rocker bottom feet, clenched hand w/ overlapping fingers, intellectual disability
Edwards Syndrome
Trisomy 18 (mean surival 14 days)
VSD, rocker bottom feed, clenched hand w/ overlapping digits
-if you survive beyond first few weeks of life, likely have mosaicism
peds single palmar crease, upslanting palpebral fissures, endocardial cushion defects, atlantoaxial instability and sleep apnea, dx?
Trisomy 21
How much of a hospital pharmacy budget is anesthesia medication
10-13%
What’s cheaper TIVA or inhaled anesthesia?
TIVA 10-100x more expensive
-meds, pumps, tumbing
-does not result in signicant PACU savings
Cost of iso v sevo
sevo 10x more expensive
des 25x more
MC cause of death in preeclampsia
Stroke
-93% hemorrhagic
-why we give meds to get BP <160 but by non more than 15-25%
MC cause of maternal death in US
cardiac dx
MC cause of maternal death worldwide
PPH
Lab tests that indicate preeclampsia with severe features
-plts < 100
-Cr > 1.1
-doubling of Cr
-doubling of LFTs
-pulm edema
-cerebral/visual symp
How is serotonin involved w/ nausea and vomiting
When toxic substances come into constant w/ enterochromaffin cells in gut walls -> release serotonin
Chemoreceptor trigger zone, how nausea?
Outside of BBB -> direct action of drugs and toxins on CRTZ **doesn’t come in contact w/ bloodstream materials
Carcinoid tumor symptoms
flushing, diarrhea, wheezing, abd cramping
**NO N/V
What inhibits serotonin nausea?
GABA, vasoactive intestinal peptide, somatostatin
Pacemaker nomenclature
I: Paced
II: Sensed
III: Resp to sensing
IV: rate modulation (O or R)
V: multisite pacing
PCR -> PaCeR
What is pacemaker syndrome?
VVI
Ventricles are pacing w/o atrial coordiation -> loss of cardiac output
Central line placement, what do after after manometry use?
Confirmed -> no further steps necessary, can dilate and place line
Why RIJ over LIJ?
Direct route to heart
Higher apex of lung on L
Thoracic duct on L
Difference b/w V-V and V-A ECMO
V-V is respiratory support -> native and artificial lung in series
V-A is cardiopulm support -> native and artifical lung in parallel
both drained through venous system, just about where it goes back
**in both native lungs can be completely or partially bypassed
Flows for V-A ECMO
peds; 100 cc/kg/min
adults: 60 cc/kg/min
Flows for V-V ECMO
peds: 120 cc/kg/min
adults: 60-80 cc/kg/min
Advantage of centrifugal pumps over roller pumps
smaller priming volume
lack of gravity drainage
prolonged operation
Disadvantage of centrifugal pumps
blood stagnation and heating (inc risk of thrombi)
cavitation (air bubbles)
hemolysis
- dec w/ modern changes
Sympathetic innervation of heart
T1-T4
alpha 1: positive inotropy
beta 1: positive chronotropy, dromotropy (n conduction), lusitropy (relaxation), inotropy
beta 2: positive chronotropy > inotropy
Dromotropy
Conduction of a nerve
Sympathetic innervation T1-T4 of heart
n travel through b/l stellate ganglions
R stellate ganglion: effect on HR
L stellate ganglion: MAP and contractility -> block can be done to red risk of arrhythmias w/ long QT
What matters w/ turbulent flow
Density -> why helium moves more
What matters w/ laminar flow?
Viscosity
Which medication increases sz duration
Etomidate
Which meds have no effect on sz duration
Methohexital
Ketamine
Dec sz duration in ECT
Propofol
Midazolam
Lidocaine
Volatiles
What is given to prevent post sz myalgias from ECT?
peds: ketorolac
elderly: acetaminophen
Contraindications to acute normovolemic hemodilution
Preop anemia
Active infxn
Cardiac hx (MI, uncontrolled HTN, aortic stenosis)
recent CVA
clinically significant kidney or liver dx
Tx for cardiac embolism in pt after CABG
support hemodynamics
re-heparinize and go back on bypass
Tx for protamine induced pulm HTN
milrinone
epi
NG
How to tx vasoplegia coming off bypass
Vasopressin and methylene blue
Which coronary artery is most susceptible to embolism post bypass
RCA
Osmolality gap
Used to figure out if non-measured solutes impacting
OG = measured serum osmolality - calculated osmolality
**MC ethanol, ketones, lactate -> DM2 does NOT cause a gap, DKA does!
Osmolality calculation
osmolality = (2 x Na) + (Glucose/18) + (BUN/2.8)
Which is more liver specific AST or ALT?
ALT
AST is present in cardiac, skeletal m, brain, kidney, pancreas
RF for postop hepatic dysfxn
1 type of surgery: more likely in cardiac
2nd: presence of acute or chronic hepatitis/cirrhosis
**asymp inc in < 2x AST is NOT
Pulm pathophysiology of drowning
Surfactant washed out -> dec compliance and V/Q mismatch -> hypoxia
How long after drowning process started irreversible brain damage?
LOC: 2 min
damage irreversible: 4-6 minutes
Cardiac changes w/ drowning
Initially tachycardia to compensate for hypoxia -> more acidosis -> bradycardia -> PEA -> asystole
O2 content
CaO2 = (hg x 1.34 x SaO2) + (.003 x PaO2)
SaO2: O2 saturation
PaO2: partial pressure of O2 mmHg (O2 dissolved in blood)
What affects myocardial blood supply
- HR: supplies during diastole
- CPP = Aortic DP - LVEDP
- Coronary vascular resistance (inc w/ vasospasm or atherosclerosis)
- Hg: affects O2 content
RF for infant postop apnea
<60 weeks post conception
hx of apnea or bradycardia
GA
regional w/ sedation
anemia
protective factor against infantile postop apnea
small for gestational age
RF for multi-drug resistant pathogens causing VAP
5 or more days in hospital
IV abx in 90 days
septic shock
ARDS or acute renal replacement therapy
If concern for multi-drug resistant MAP what abx?
MRSA coverage + 2 anti-pseudomonal
(Vanc or Linezolid) + (Pip-tazo or penem or cephalosporins or aztrenoam) + (floxacin or gent or colistin)
American Spinal Injury Association scoring system, what impairment is A
A: Complete cord injury w/ complete motor and sensory deficits in S4/5
B: Incomplete cord injury w/ sensation preserved below level of injury, intact S4 and S5
C: Incomplete cord injury w/ motor function preserved below level of injury, < 3 out of 5 motor strength in 1/2 major muscle groups
D: Incomplete cord injury w/ motor function preserved below level of injury, > 3 out of 5 motor strength in 1/2 major muscle groups
E: No evidence of cord injury w/ intact motor and sensory innervation
Which lead alone has the highest sensitivity for myocardial ischemia?
V5
Preferred intraop lead monitoring
II: biggest p wave
V4: sens for ischemia
Carbamazepine MOA
Blocks sodium channels -> inhibit generation and propagation of action potentials
Carbamazepine tx
tx: sz, trigeminal neuralgia, bipolar d/o, neuropathic pain
Carbamazepine P450
P450 inducer -> inc metabolism of other antiepileptic drugs
Carbamazepine toxicity
Cardiac: wide QRS, prolonged QT, vent arrhythmias, tachycardia, hypoTN
Neurologic: nystagmus, AMS, delirium
Anticholinergic: mydriasis, hyperthermia, flushing, dry mouth, urinary retention
Superior way to dx brain death
Clinical exam is considered superior to all imaging when dx brain death
-ancillary studies can be used to support when prereqs for clinical exam can’t be met or when apnea test invalid due to chronic CO2 retainers (cerebral angio gold)
When in a disaster planning, what is the first staff that is short-handed?
Nursing due to direct pt contact
In a disaster which pts arrive at the hospital first?
Those that can bring themselves: minimally injured
2nd wave of very sick pts that require help w/ transportation
Prep for mass casuality
- staffing: nurses run out 1st, getting ppl mentored for ICU coverage
- space: being able to make non ICU places have resources to cover ICU pts
- stuff: resources, must get enough stuff to have 72 hrs w/o help
- strategy:
Palpable taut band w/ radiating pain
myofascial pain syndrome
-localized pain in single m or region w/ trigger pts
-can do dry needling or local anesthesia injxn
Lean body weight
weight - adipose tissue
usually 80% of obese male, 70% of obese female
What meds doses by lean body weight?
Induction Thiopental and prop, fent, remi, vec, roc, cistatracurium
What meds dosed by total body weight?
Maintenance thiopental, prop, succ
What molecules inactivated w/ pass through lungs?
Serotonin (98%)
Norepi (30%)
Bradykinin
What intranasal meds are vasoconstrictors to prevent epistasxis with fiberoptic
oxymetazoline and phenylephrine
