Jensen1 Flashcards
Bodies response to removal of carotid bodies
little change to ventilation at rest, response to hypoxia is lost and there is a 30% reduction in ventilatory response to CO2
chemoreceptors that mediate hyperventilation after carotid and aortic body denervation are located where
medulla oblongata - medullary chemoreceptors
PEEP effects (pulmonary)
prevent alveolar collapse, promote gas exchange, increases FRC, increases lung compliance, decreases intrapulmonary shunt, increases PaO2, increases dead space
PEEP effects (cardiac)
high airway pressure 2/2 to decreased pulmonary compliance can decrease CO - decreases ventricular filling, decreased coronary blood flow
PEEP complications
decreases CO, causes fluid retention (depresses ANF, increases ADH), increases pressure in SVC - can increase ICP, barotrauma
PEEP recommended for? not recommended? no evidence?
recommended for pulmonary edema, not recommended for localized lung disease (over-distends normal lung and redirects blood to diseased area, creating V/Q mismatch), no evidence that it increases incidence of ARDS, beneficial routinely, or decreases mediastinal bleeding
Eaton-Lambert definition
muscular weakness because of decreased release of acetylcholine 2/2 destruction of pre-synaptic voltage gated Ca channels by IgG antibodies
Eaton-:Lambert presentation and associated diseases
bronchial CA (oat cell), SLE, thyroid disease, present with dry mouth, proximal muscle weakness, muscle pain, weakness improves with exercise. more in men, sensitive to all NMBD
Eaton-Lambert treatment
excision of cancer, 4-aminopyridine (immunosuppressant) stimulates release of pre-synaptic acetylcholine, acetylcholinesterase is not effective
Increased mixed venous
left to right shunt, high cardiac output, cyanide poisoning, CO poisoning, methgb, hypothermia (decreased O2 consumption), sepsis, sampling error (permanently wedged PAC)
decreased mixed venous
increased O2 consumption (fever, thyroid storm, MH), decreased O2 delivery (hypoxia, decreased CO, decreased Hgb, abnormal Hgb)
mixed venous normal values
O2 40 mm Hg, CO2 45 mm Hg, 65-75% sat
shivering, mechanism and treatment
when preoptic region of hypothalamus is cooled, increases metabolic heat production up to 600%, increases O2 consumption and CO2 production, hypoxia inhibits shivering response, treatment with meperidine - decreases the shivering threshold
amide locals metabolism dependent on…
liver which is dependent on hepatic blood flow (decreased with NE, propranolol, GA) and extraction capacity (decreased with HF, cirrhosis, hypothermia)
ester locals metabolism dependent on…
pseudocholinesterase - low in renal failure, severe hepatic failure, pregnancy
which anticholinergic crosses BBB
scopolamine and atropine
Cholinergic (parasympathetic) crisis
SLUDEBBP - salivation, sweating, lacrimation, urination, defecation, erection, bradycardia, bronchial constriction, pupillary constriction
anticholinergic crisis - central anticholinergic syndrome
atropine and scopolamine because cross BBB, treatment is physostigmine; symptoms are fever (blocks sweating), blurred vision, photophobia, tachycardia, restlessness, somnolence
Horner’s syndrome
ptosis, miosis, anhidrosis, enophthalmos, flushing of conjunctiva and skin, nasal congestion (engorged blood vessels)
O2 consumption decreases with 1 degree centigrade
10%
oculocardiac reflex pathway
afferent: ciliary ganglion to ophthalmic division of trigeminal nerve (V), through Gasserian ganglion to sensory nucleus of the 4th ventricle, efferent: vagus nerve –> bradycardia, hypotension, PVCs
Phase II block characteristics
fade with twitch and tetanus, TOF <0.7 (T4/T1), post-tetanic potentiation
minimum fresh gas flow
150-500 ml/min for metabolic demands and replace anesthetic gas
advantages/disadvantages of closed circuit
ad: conservation or heat/humidity, economical, low pollution; dis: anesthetic concentration cannot be changed quickly and delivered anesthetic concentration uncertain, uptake of nitrous oxide can decrease O2
right shift oxy-hgb
O2 unloads easily, high H, high CO2, high temp, chronic anemia, high 2,3 DPG
left shift oxy-hgb
O2 binds more to hgb, low H, low temp, low 2,3 DPG, met-hgb, fetal hgb, hypophosphatemia, hypothermia
TPN complications
hypo/hyperglycemia, hypercarbia, hypophosphatemia (left shift oxy-hgb, muscle weakness), fatty acid deficiency, metabolic acidosis (from amino acid metabolism), sepsis
ECT response
parasymp - bradycardia, hypotension, cerebral vasoconstriction, asystole; symp - tachy, HTN, increased cerebral blood flow, increased metabolic demands
ECT drugs
ketamine - seizure potential, methohexital lowers seizure threshold, thiopental and propofol tend to suppress seizures, hyperventilation and caffeine can increase seizure duration
does not require cross match
FFP, cryo, platelets
type specific/Rh required
pRBCs need both, cryo and FFP need ABO (Rh not required), platelets better with both, but not required
Induces ADH secretion
Pain, PEEP, decrease intravascular volume, positive pressure ventilation
Monophasic vs biphasic defibrillation
Monophasic current travels From one electrode to another in one direction; Biphasic current flows in one direction for 1st phase then reverses for 2nd phase so adjusts for impedance by varying waveform, more effective, less injury prone
trigeminal neuralgia
V2 maxillary, can treat with carbamazepine which is membrane stabilizer or gasserian block at middle cranial fossa by meckel’s cave (contains CSF)
treatment of LA CNS toxicity
intubate, barb/benzo, hyperventilate (alkalosis increases ionized percentage)
LA weak acids or bases?
weak bases except for benzocaine
co-ox for methgb, carboxhgb, and dyes
methgb absorbs both wave lengths equally 85%, carboxy absorbs red (660) but not infrared (940) so measurement varies, methylene blue can cause 65%
carbohgb levels mild? mod? severe?
10-20%, 20-40%, >40%
hypercalcemia EKG, symptoms
PR prolonged, QT short, muscle weakness
hypocalcemia EKG, symptoms
Qt prolonged, tetany and laryngospasm, seizures
H’s
Hypovolemia, Hyper/Hypokalemia, Hypothermia, Hydrogen ions, Hypoxia, Hypoglycemia
T’s
Tension pneumo, Thrombosis (pulmonary, coronary), Trauma, Tamponade (cardiac), Toxins
Hyperventilation/hypocarbia
AVCO - apnea, alkalosis, airway constriction, V/Q mismatch, decreased CO, CBF, coronary blood flow, and Ca, oxyhbg left shift
Hypoventilation/hypercarbia
A RIPE - acidosis/arrhythmia, right shift oxyhgb, intracerebral steal, PA pressure increase, epi/norepi release (cutaneous vasodilation, splanchnic vasoconstriction)
cardioselective beta blockers
Metoprolol, Esmolol, Atenolol, Acebutolol
amiodarone mechanism
used for refractory VT/VF, prolongs refractory period and reduces membrane excitability
adverse amiodarone effects
pulmonary toxicity due to enhanced O2 free radial formation, increased risk for ARDS
digoxin mechanism and therapeutic margin
increases INTRACELLULAR calcium; inhibits the Na-K pump; 0.9-2.0 ng/mL
what is calcium hydroxide? advan/disad?
combination of calcium hydroxide, calcium chloride, calcium sulfate, and polyvinylpyrrolidine (lacks strong bases sodium and postassium which ELIMINATES CO and compound A production), 50% less absorptive than soda lime with higher cost
umbilical artery and vein ABG
artery: 7.28/20/50 sat 40% vein: 7.35/30/40 sat 70%
organophosphate mechanism
irreversibly inhibits pseudocholinesterase, acetylcholinesterase, and non-specific plasma cholinesterases, also affects GABA and NMDA
organophosphate treatment
pralidoxime (oximes) activates acetylcholinesterase (primarily reverses muscle weakness - nicotinic), atropine helps with other symptoms (muscarinic)
stellate ganglion block
covers inferior cervical and first thoracic ganglion, blocks head and upper extremity (T2-T9), block at transverse process of C6 at level of cricoid cartilage
CO2 values with apnea
6 mmHg increase after 1 minute, 3 mmHg every minute after
ketamine indications
burns, shock, COPD, asthma, CHF, cardiac tamponade, hypothyroidism, TOF
ketamine contraindications
heart: HTN, cardiac ischemia, digitalis toxicity, brain: increased ICP, CVA, lungs: pHTN, pulm emboli, endocrine: hyperthyroidism, eye: nystagmus, pregnancy: severe pre-eclampsia
ketamine pharmacology
phencyclidine derivative, NMDA receptor antagonist, dissociates thalamus from limbic system (reticular activating system to cerebral cortex), provides analgesia (modest LA action)
increased closing capacity
ACLSS - age, chronic bronchitis, LV failure, smoking, surgery
decreased FRC
PANGOS - pregnancy, ascites, neonates, GA, obesity, supine position
porphyria neurologic problem types, diagnosis, treatment
types 1, 3, 4; check urine for aminolevulinic acid (ALA) and pophobilinogen (both not seen in cutanea tarda type); treat with glucose infusion suppresses ALA synthetase
Porphyria triggers (induce ALA synthetase)
barbituates, diazepam, chlordiazepoxideam, meprobamate, glutethimide, hydroxydione, imipramine, pentazocine, OCPs, griseofulvin, phenytoin, methsuximide, sulfonamides, chloramphenicol, estrogens, progesterone, (sulfonylureas) chlorpropamide & tolbutamide, lead, ethanol, ergots, amphetamines, methyldopa, etomidate?, hydralazine, phenoxybenzamine, nifedipine
porphyria pathophys
enzymatic defect of heme synthesis resulting in over production of heme precursors (increased ALA synthetase activity)
porphyria symptoms
n/v, abdominal pain, dehydration, anxiety, electrolyte abnormalities, confusion
complications of mediastinoscopy
(suprasternal incision to pass scope anterior to trachea and posterior to innominate vessels and aortic arch) hemorrhage, pneumo, RLN injury, tracheal collapse, “apparent” cardiac arrest (severe vagal reflex), air embolus
mediastinoscopy contraindications
previous mediaastinoscopy, distorted anatomy, SVC syndrome, cerebrovascular disease (risk of carotid compression)
special mediastinoscopy considerations
pulse ox on both sides of upper extremities (pressure on right innominate can cause radial pulse to disappear), IV lines placed in LE (resuscitation in UE can increase blood loss in mediastinal cavity)
metoclopramide contraindications
Parkinson’s (antagonizes dopamine), patients taking phenothiazines, butyrophenones, MAOIs, or TCAs, pheochromocytoma, GIB, bowel obstruction, seizures
MAOIs and meperidine
fatal excitatory reactions
MOAI food interactions and why
chocolate, beer, wine, cheese because they contain tyramine (monoamine)
MOAIs and pressors
see exaggerated response with indirect and direct
postural hypotension and MAOIs
accumulation of false neurotransmitter octopamine
most common serious adverse flumazenil side effect
convulsions and death (patients with serious underlying disease and s/p ingestion of non-benzo drugs)
garlic
used for vasodilatory and anti-cholesterol effects; decreases platelet aggregation
ginseng
used for anti-aging, energy, and aphrodisiac; hypoglycemic effect, avoid ASA, NSAIDs, Coumadin, heparin, and neuraxial blocks (like garlic), causes HTN, avoid with MAOIs (manic episodes)
ginkgo
used for intermittent claudication, memory loss, tinnitus, impotence; can cause hypema, subarachnoid hemorrhage, and spontaneous subdural hemorrhage, avoid avoid ASA, NSAIDs, Coumadin, heparin, and neuraxial blocks, decreases effectiveness of TCAs and anticonvulsants
st. john’s wort
used for anxiety, depression, sleep disorders; can cause photosensitivity, do not use with tetracycline or piroxicam
banked blood survival
blood bank survival based on 70% RBC survival 24 hours after transfusion
CPD-A half-life, ACD half-life?
35 days; 21 days
changes to banked blood
decreased 2.3 DPG, increased CO2 (acidemia), decreased platelets, increased potassium, decreased factors (esp V and VIII)
interscalene block complications
vertebral artery puncture, spinal/epidural injection, brachial plexus injury, phrenic nerve paralysis (100%), pneumo, RLN block, horner’s
hypophosphatemia
heart failure, respiratory failure, rhabdomyolysis, hyporeflexia, seizures, decreased mental status, n/v, low levels of ATP and 2.3 DPG cause left shift of oxyhgb
hyperphosphatemia
tetany, seizures, laryngospasm
augment NMB
volatiles, LA (procaine), anticholinesterases, tetracycline, aminoglycosides (gentamycin), lincosamides (clinda), polymixins, lidocaine, quinidine, Ca channel blockers, magnesium, lithium, hypernatremia, hepatic dysfunction, hypothermia, acidosis
intraarterial thiopental injection treatment
inject with lido/procaine/papverine (prevent smooth muscle spasm), sympathetic block at stellate/brachial, heparinize (prevent thrombus), possible alpha block (phentolamine)
hyperbaric O2
allows arterial O2 tension to increase 3x than at normal barometric pressure, used for decompression sickness, CO poisoning
hyperbaric O2 complications
seizures 2/2 CNS O2 toxicity (lower O2 concentration), lung damage (free O2 radicals), hyperoxic myopia (HBO >20-30), middle ear rupture, pneumothorax
first stage of labor
T10-L1, uterus, cervix, upper vagina; can use spinal, epidural, paracervical, caudal, general
second stage of labor
S2-S4; can use spinal, epidural, caudal, general, pudendal
beat to beat variability
best indicator of fetal well being, decreased happens with sleep and prematurity but can also indicate CNS damage, hypoxia, or drug effects
length of ETT placement
1 kg 7 cm
2 kg 8 cm
3 kg 9 cm
3.5 kg 10 cm (at term) OR multiply diameter x 3
diameter of ETT
(age + 16)/4
CDH
1:4000, defect in left posterior foramen of Bochdalek, associated with cardiac defects, pulmonary hypoplasia/HTN, GI abnormalities, spina bifida/hydrocephalus
CDH management
insert NG or OG to decompress stomach, maintain preductal O2 sat 90%, airway pressures <25, and PaCO2 60-65
pralidoxime dose
15-30 mg/kg over 20 min IM/IV to avoid laryngospasm, HTN, muscle rigidity, repeat after 4 hours or 1 hour if paralysis worsening
agent protective against organophophate poisoning
pyridostigmine - carbamylate-complexed acetylcholinesterase resists attack
sulfonylureas
glyburide/glipizide increase insulin secretion, contraindicated with sulfa allergy
metformin
is a biguanide that decreases GI glucose absorption and decreases liver glucose production –> decreased insulin resistance and blood glucose
metformin contraindications
renal insufficiency, metabolic acidosis, hold 48 hours before contrast media (acidosis risk), caution with hypoxemia, liver disease, alcohol abuse (lactic acidosis risk)
thiazolidinediones
tro/pio/rosiglitazone reduce insulin resistance, potential liver toxicity
alpha glucosidase inhibitors
acarbose and miglitol delay GI absorption and prevent complex carb breakdown, potential liver toxicity
repaglinide
is a meglitinide (similar to sulfonylurea) increases insulin secretion , more rapid onset, less risk of hypoglycemia, caution with renal/hepatic dysfunction
Artificially increased HbA1c
increased HgF, CRF, splenectomy, dialysis, thalassemia, increased triglycerides
decreased HbA1c
chronic blood loss, anemia, HbS
why does CO2 leave capillaries to alveoli more than O2 leaves alveoli to capillaries
CO2 20x more diffusible across membranes than O2 –> hypercarbia is never due to defective diffusion
Ondine’s curse
loss of autonomic control of breathing - always need to be awake and thinking of breathing
Bainbridge reflex
increased right atrial pressure (ass with increased filling) leads to increased HR from afferent inhibition of parasympathetics
Bezold-Jarisch reflex
triad of apnea, bradycardia, hypotension –> certain noxious stimuli sensed by chemoreceptors/mechanoreceptors in left ventricle stimulates C fibers that increases parasympathetic tone, triggers myocardial infarction/ischemia, thrombolysis, revascularization, syncopy
carotid sinus/aortic arch baroreceptor reflex
carotid (IX) and aortic (X) afferent signal relays change in BP to nucleus solitarius in CV center of medulla –> changes parasympathetic tone
carotid sinus/aortic arch baroreceptor reflex augmentation
loses function when BP <50, volatiles, CCB, ACE-I, phosphodiesterase inhibitors, chronic HTN decrease baroreceptor reflex
chemoreceptor reflex
found in carotid and aortic bodies, respond to changes in pH and PaO2 –> acidotic/hypoxemic causes stim of respiratory center via IX and X (and HR and contractility decrease)
cushing reflex
increased ICP causes cerebral ischemia which initially cause sympathetic response (tachy, HTN, increased myocard contractility), then HTN causes bradycardia reflex “HTN and bradycardia”
Pulmonary stenosis
2nd left ICS at left sternal border
MR
apical (5th ICS midclavicular)
AS
2nd right ICS at right sternal boarder
VSD
left sternal border ICS 4-6
TR
5th ICS at left sternal border
acute pericarditis
J point elevation, friction rub, referred pain in area of trapezius
CV changes with age
decreased vascular compliance, decreased hepatic blood flow and decreased protein binding
carcinoid treatment
bronchospasm - volatiles, steroid, H1&2 blockers, Benadryl, hypotension - volume repletion, HTN (serotonin release) - SNP, NTG –> long acting somatostatin analog, octreotide, treats all
pRBCs Hct
60
blood volume preterm? newborn? infant? child? adult?
100, 85, 80, 70-75, 70-75
DI
absence of ADH or renal insensitivity, see dilute urine, hypernatremia, hypovolemia; treat with IM ADH/DDAVP (vasopressin) or chlorpropamide if renal
SIADH
seen with surgery, tumors, hypothyroid, porphyria; see concentrated urine, decreased serum osmolality, hyponatremia; treat with fluid restriction, demeclocyline, hypertonic saline (0.5 meq/hr)
protamine
strong base; can cause flushing, edema, bronchospasm, pHTN; IgE mediated histamine release, complement activation, and thromboxane production
protamine susceptibility
prior exposure to protamine containing substances (NPH insulin), seafood allergy (derived from salmon sperm), vasectomy; tx: cyclooxygenase inhibitors (NSAIDs, ASA) can decrease adverse
retrobulbar complications
retrobulbar hemorrhage, globe perforation, optic nerve atrophy, convulsions, oculocardiac reflex, trigeminal block, respiratory arrest, acute neurogenic pulmonary edema
thermodilution inaccuracies
atrial fibrillation, TR, intracardiac shunts
neuromonitoring sensitivity
Visual>SSEP>MEP>BAEP
pulse ox limitations
no pulse - need arterial pulsations to distinguish from background venous (hypotension, hypothermia), hemoglobin variants, severe anemia (Hgb 3, Hct 10), venous pulsations (R heart failure, TR), fluorescent light underestimates, nail polish varies
CVP waves
All College Xams Vary Yearly - a wave atrial contraction, c wave tricuspid closure, x descent atrial relaxation, v wave atrial filling, y descent atrial emptying
a wave absent
atrial fibrillation or flutter
cannon a waves
junctional rhythms, TS, RVH, pulmonary/mitral stenosis, pHTN
artificially high PCWP > LVEDP
mitral stenosis, atrial myxoma, PEEP
artificially low PCWP < LVEDP
noncompliant LV, LVEDP >25, AI, premature closure of mitral valve
sensitivity to air embolism
TEE (gold standard), TT Doppler (0.25 ml), decreased ETCO2, increased nitrogen, increased PA pressure, hypotension, mill-wheel murmur
retrobulbar blocked nerves
II, III, V, VI
concentration effect
the higher the concentration of gas used the faster the alveolar concentration of that gas
2nd gas effect
large volume uptake of one gas accelerates the rate of increase of a concurrently administered gas
underdamped
short tubing (1.5 mm), long tubing (1.5 m), stiff tubing, big catheter (18g)
overdamped
high viscosity, soft/high compliance tubing
preductal measurement
(proximal to ductus arteriosus) right radial or temporal aa
awareness
routine monitoring of brain not recommend, small percentage of patients that report awareness will file a claim, they are only 2% of the claims, awareness is more likely under TIVA than volatiles, hemodynamics are also unreliable markers
ROP retinal O2 tension goals
60-90 mm Hg
hyperventilation disadvantages
Bohr effect results in a left shift of the hgb to have a greater affinity for O2, reducing the amount of O2 delivered to organs, PaCO2 < 30 mmHg, CBF can fall below a critical level and cause cerebral ischemia; pulmonary effects of alkalosis include increased permeability, decreased surfactant and decreased pulmonary compliance - acute lung injury.
VATER
VSD, vertebral defects, vascular problems, Anal stenosis, TEF, Esophageal atresia, Radial/renal anomalies
TEF complications
pre surgery: aspiration, PNA, congenital anomalies, post surgery: pneumo, atelectasis, anastomotic leaks, esophageal strictures
Lead V1-V2 changes
LCA:LAD septal branch, damage HIS, BB, septum
Lead V3-V4 changes
LCA:LAD diagonal, damage anterior wall
Lead V5-V6 changes
LCA:circumflex branch, damage high lateral wall
II, III, aVF changes
inferior wall LV, post LV
V4R (II, III, aVF) changes
RCA proximal branches damage RV, inferior wall, LV, posterior wall LV
V1-V4 changes
LCA circumflex or RCA posterior descending branch, damage posterior wall LV
R-L shunt effect on alveolar concentration
decreases 2/2 blood bypassing lungs, most effect on least soluble agents
CO2 response left
increased sensitivity to CO2: arterial hypoxemia, metabolic acidemia, central causes (ICP, anxiety, fear, cirrhosis), drugs (doxapram, strychnine, picrotoxin-analeptics
CO2 response right
decreased sensitivity to CO2: aminophylline, salicylates, catecholamines, opioids, Physiologic changes (metabolic alkalemia, denervation of peripheral chemoreceptors, normal sleep, drugs, hypothermia)
CO2 response down and right
high dose opioids, potent anesthetics - higher doses curve become horizontal (enflurane>halothane>isoflurane), neuromuscular blockade
no effect CO2 response
droperidol
sphincter of Oddi spasm
narcotics: morphine>fentanyl=alfentanyl>meperidine>butorphanol>nalbuphine, can be reversed with naloxone (except meperidine), glucagon, atropine, volatiles
dorsal colum medial lemniscal
tactile sense and limb proprioception
anterolateral (spinothalamic)
pain and temperature
signs of successful stellate block
best-temperature increase, can also use horners, cobalt sweat test, psychogalvanic reflex, plethysmography, and thermography
major CV risk
acute/recent MI, unstable/severe angina, decompensated HF, significant arrhythmia, severe valvular disease
intermediate CV risk
mild angina, previous MI, compensated/prior CHF, DM, CKD, CVA
minor CV risk
advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, uncontrolled HTN
exaggerated x and y descents
restrictive pericarditis
abolished y descent
cardiac tamponade
carbon monoxide half-life
4-6 hours with air, 40-80 min with O2, 15-30 min HBO
CO HBO indications
Co >40%, pregnant >15%, coma
mannitol onset,peak,duration
onset 15 min, peak 30-60 min, duration 3-6 hours
CSF drain
placed 15-20 cm above ext auditory meatus to avoid big drops in ICP, leave it closed until dura is open
transmural pressure
difference between arterial pressure minus CSF pressure
normal PaO2
102-(age/3)
abciximab, tirofiban, eptifibatide
platelet GIIb/IIIa inhibitors
ticlodipine, clopidogrel
inhibits binding of ADP to platelet receptors
ASA
irreversible inactivation of COX enzyme which decreases prostaglandin and thromboxane
common finding with epidural and first stage of labor
fever more common than prolonged labor
one lung ventilation indications
hemorrhage, abscess/infection, bronchopleural fistula, lung cyst, tracheobronchial disruption (tracheoesophageal fistula), unilateral bronchial lavage
relative one lung ventilation
thoracic aortic aneurysm, upper lobectomy, pneumonectomy, esophageal resection, middle/lower lobectomy
NO mechanism and precautions
NO stim cGMP which decreases intracellular Ca, NO is tightly bound to hemoglobin, limit of NO exposure is 2 ppm, >150 ppm fatal
laminar flow equation
Flow(Q) = pi/8 x (change in pressure x r^4)/(viscosity x L)
turbulent flow
when Reynolds number is >2000, Reynolds number = (V x r x density)/(viscosity)
cm to mm Hg conversion
1.36 cm = 1 mm Hg
treatment of pneumothorax
decompression at mid axillary line of 2nd intercostal space at right sternal border (can hit internal mammary artery aka internal thoracic artery)
NO expansion
34 x more soluble than nitrogen and 30 x more soluble than CO2, this will occur more rapidly in blood (PA catheter/air embolus expand faster than pneumo)
Etomidate on neuro monitoring
increased amplitude and increased latency
pediatric airway
more cephalad, larger tongue/epiglottis/tonsils/adenoids, cricoid most narrow, narrow, more anterior glottis, more angled (adult perpendicular)
hyperglycemic hyperosmolar non-ketotic coma
BG >600, serum osm >310, no acidosis, serum bicarb >15, normal anion gap
propofol CNS effects
decrease CMRO2, CBF (via cerebral vasoconstriction, ICP, CBV, and EEG activity
pRBCs component disappearance
I, V, VIII, platelets
whole blood component disappearance
platelets, I, V, VIII
LA toxicity ECG changes
prolonged PR, wide QRS
definitive test for acute hemolytic reaction
direct coombs (RBCs into serum) to rule out attachment of attachment of RBC antibody to donor RBCs
acute AF treatment
digitalis, verapamil, propranolol, D/C countershock, pacing (a flutter not AF), avoid lidocaine because increases AV conductance
digitalis uses
CHF and AF to slow ventricular response
dig toxicity symptoms
ventricular arrhythmias, anorexia, n/v
dig toxicity causes and treatment
hypokalemia, hypomagnesemia, hypothyroid, hypercalcemia - treat with potassium, magnesium, lidocaine, phenytoin, fab fragment antibodies (no cardioversion because can cause Vfib)
TET spell pathophys
2/2 spasm of RV outflow tract and infundibulum –> increased outflow resistance, decreased pulm blood flow, increased R-L shunt
TET spell treatment
beta blocker to decrease HR and stop infundibular spasm, phenylephrine to increase SVR and decrease R-L shunt
Cushings symptoms
HTN, hypokalemic alkalosis, hyperglycemia, hypernatremia, osteoporosis, easy bruising, polyuria, buffalo hump, moon facies, hirsute, menstrual abnormalities
standard deviation
measure of variability: 1 68%, 2 95%, 3 99%
type I error
null incorrectly rejected (probability of this error - alpha)
type II error
null incorrectly accepted (probability of this error - beta)
p value
probability that result could have happened by chance is less than 1/5 in 100
compare means of two different groups (continuous)
unpaired t-test
compare means of >2 groups (continuous)
ANOVA
Wilcox rank sum
used like a t-test when the data is normally distributed
compare means of two different groups (categorical)
chi-square
power
= 1 - beta
confidence interval 95
95% chance that true population parameter is contained within interval
normal urine osm
300
normal urine sodium
> 20
FeNa
1% (>ATN or other kidney injury)
antibiotic prophylaxis
- prosthetic cardiac valve 2. previous IE 3. congenital heart disease - unrepaired, repaired with device in last 6 months, repaired with residual defect 4. cardiac transplant with valvulopathy
ROP presentation and pathophys
usually <1500g, norm retinal vasc develops 40-44 wks, hyperoxia disrupts this process
ROP management
O2 sat 93-95%, PaO2 50-80 mm Hg
tocolytics
beta agonists, magnesium, ethanol, prostaglandin synthetase inhibitor, NSAIDS, CCB
ethanol as tocolytic
given in 10% solution of D5W, probably inhibits oxytocin
prostaglandin synthetase inhibitor SE
premature close of PDA, primary pHTN, inhibits cox, which decreases thromboxane production - decrease platelet adhesiveness
ephedrine in pregnancy
beta agonist that crosses placenta, increases beat to beat variability and fetal HR
epiglotitits
supraglottic inflammation, H. Influenza, intubation in OR, thumb sign
croup
laryngo-tracheo-bronchitis, barking cough, narrowing of subglottic inlet - steeple sign , treat with racemic epi neb, cool mist, steroids, intubation in OR
esmolol metabolism
RBC esterases, short half life
rhabdomyolysis triggers
suc, volatiles, ketamine, propofol
termination of thoracic duct
left subclavian and left jugular veins
paresthesia vs dyesthesia
parethesia no unpleasant vs dyesthesia unpleasant
dibucaine
amide local that inhibits pseudocholinesterase - 80 homozygous normal
3rd degree heart block vessel
RCA - most often supplies SA and AV nodes
best TEE view for ischemia
Transgastric mid short axis view
volatile metabolism
methoxyfluran 40%, halothane 20%, enflurane 2%, iso 0.2%, des <0.2%
mivacurium
anticholinesterase and NDMR will prolong duration 2/2 mivacurium metabolized by pseudocholinesterase
cocaine intoxication contraindicated drugs
beta blockers, beta agonists, alpha agonists, meperidine
dexmedetomidine
alpha agonist that causes analgesia and sedation with little resp depression - supraspinal site of action for sedation (locus coeruleus)
dexmed metabolism
liver
dexmed side effects
transient HTN and bradycardia followed by decrease in BP and stabilization of HR
dexmed contraindications
patients with bradycard disorders, severe ventricular dysfunction, CHF - conditions where need sympathetic tone
sentinel event
unexpected occurrence involving death or serious physical or psychological injury or risk thereof
bleomycin
pulmonary fibrosis
doxirubicin
cardiomyopathy, GI upset, alopecia, myelosupression
dead space on ventilator
distal to y-piece
Guanethidine
antihypertensive drug that reduces the release of catecholamines
