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Anesthesia: ITE, lectures > ITE Chiefs Review > Flashcards

ITE Chiefs Review Flashcards

1
Q

What does P wave represent?

A

electrical activation of atria; precedes atrial contraction

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2
Q

Atrial systole contributes to __% of filling of ventricle

A

25%

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3
Q

What does QRS represent?

A

electrical activation of ventricles

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4
Q

What does T wave represent?

A

ventricular repolarization; marks end of ventricular contraction/rapid ejection

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5
Q

What action begins after QRS wave?

A

isovolumetric contraction

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6
Q

What is normal LVEDV?

A

120 mL

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7
Q

What is the average stroke volume?

A

80 mL

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8
Q

What are the three parts of systole?

A
  1. isovolumic contraction
  2. rapid ejection (2/3 LVEDV)
  3. slower ejection
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9
Q

What are the four parts of diastole?

A
  1. isovolumic relaxation
  2. early filling (70-75%)
  3. diastasis (<5%)
  4. atrial systole (15-20%)
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10
Q

____ = amt of blood per minute

A

cardiac output

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11
Q

What four things affect cardiac output?

A
  1. preload (LVEDV)
  2. afterload (aortic pressure/BP)
  3. myocardial contractility (inotropy)
  4. HR (chronotropy)
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12
Q

The primary determinant of myocardial O2 consumption is ___.

A

HR

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13
Q

Formula for CO

A

CO = HR x SV

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14
Q

Formula for Ohm’s law

A

Q (output) = pressure/resistance

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15
Q

An increase in ___ is most likely to result in increased myocardial wall tension

A

ventricular cavity size

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16
Q

What causes LVH?

A

chronic HTN (increased pressure load on LV) causes hypertrophy => decreased wall tension

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17
Q

Formula for LaPlace’s law

A

T = Pr/2h

  • T(ension)
  • P(ressure)
  • r(adius) of chamber
  • h = wall thickness
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18
Q

Why do you diurese/venodilate CHF?

A

reduces preload => decreased radius, decreased wall tension, less myocardial O2 consumption

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19
Q

What happens to heart with decompensated HFrEF?

A

increased r and thin myocardium (decreased h) => increased wall tension

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20
Q

How is parasympathetic innervation of heart accomplished?

A

craniosacral: long preganglionic fibers with short postganglionic fibers in heart

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21
Q

Function of parasympathetic innervation of heart?

A
  • slows HR

- reduces conduction velocity

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22
Q

What is the primary neurotransmitter for parasympathetics?

A

ACh

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23
Q

What neurotransmitters are involved in sympathetic innervation of heart?

A
  1. ACh (stellate gang synapse)

2. NE (postganglionic)

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24
Q

How is heart innervated sympathetically?

A

thoracolumbar; synapse in stellate ganglion

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25
Q

Through what receptors in the heart does sympathetic innervation work?

A

beta-1: increases rate and conduction cells

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26
Q

What is the Bezold Jarisch reflex?

A

incr ventricular volume => vagal => decreased HR and MAP

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27
Q

Effects of sympathetic stimulation in heart?

A
  1. chronotropic
  2. dromotropic incr conduction velocity)
  3. inotropic
  4. lusitropic (incr rate of myofibrillar relaxation)
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28
Q

____ = systemic HTN in response to increased ICP

A

Cushing reflex

attempt to maintain cerebral perfusion/O2 delivery

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29
Q

What is the occulocardiac reflex?

A

pressure on ocular globe => brady, hypoT

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30
Q

What are the two types of sensitive receptors involved in heart innervation?

A
  1. baroRs (arterial; depends on arterial BP)

2. chemoRs (periph; senses incr PaCO2, decr in pH)

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31
Q

During off pump CABG, a clamp is placed on a coronary artery. New onset junctional rhythm is seen on the EKG monitor and new inferior wall motion abnormalities are seen on TEE. What coro is affected?

A

RCA

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32
Q

What makes up the L main?

A

L main = LAD + L circumflex

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33
Q

What part of heart does the right main cover?

A
  • ant/post RV wall
  • RA
  • SA node
  • upper half of atrial septum
  • post 1/3 interventricular septum
  • inferior LV wall
  • AV node
  • post base LV
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34
Q

What circulation supplies the SA node and the AV node?

A

R main

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35
Q

What does the LAD supply?

A
  • anterior LV wall

- anterior 2/3 of interventricular septum

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36
Q

What does the L circumflex supply?

A
  • lateral LV wall

- part of LV posterior wall

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37
Q

Wall abnormality associated with RCA

A

RCA = inferior wall

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38
Q

Wall abnormality associated with LAD

A

LAD = anterior wall

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39
Q

Wall abnormality associated with circumflex

A

circumflex = lateral wall

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40
Q

Formula for coronary perfusion

A

coronary perfusion = aortic pressure (DBP) - LVEDP

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41
Q

What is resting coronary blood flow, and how much of cardiac output does it make up?

A

250 mL/min

5% of CO

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42
Q

What layer of heart tissue is most at risk for ischemia?

A

subendocardium

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43
Q

What does the Frank-Starling curve describe?

A

contractile state of myocardium

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44
Q

What three things are inotropic?

A
  1. catecholamines
  2. digitalis
  3. sympathetic stimulation
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45
Q

What two things are negative inotropes?

A
  1. pharm depressants

2. loss of myocardium

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46
Q

In what 4 cases is PAOP > LVEDP?

A

PAOP > LVEDP:

  1. mitral stenosis
  2. L atrial myxoma
  3. pulm venous obstruction
  4. elevated alveolar pressure
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47
Q

In what 3 cases is PAOP < LVEDP?

A

PAOP < LVEDP:

  1. aortic regurg
  2. stiff LV
  3. LVEDP > 25 mmHg
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48
Q

25 yo man with known rheumatic heart disease is being evaluated in the ICU. Despite decreasing C.O., mixed venous blood from a PAC shows an increase in SvO2. Why?

A

wedging of catheter

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49
Q

The acute onset of hypotension without a decrease in mixed venous oxygen saturation in most likely associated with the onset of ____.

A

sepsis

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50
Q

In a patient with hypovolemic shock, what factor is the best measure of the overall balance between oxygen supply and demand?

A

mixed venous O2 sat

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51
Q

Formula for SvO2

A

SvO2 = SaO2 - (vO2/1.3 x CO x Hg)

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52
Q

What is a normal mixed venous O2 sat?

A

70%; 40 mmHg

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53
Q

With what tool must you measure mixed venous O2 sat?

A

PAC

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54
Q

With what tool must you measure mixed venous O2 sat?

A

PAC

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55
Q

What are the two broad reasons for decreased SvO2?

A
  1. incr O2 consumption

2. decr O2 delivery

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56
Q

What are the four things that decrease SvO2 by increasing O2 consumption?

A
  1. fever
  2. shivering
  3. MH
  4. thyroid storm
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57
Q

What are the four things that decrease SvO2 by decreasing O2 delivery?

A
  1. hypoxia
  2. decreased CO
  3. decreased Hgb (hemorrhage)
  4. abnormal Hgb
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58
Q

Effect on SvO2:

fever

A

decreased SvO2

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59
Q

Effect on SvO2:

shivering

A

decreased SvO2

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60
Q

Effect on SvO2:

MH

A

decreased SvO2

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61
Q

Effect on SvO2:

thyroid storm

A

decreased SvO2

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62
Q

Effect on SvO2:

hypoxia

A

decreased SvO2

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63
Q

Effect on SvO2:

decreased CO

A

decreased SvO2

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64
Q

Effect on SvO2:

decreased Hgb

A

decreased SvO2

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65
Q

Effect on SvO2:

abnormal Hgb

A

decreased SvO2

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66
Q

Effect on SvO2:

L=>R shunting

A

increased SvO2

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67
Q

Effect on SvO2:

high CO

A

increased SvO2

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68
Q

Effect on SvO2:

cyanide

A

increased SvO2

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69
Q

Effect on SvO2:

hypothermia

A

increased SvO2

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70
Q

Effect on SvO2:

sepsis

A

increased SvO2

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71
Q

Effect on SvO2:

wedged PA

A

increased SvO2

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72
Q

What are some broad reasons for increased SvO2?

A
  • L=>R shunt
  • high CO
  • impaired tissue uptake
  • decr O2 consumption
  • sepsis
  • sampling error
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73
Q

Thermodilution is used to measure ___.

A

CO

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74
Q

What two issues invalidate thermodilution?

Why?

A
  1. tricuspid regurg
  2. cardiac shunts

only RV output is measured

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75
Q

How does thermodilution work?

A
  1. known amt of fluid injected in proximal port of PAC (into RA)
  2. temp measured at tip of PAC (in pulm a.)
  3. temp change is inversly proportional to CO
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76
Q

What three things cause falsely high CO by thermodilution?

A
  1. too little injectate
  2. TR
  3. cardiac shunts
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77
Q

Which of these are contraindicated in pulm HTN?

a) 15-methylprostaglandin F2alpha
b) sildenafil
c) nitric oxide
d) epoprostenol

A

15-methylprostaglandin F2alpha

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78
Q

MC sx associated with pulm HTN?

A
  • incr SOB with activity
  • CP at low exertion
  • fatigue
  • lethargy
  • fainting
  • leg swelling
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79
Q

What is the definition of pulm HTN?

A

mean PAP > 25 mmHg at rest

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80
Q

What are the 5 classifications of pulm HTN?

A
  1. PAH
  2. 2/2 L-sided heart dz
  3. 2/2 lung dz/hypoxia
  4. chronic thomboembolic pulm HTN
  5. unclear/multifactorial
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81
Q

What are some predictors of poor outcome with surg/anesth?

A
  • poor exercise capacity (6-min walk)
  • elevated RA pressure
  • decreased RV fxn/failure
  • low CI
  • elevated BNP
  • elevated CRP
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82
Q

Moderate/severe pulm HTN is a contraindication for ____.

A

liver transplant

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83
Q

What are some goals for anesthetizing people with pulm HTN?

A
  • prevent hypoT
  • tx hypoT with phenylephrine, vasopressin, NE
  • maintain adequate preload/contractility
  • prevent hypoxia, hypercapnia, acidosis
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84
Q

Three classes of tx for pulm HTN?

A
  1. prostacyclins (epoprostenol infusion, iloprost inhaled)
  2. PDE inhibitors (sildenafil, tadalafil, milrinone)
  3. consider inhaled NO
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85
Q

What is protamine?

A

only compound that reverses heparin

basic compound that binds acidic residues of heparin

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86
Q

What happens in a protamine reaction?

A

pulm HTN:

  • heart pressure equalize = tamponade
  • CO decr, PVR decr, SVR incr
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87
Q

What causes protamine reaction

A

increased plasma thromboxane

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88
Q

How do you treat a protamine reaction?

A

can do:

  • epi
  • heparin/bypass
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89
Q

What are the four components of the pathophysiology of protamine reaction?

A
  1. coagulopathy
  2. histamine release
  3. IgE-mediated (type II): d/t prev sensitization (NPH, fish allergy, vasectomy)
  4. anaphylactoid rxn (type III): complement/IgG; TXA2 release => severe pulm vasoconstriction, pulm HTN, possible R heart failure
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90
Q

A 77 yo woman with a biventricular implantable cardioverter-defibrilator (ICD) device is scheduled for an elective thyroidectomy. Interrogation of her device 2 days ago revealed 99.9% of beats were paced in DDD mode at 60 bpm. Per report, there is no underlying (intrinsic) cardiac rhythm. How do you prevent pacemaker inhibition by surgical electrocautery?

A

reprogramming pacer to asynchronous mode

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91
Q

Name four ways to inhibit/inactivate programmable DVI pacemaker.

A
  1. myopotentials from shivering
  2. succ-induced fasciculations
  3. ventricular R wave
  4. magnet over it
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92
Q

T or F: AICDs are not affected by ECT.

A

true

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93
Q

Name four things that affect AICDs.

A
  1. MRI
  2. radiation
  3. unipolar cautery
  4. radiofreq ablation
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94
Q

Given the complete general defibrillator code of VVE-DDDRV, what is true about this ICD?

A

provides ventricular chamber antitachycardia pacing

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95
Q

What are the five parts of pacer codes, and what are the options for these?

A

1st = chamber paced
-0 (none), A, V, D (dual)

2nd = chamber sensed
-0, A, V, D

3rd = response
-0, T (triggered), I (inhibited), D

4th = programmability/rate modulation
-0, P, M, C, R

5th = antitachy fxn
-0, P, S, D

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96
Q

What are the four parts of ICD codes, and what are the options for these?

A

1st = shock chambers
-0, A, V, D

2nd = antitachy pacing chambers
-0, A, V, D

3rd = tachy detection
-E (electrogram), H (hemodynamic)

4th = antibrady pacing chambers
-0, A, V, D

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97
Q

What are the parts of the CPB machine?

A
  • reservoir = grav-dependent; accumulates deoxy blood from venous circ
  • heat exchange (uses water countercurrents)
  • oxygenator (membrane or bubble)
  • filter system

then returned to ascending aorta

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98
Q

What are the two types of CPB pumps?

A
  1. centrifugal pumps

2. roller pumps

99
Q

What are the cons of CPB centrifugal pumps?

A

potential for retrograde flow and exsanguination

100
Q

What are the cons of CPB roller pumps?

A
  • incr trauma to RBCs

- can pump massive amts of air into circuit

101
Q

How do CPB centrifugal pumps work?

A
  • nonpulsatile flow
  • non occlusive (less RBC trauma)
  • afterload dependent (no line rupture)
  • no air can be pumped (less dense than blood)
102
Q

How do CPB roller pumps work?

A
  • occlude blood tubing and move forward

- generates high pos/neg pressures

103
Q

In what type of cases is microultrafiltration used?

A

peds hearts

104
Q

What are the benefits of microultrafiltration

A
  • decr total body water
  • blunts anemia/coagulopathy
  • decr blood requirements
  • narrows A-a gradient
  • improved LV compliance/systolic fxn
  • decr inotropic requirements
  • decr pleural/pericardial effusions
  • decr inflammatory markers
105
Q

What is the choice induction agent for emergent cardiac tamponade surg?

106
Q

What is Beck’s triad?

A

for tamponade:

  1. hypoT
  2. incr CVP
  3. distant heart sounds
107
Q

What is pulsus paradoxus?

A

decr in SBP >12 mmHg during inspiration

hallmark for tamponade

108
Q

What EKG changes are seen with tamponade?

A
  • electrical alternans (also seen with pericardial effusion)

- low-voltage QRS complexes

109
Q

What do you see with PAC measurements in patients with tamponade?

A

PAOP = PAP = CVP

pressures equalize in heart

110
Q

What are the hemodynamic goals when caring for someone with tamponade?

A
  • incr HR/contractility to maintain preload
  • incr afterload to maintain BP
  • incr preload to promote filling
111
Q

What do you use for patients with decreased CO in setting of isolated AI?

A

dobutamine

112
Q

How do you want to keep someone’s hemodynamics with PMH isolated AI?

A

“full, fast, forward”

  • HR 80-100
  • maintain preload
  • decr afterload to promote fwd flow

but excessive tachy can => myo. ischemia

113
Q

What two hemodynamic issues can increase regurgitant volume in AI?

A
  1. bradycardia

2. increased SVR

114
Q

A 75 yo man with aortic stenosis and coronary artery disease has a preinduction HR of 68 and a BP of 125/70. After induction with fentanyl, versed and pancuronium, the HR is 90 and the BP is 85/45. ECG shows new ST elevation in lead II. Most appropriate initial management is with what agent?

A

phenylephrine

115
Q

After a ground level fall, a 65 year-old woman with severe aortic stenosis develops atrial fibrillation. Vital signs include HR 150 and irregular with BP 50/20 mmHg. The MOST appropriate initial treatment is
what?

A

synchronized cardioversion (unstable brady)

116
Q

What is a specific anesthetic contraindication in patients with severe AS?

A

spinals/epidurals

if sympathetic block to T6, can cause decreased afterload

117
Q

Hemodynamic goals in patients with AS?

A
  • sinus rhythm at all costs
  • keep HR 60-80
  • maintain both preload/afterload
118
Q

Hemodynamic goals in pts with MR?

A

“full, fast, forward” (like AI)

  • HR goal 80-100
  • avoid brady and acute incr in afterload
119
Q

What can cause worsened regurgitant flow in MR?

A
  • bradycardia
  • acute incr in afterload
  • excessive volume (can dilate LV)
120
Q

A patient with a history of mitral stenosis but without evidence of congestive heart failure presents for emergency appendectomy. The patient’s EKG shows normal sinus rhythm, blood pressure is 140/85 mmHg, and heart rate is 105 beats/min. What would you give?

A

start beta-blocker

121
Q

A 45 yo woman with mitral stenosis is scheduled for elective mitral valve replacement. 2 minutes after tracheal intubation, she develops new onset Afib with a rapid ventricular response of 150 bpm and a decrease in BP to 75/45. Which of the following is the most appropriate 1st step in management?

A

electrical cardioversion

if pt suddenly develops new rhythm and BP is unstable, ALWAYS SHOCK

122
Q

Hemodynamic goals for MS?

A
  • HR low (60-80)
  • avoid large incr in CO
  • preload incr but not fluid-overloaded
123
Q

What is an issue that can happen in patients with MS?

A

LA dilated => promotes SVTs, esp afib

124
Q

What do you do with the following in stenotic valvular lesions:

  • preload
  • afterload
  • HR
A

MS, AS:

  • preload: maintain
  • afterload: maintain
  • HR low
125
Q

What do you do with the following in regurgitant valvular lesions:

  • preload
  • afterload
  • HR
A

MR, AR:

  • preload: keep high
  • afterload: keep low
  • HR high
126
Q

What do you do with the following in tamponade:

  • preload
  • afterload
  • HR
A
  • preload: high
  • afterload: high
  • HR: high
127
Q

What do you do with the following in HOCM/SAM:

  • preload
  • afterload
  • HR
A
  • preload: high
  • afterload: high
  • HR: low
128
Q

What do you see on echo in patient with HOCM, in terms of the heart structure?

A

left ventricular hypertrophy (LV wall thickness > 15mm) in the absence of an enlarged ventricular cavity

can also be asymmetric septal hypertrphy

129
Q

What are some other names for HOCM?

A
  • asymmetric septal hypertrophy

- idiopathic hypertrophic subaortic stenosis

130
Q

What do you see on echo in patient with HOCM, in terms of valvular issues?

A

SAM = systolic anterior motion of MV

131
Q

Where is murmur for HOCM best heard?

A

left lower sternal border and apex

132
Q

What increases HOCM murmur?

A

decr ventricular filling (Valsalva)

133
Q

What improves HOCM murmur?

134
Q

How is HOCM inherited?

A

autosomal dominant

135
Q

Hemodynamic goals for HOCM?

A
  • incr preload
  • maintain afterload
  • maintain NSR
  • AVOID inotropes
136
Q

What do you do preop for acute AR if:

  • CI >2.1
  • PCWP <18
A

nothing, just induce

137
Q

What do you do preop for acute AR if:

  • CI >2.1
  • PCWP >18
138
Q

What do you do preop for acute AR if:

  • CI <2.1
  • PCWP <18
A

incr preload with fluids

139
Q

What do you do preop for acute AR if:

  • CI <2.1
  • PCWP >18
140
Q

A healthy subject has indwelling arterial catheters simultaneously transducing pressures from the brachial, radial, femoral, and dorsalis pedis arteries. Which of the catheters is likely to record the HIGHEST systolic pressure?

A

dorsalis pedis

141
Q

What does pulsus alternans indicate?

A

LV failure

142
Q

What does collapsing pulse indicate?

A
  • AR

- hyperdynamic circulation

143
Q

What does pulsus biferens indicate

144
Q

What does anacrotic pulse indicate

A

aortic stenosis

145
Q

____ = arterial waveform seen with LV failure

A

pulsus alternans

146
Q

____ = arterial waveform seen with AR or hyperdynamic circulation

A

collapsing pulse

147
Q

____ = arterial waveform seen with AR or HOCM

A

pulsus biferens

148
Q

____ = arterial waveform seen with AS

A

anacrotic pulse

149
Q

A 32 yo man who is 5 years post heart transplant for cardiomyopathy is tachycardic at baseline on pre-op evaluation. What is the cause?

A

cardiac denervation

no sympathetic/parasympathetic input

preload dependent, but do respond to circulating catecholamines

150
Q

What two agents can increase HR in post-tx patients?

A
  1. epi

2. isoproterenol

151
Q

What do you see on EKG of post-tx patients?

A

2 P waves (d/t 2 SA nodes)

152
Q

What are some issues with post-tx cardiac health?

A
  1. accelerated atherosclerosis

2. silent MI (no pain sensors)

153
Q

What’s the goal SBP range with aortic dissection?

A

90-120

to reduce aortic wall stress

154
Q

What is/are the drug(s) of choice for BP maintenance in aordic dissection?

A
  • sodium nitroprusside
  • beta blockers

DON’T use nitroprusside alone, as it may raise shearing forces

155
Q

A 55 yo man with a history of cocaine abuse presents to the operating room with a Stanford type A aortic dissection. He is awake, alert, and complaining of chest pain. His blood pressure is 75/40 mmHg, pulse 105 bpm, SaO2 95% on 2L nasal cannula. A 12 lead EKG reveals ST elevation in leads II, III, and aVF. An echocardiogram reveals large pericardial fluid with right ventricular compression during systole. What is the BEST initial management strategy for this patient?

A

surgical repair

156
Q

A 58 yo woman is admitted to the intensive care unit after open repair of a type-III thoracoabdominal aortic aneurysm. Preoperatively, an intrathecal catheter was placed for cerebrospinal fluid drainage. Estimated blood loss was 6L, and PRBCs, cell saver blood, platelets, FFP, and cryoprecipitate were administered to treat anemia and coagulopathy. Postoperatively, the patient is unable to move her lower extremities. Sensation is normal. She has no back pain. What is MOST likely to account for her neurologic deficit?

A

anterior spinal a. syndrome

157
Q

A 56 yo patient is undergoing a thoracic aortic aneurysm repair with the use of an aortic cross clamp. What vessel provides blood supply to the anterior 2/3 of the spinal cord?

A

artery of Adamkiewicz

158
Q

What situation is MOST likely the cause of paraplegia following repair of a descending thoracic aortic aneurysm?

A

prolonged aortic cross-clamp time

159
Q

What three vessels supply the spinal cord?

A
  1. anterior spinal a: ant 2/3 of cord
  2. posterior spinal aa: post 1/3 of cord
  3. artery of Adamkiewicz (arteria radicularis magna): thoracolumbar radicular a. off aorta that is major blood suppy to anterior, lower 2/3 of spinal cord
160
Q

____: loss of motor fxn (paralysis, ataxia) and sensation below lesion

A

Brown-Sequard syndrome

  • lateral hemisection/transection of spinal cord
  • spinothalamic tract, one or both dorsal columns and corticospinal tract
161
Q

____: loss of motor fxn/pinprick sensation with preservation of vibration and proprioception

A

anterior spinal a. syndrome

  • usually d/t ischemia or dissection
  • bilat spinothalamic tract and corticospinal tract
162
Q

What part of spinal cord is affected by anterior spinal a. syndrome?

A

bilat spinothalamic tract and corticospinal tract

163
Q

What part of spinal cord is affected by Brown-Sequard syndrome?

A

spinothalamic tract, one or both dorsal columns, corticospinal tract

164
Q

What are the two main causes of anterior spinal artery syndrome?

A
  1. ischemia

2. dissection

165
Q

What are the two overall methods of classifying aortic dissections?

A
  1. Stanford

2. DeBakey

166
Q

What are the two types of aortic dissections per the Stanford classification?

A
  1. type A = ascending aorta

2. type B = descending aorta

167
Q

What are the three types of aortic dissections per the DeBakey classification?

A
  1. type I: ascending aorta, aortic arch, and descending aorta
  2. type II: ascending aorta
  3. type III: descending aorta distal to L subclavian a.
168
Q

What are some signs of PE in the OR?

A
  • hypoT
  • hypoxemia
  • bronchospasm
  • decr etCO2
  • incr CVP
  • incr PAP (not PAOP)
169
Q

A patient with a history of hypertension (baseline blood pressure 160/100 mmHg) experiences an acute myocardial infarction (MI). What risk factor is MOST likely to be associated with an increased risk of developing cardiogenic shock following an acute MI?

A

ST segment elevation MI

170
Q

The diagnosis of cardigenic shock is established and the decision is made to institute intra-aortic balloon counterpulsation. What parameter is MOST likely to decrease as a result of this intervention?

A

LV afterload

171
Q

What happens to each of the following in hypovolemic shock:

  • HR
  • MAP
  • CVP
  • PAOP
  • SVR
A

Hypovolemic:

  • HR = incr
  • MAP = decr
  • CVP = decr
  • PAOP = decr
  • SVR = incr
172
Q

What happens to each of the following in cardiogenic shock:

  • HR
  • MAP
  • CVP
  • PAOP
  • SVR
A

Cardiogenic:

  • HR = incr
  • MAP = either
  • CVP = nml (LV fail) or incr
  • PAOP = nml (RV fail) or incr
  • SVR = incr
173
Q

What happens to each of the following in distributive shock:

  • HR
  • MAP
  • CVP
  • PAOP
  • SVR
A

Distributive:

  • HR = incr (except maybe decr in neurogenic shock)
  • MAP = decr
  • CVP = decr/nml early, incr/nml late
  • PAOP = decr/nml early, incr/nml late
  • SVR = decr
174
Q

What happens to each of the following in obstructive shock:

  • HR
  • MAP
  • CVP
  • PAOP
  • SVR
A

Obstructive:

  • HR = incr
  • MAP = decr
  • CVP = incr
  • PAOP = incr
  • SVR = incr
175
Q

What defines severe sepsis?

A

sepsis + organ dysfxn

176
Q

What differentiates SIRS from sepsis?

A

infectious etiology = sepsis

177
Q

What defines septic shock?

A

sepsis + hypoT

178
Q

What patients need endocarditis prophylaxis?

A
  • prosthetic cardiac valve
  • previous IE
  • CHD (unrepaired cyanotic CHD, repaired CHD with prosthetics or within 1st 6 mo, or repaired with residual defects)
  • heart tx with cardiac valvulopathy
179
Q

What procedures need endocarditis prophylaxis in appropriate pts?

A
  • dental procedures with gum manipulation/perf of mucosa

- procedures on resp tract, infected skin or muskuloskeletal tissue

180
Q

What is a component of protocol for early (first 6 hrs) goal-directed therapy in tx sepsis?

A

central venous oxygenation sat of at least 70%

181
Q

____ view is the most optimal TEE view to monitor intraop myocardial ischemia.

A

transgastric short axis

provides view of all 3 coronary a distributions

182
Q

What is the primary cause of neurologic deficit following CEA?

A

thromboembolism

183
Q

What’s the best method to check for cerebral perfusion during CEA?

184
Q

Following a carotid endarterectomy in a 72 year old man, the nurse in the postanesthesia care unit calls you to report the patient’s blood pressure is 220/103. His preoperative pressure was 140/80 mmHg. This is MOST likley due to denervation of what structure?

A

carotid sinus

185
Q

What are the indications for CEA?

A
  • TIAs with >70% occlusion
  • severe stenosis with minor CVA
  • mod occlusion (30-70%) in pts with ipsilat sx
186
Q

What is the role of a shunt in CEA?

A

can place if signs of cerebral ischemia, but carry risk of thromboembolism

187
Q

What is the major cause of mortality post-CEA?

A

myocardial ischemia (1-2%)

188
Q

What are four types of post-op complications in CEA, and why?

A
  1. HTN: pain, hypoxemia, hypercarbia, surgical denervation of ipsilat carotid baroR (carotid sinus)
  2. hypoT: removal of atheroma exposes baroR (carotid sinus) to higher BP, causing brain stem-mediated hypoT/brady
  3. resp insufficiency: damaged to recurrent laryngeal n, impaired carotid body response to hypoxemia
  4. neuro deficits: thromboembolism (causing cerebral hypoperfusion), regional cerebral hyperperfusion
189
Q

After termination of cardiopulmonary bypass, a patient who is chronically digitalized receives digoxin 0.5 mg in error. An EKG shows sinus brady with intermittent sinus arrest. Blood pressure is 90/60. What BP drug is contraindicated?

A

calcium chloride

190
Q

What electrolyte abnormalities are associated with digoxin toxicity?

A

Dig Tox May Keep Coming Back:

  • decr Thyroid
  • decr Mag
  • decr K
  • incr Ca
  • incr BUN
191
Q

What are the factors looked at with the RCRI?

A
  • ischemic heart dz
  • CHF
  • CVA
  • Cr > 2.0
  • IDDM
  • high-risk surg

if 3 or more, consider more workup

192
Q

If you have 2 RCRI factors, risk of cardiac complications is __%, whereas with 3 RCRI factors it is __%.

A 
2 = 7% risk
3 = 11% risk
193
Q

What innervates diaphragm?

A

phrenic n. (C3-C5)

194
Q

How much does unilat phrenic n. injury affect pulm fxn?

195
Q

What does general anesthesia do to O2 consumption and CO2 production?

A

reduces VO2 and VCO2 by 15% (mostly within cerebral/cardiac metab)

196
Q

What effect does vagus n. have on lungs?

A

parasympathetics via muscarinic Rs:

  • bronchoconstriction
  • incr bronchial secretions
197
Q

What type of sympathetic Rs are present in lung tissue, and what are their actions?

A
  • beta-2: bronchodilation, decr bronchial secretions

- alpha-1: decreased secretions, maybe bronchoconstriction

198
Q

How do sympathetics/parasympathetics act on lung vasculature?

A

sympathetic:

  • alpha-1: vasoconstrxn
  • beta-2: vasoD

parasympathetic:
-vasoD via nitric oxide

199
Q

Formula for transpulmonary gradient

A

P(transpulm) = P(alveolar) – P(intrapleural)

+5 at end expiration, -4 at inspiration (gradient)

200
Q

A patient under general anesthesia maintains saturation levels of 85-90%. Despite 100% oxygen therapy the saturation does not rise above 90%. What is the MOST likely reason?

A

methemoglobinemia

201
Q

What 6 things cause left shift on O2-Hgb dissociation curve?

A
  1. hypothermia
  2. alkalosis
  3. decreased 2,3-DPG
  4. fetal Hgb
  5. carboxyHgb
  6. methemoglobin
202
Q

What 6 things cause right shift on O2-Hgb dissociation curve?

A
  1. hyperthermia
  2. acidosis
  3. incr 2,3-DPG
    4, abnormal Hgb
  4. incr CO2
  5. pregnancy
203
Q

What effect does the following have on the O2-Hgb dissociation curve:
hypothermia

A

left shift

204
Q

What effect does the following have on the O2-Hgb dissociation curve:
alkalosis

A

left shift

205
Q

What effect does the following have on the O2-Hgb dissociation curve:
decreased 2,3-DPG

A

left shift

206
Q

What effect does the following have on the O2-Hgb dissociation curve:
fetal Hgb

A

left shift

207
Q

What effect does the following have on the O2-Hgb dissociation curve:
carboxyHgb

A

left shift

208
Q

What effect does the following have on the O2-Hgb dissociation curve:
methemoglobin

A

left shift

209
Q

What effect does the following have on the O2-Hgb dissociation curve:
hyperthermia

A

right shift

210
Q

What effect does the following have on the O2-Hgb dissociation curve:
acidosis

A

right shift

211
Q

What effect does the following have on the O2-Hgb dissociation curve:
increased 2,3-DPG

A

right shift

212
Q

What effect does the following have on the O2-Hgb dissociation curve:
abnormal Hgb

A

right shift

213
Q

What effect does the following have on the O2-Hgb dissociation curve:
incr CO2

A

right shift

214
Q

What effect does the following have on the O2-Hgb dissociation curve:
pregnancy

A

right shift

215
Q

What is normal lung compliance?

A

150 - 200 ml/cm H2O

216
Q

Formula for lung compliance

A

change in lung vol/change in transpulm pressure

217
Q

formula for chest wall compliance

A

change in chest vol/change in transthoracic pressure

218
Q

Name three factors that reduce lung compliance

A
  1. pulm fibrosis
  2. pulm edema
  3. consolidation

compliance incr by emphysema

219
Q

Name three factors that reduce chest wall compliance

A
  1. severe obesity
  2. laparoscopy
  3. incr abd pressure
220
Q

Name 5 intraop issues that can decrease lung compliance

A
  1. mainstem intubation
  2. bronchospasm
  3. pneumo
  4. changes in position
  5. insufflation of abd
221
Q

What does it mean when the compliance curve is shifted to the R?

A

addition of PEEP

222
Q

What does it mean when the compliance curve is flattened?

A

incr airway resistance

223
Q

What does it mean when the compliance curve doesn’t return to zero?

224
Q

What lung measurement can be made with an IS?

A

inspiratory reserve volume

225
Q

What effect does obesity have on the following:

pulm compliance

226
Q

What effect does obesity have on the following:

FRC

227
Q

What effect does obesity have on the following:

vital capacity

228
Q

What effect does obesity have on the following:

TLC

229
Q

What effect does obesity have on the following:

expiratory reserve volume

230
Q

What effect does obesity have on the following:

residual volume

231
Q

What effect does obesity have on the following:

closing capacity

232
Q

What effect does obesity have on the following:

O2 consumption

233
Q

What effect does obesity have on the following:

CO2 production

234
Q

What is the average adult tidal volume?

235
Q

What is the average adult inspiratory reserve volume?

What does IRV mean?

A

3000 mL

max additional vol that can be inspired above TV

236
Q

What is the average adult expiratory reserve volume?

What does ERV mean?

A

1100 mL

max vol that can be expired below tidal vol

237
Q

What is the average adult residual volume?

What does RV mean?

A

1200 mL

vol remaining after max exhalation

238
Q

What is the average adult TLC?

Formula for TLC?

A

5800 mL

RV + ERV + Vt + IRV

239
Q

What is the average adult FRC?

Formula for FRC?

A

2300 mL

RV + ERV

240
Q

What is closing capacity?

A

volume that small airways and alveoli begin to close in dependent parts of lung

incr with age

241
Q

What is the normal ratio of FEV1/FVC?

242
Q

What is a shunt?

A

desaturated, mixed venous blood from R heart returns to L heart without being oxygenated

243
Q

If minute ventilation remains constant, what happens to PetCO2 and PaCO2 will result from a decrease in cardiac output?

A

PetCO2 decreases

PaCO2 increases

244
Q

What are three factors that can incr physiological dead space?

A
  1. decreased CO
  2. PE
  3. upright position

Anesthesia: ITE, lectures (1 decks)

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