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Clinical Reference Deck > PoA2 > Flashcards

PoA2 Flashcards

1
Q

Supine Position Complications

A

* Backache (worse if over 3 hours, normal lumbar curvature is lost from lack of paraspinous muscle tone
* Pressure allopecia
* Brachial Plexus Injury or Axillary nerve injury if arms abducted over 90 degrees
* Ulnar nerve injury if hand arm is pronated down
* stretch injury when neck is extended and head turned away

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2
Q

Trendelenburg Pathophysiologic Considerations

A
  • Increased CO (from Inc VR from LE)
  • ** increased ICP and IOP, possible Vision loss**
  • Edema of face, conjunctiva, larynx, tongue (worse with longer surgery and fluid overload)
  • increased intraabdominal pressure
  • Decreased FRC and pulmonary compliance (diaphram shifts cephalad
  • Higher pressures may be needed to vent well
  • Enodbronchial intubation risk as carina also shifts cephalad
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3
Q

Beach Chair Position Risk

A
  • Zero a-line at the tragus- cerebral hypoperfusion risk/air emboli
  • pnemoceph-air in sudural/ventricles putting pressure on surrounding structures
  • Quadriplegia and spinal cord infarct-c-spine overextension
  • cerebral ischemia-c-spine overextension
  • Peripherial Nerve injury- Sciatic most often
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4
Q

Prone Position Risks

A
  • Facial/airway edema
  • Nerve injuries: Ulnar if elbows not padded, brachial plexus is arms abdudcted over 90 degrees
  • POST OP VISUAL LOSS FROM ISCHEMIA/HYPOPERFUSION
  • Eye injuries from head position
  • ETT dislodgement
  • loss of monitors/IV
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5
Q

Lithotomy Position and Considerations

A
  • Patient laying supine with legs up in padded or “candy cane” stirrups
  • Arms tucked or on arm boards
    If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress
  • Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed
  • Lower extremities MUST be raised and lowered in synchrony together-prevents lower spine injury
  • Foot of the bed is lowered, must protect the hands and fingers from crush injury-MITTENS
  • Surgery > 2-3 hours, periodically lower the legs
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6
Q

Lithotomy Risk

A
  • Back pain
  • Nerve injuries
  • Brachial plexus
  • Ulnar nerve injury
  • Common peroneal injury- common from leg supports
  • Lateral femoral cutaneous injury-KEEP LEGS FROM BEING FLEXED 90DEGREES OR MORE AT HIP TO PREVENT INGUINAL STRAIN
  • Compartment syndrome-OCCLUSION OF LOWER EXTREMITY VENOUS PLEXUS
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7
Q

Lateral Decubitus Positioning

A
  • If bed flexed or kidney rest used, needs to be placed under iliac crest
  • Inferior vena cava compression can occur
  • Allowing best possible expansion of the dependent lung
  • Nerve injuries
  • Ulnar nerve injury if elbows are not padded
  • Brachial plexus injury if arms are abducted > 90 degrees
  • ETT dislodgement(with patient turns); caution with use of LMA
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8
Q

A patient is supine with the neck extended and the head turned to the right, away from the surgical site. Which positioning complication may occur?

A

Stretch injury (brachial plexus)

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9
Q

Where does HCO3- enter and leave

A

Kidneys at the proximal tubule

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10
Q

Where does H+ enter and leave the body

A

Distal Tubule and collecting duct

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11
Q

If PaCO2 and HCO3- are changing in the same direction what kind of issue is it

A

Primary Disorder with secondary compensation

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12
Q

PaCO2 and HCO3- are changing in the OPPOSITE directions what type of issue is it

A

Mixed Acid/Base disorder

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13
Q

Acidosis Cardiac consequences

A
  • pH 7.2-Decreased contractility/MAP
  • sensitive to dysrhythmia
  • lower threshold for VF
  • pH 7.1 dec responsiveness to catecholamines
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14
Q

Respiratory Acidosis bicarb compensation

A

Acute Hypercarbia- per 10mmHg of PaCO2 increase, plasma HCO3- increases 1 mmol/L
Chronic hypercarbia- per 10 mmHg of PaCO2 increase, HCO3- increases 3 mmol/L

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15
Q

Respiratory Acidosis Intervention and concern with chronic hypercarbia

A

Mechanical ventilation If hypercarbia marked and CO2 narcosis present
Caution with chronic hypercarbia reversal….excessive bicarb causes CNS irritability…seizure

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16
Q

Acute metabolic acidosis expected PaCO2 shift

Formula and rating of compensation card

A
  • “Lowered blood pH indicating problem:
  • Respiratory compromise doesnt counter acid production
  • Caused by: increased acid production, decreased excretion
  • You ingest something ridiculous or Renal/GI system cant hold on to bicarb
  • (1.5 x HCO3- + 8)

If 1 mEq/L decrease in base excess- PaCO2 should decrease 1.2 mmHg-if not compensation is indequate

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17
Q

Simple Anion Gap formula

A

Na - (Cl- + HCO3-) = 12-14 mEq/L ish

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18
Q

Conventional anion gap

A

(Na+ + K+) - (Cl- + HCO3-) = 14-18 mEq/L
both simple and conventional underestimate disturbance-hypoalbuminemia and hypophosphatemia are a thing

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19
Q

Bicarb Correction formula, tissue effect interplay in situ, and how to admin

A

reacts w/ H+ → generates CO2 →dec pH further
-in chronic metabolic acidosis, acute pH changes negates right shift (Bohr effect is countered) → tissue hypoxia

-bicarb correction dose = 0.3 x base deficit x kg (give ½ dose and reassess)

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20
Q

Respiratory Alkalosis Causes

A
  • High altitude
  • PREGNANCY
  • Salicylate Poisioning (Aspirin)
  • Iatrogenic Hyperventilation (spooked about surgery-then hyperventilates)
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21
Q

Respiratory Alkalosis symptoms and Ion consideration

A

Lightheadedness, Vision issues, and dizziness from low PaCO2
* GREATER BINDING OF CA++ TO ALBUMIN
* Leads to hypocalcemia and thus cramps, spasms, circumoral numbness and seizures
* Trousseau’s and Chvostek’s signs

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22
Q

Metabolic Alkalosis causes

A
  • DIURETIC THERAPY
  • Hyperaldosteronism
  • NG Suction
  • Hypovolemia
  • Vomitting
    give Spironolactone (K sparing → H+ sparing)
    give carbonic anhydrase inhibitor (Acetazolamide) to renally excrete bicarb
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23
Q

Definition of a breathing system

A
  • delivers gas to patient
  • removes CO2
  • provides heating/humidification of gas mixture
  • allows spontaneous, assisted, or controlled respiration/ventilation
  • provides gas sampling, measures airway pressure, monitors volume
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24
Q

Open Circuit Classification

A

NO RESERVOIR BAG, NO REBREATHING
Open to atmosphere, think nasal cannula

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25
Q

Semi-open breathing system

A

Resevoir bag no rebreathing
Mapleson circuit, or a vent with FGF greater than MV

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26
Q

Semi-closed

A

Resevoir bag, and partial rebreathing
Partial rebreathing occurs but some waste flow is vented through APL or waste gas valve of ventilator
e.g. low-flow anesthesia
FGF is LESS than minute ventilation
50% of expired gas is rebreathed after CO2 removal

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27
Q

Inspiratory Valve

A

Prevents backflow of gas
gotta be hydrophobic

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28
Q
A
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29
Q

Expiratory Valve

A

Prevents rebreathing
hydrophobic
Must be between patient and resevoir bag

30
Q

Apparatus Deadspace

A

From Y-piece to patient
if inspiratory valve is stuck that arm is now apparatus deadspace also

31
Q

Breathing/Resevoir Bag Specs

A

ELLIPSOIDAL for 1 hand operation
3L for adults (0.5-6L)
must have 22mm female connector on neck
min pressure 30 cmH2O, 40-60cmH20 max (rubber bags)

plastic has 2x distending pressure vs rubber

32
Q

Resevoir Bag Function

A

Resevoir for O2/Volatiles
manual vent or assisting with spontaneous venting
Tactile/visuall indicator of ventilation
protects against excessive positive pressure
Visual monitor of ventilation/accumulation of gases within circuit

33
Q

APL Valve

A

Adjustable Pressure limiting valve/ Pop-off Valve
controls pressure in system
CLOCKWISE CLOSES APL, INCREASING SYSTEM PRESSURE (PEEP)
CCWOpposite motion, decreases pressure
1-2 clockwise turns from fully open to fully closed
An arrow must indicate direction to close valve

34
Q

Absorbant Indicators function and colors

A

Ethyl violet is the most common dye
Ethyl orange, cresyl yellow

Color change is from Carbonate formation

pH becomes less alkaline
White to blue violet

Undergoes color change around pH of 10.3
Fresh absorbent is colorless, pH > 10.3
Exhausted absorbent is purple, pH < 10.3

Bleaching-fluorescent light deactivates dye

depend on capnography as color abosrption could be altered

35
Q

Channeling, and methods of prevention

A

Small passage ways allowing gas to flow through low-resistance areas
-Decreases functional absorptive capacity

Minimized by
Circular baffles(round circular tube in absorbent)

Placement for vertical flow
Permanent mounting
Prepackaged cylinders
Avoiding overly tight packing-can lead to channeling

36
Q

Carbon Monoxide formation

A

Dry absorbent/Dessicated
more likely if FGF inlet is close to CO2 abosrber, or leaving FGF on
Carboxyhemoglobin levels can reach 35% in patient
Pulse ox or IR gas monitors will not detect it
’Monday, 1st case’
Highest levels Desflurane ≥ enflurane > isoflurane > halothane > sevoflurane
Increased temperatures
Increased concentrations of anesthetic gases
Low FGF rates
Strong base absorbents (KOH or NaOH)

37
Q

Mapleson Circuits do have and do not have what

A

Reservoir bag
Corrugated tubing
APL valve
Fresh gas inlet
Patient connection (Maple E doesnt have Bag or APL
NO CO2 absorber
NO UNIDIRECTIONAL VALVES
NO SEPARATE INSPIRATORY OR EXPIRATORY LIMBS (except bain)

38
Q

Mapleson efficency for SV and Controlled ventilation

A

Mapleson A is best for SV (DEF, then BC)
Mapleson D(E or F) is best for controlled, (BC, then A)

39
Q

Humidify Definition

A

Amount of water vapor in a gas

40
Q

Absolute Humidity

A

Mass of water vapor in gas (mg H2O/L of gas)

41
Q

Relative Humidity

A

% Saturation, amount of water vapor at a given temp

42
Q

Under humidification issues

A
  • Damage to respiratory tract
  • Secretions thicken
  • Ciliary function decreases
  • Surfactant activity is impaired
  • Mucosa susceptible to injury
  • Body heat loss-neonates and children
  • Tracheal tube obstruction
  • Increases resistance and work of breathing from thickened secretions
43
Q

Over humidification issues

A
  • Condensation of water in the airway
  • Reduced mucosal viscosity and risk of water intoxication
  • Inefficient mucociliary transport
  • Airway resistance, risk of pulmonary infection, surfactant dilution, atelectasis, and V/Q mismatch
  • Obstruction to sensors
44
Q

HME (Heat and Moisture Exchanger) Function, location, and affect on deadspace

A
  • Conserves some exhaled heat and water and returns them to the pt
  • Bacterial/viral filtration and prevention of inhalation of small particles (HMEF)
  • Disposable with exchange medium enclosed in plastic housing
  • Placed close to the pt, between Y piece and proximal end of ETT or LMA
  • increased deadspace (apparatus)
45
Q

Humidifier use, location, special population considerations, and forms

A
  • Neonates, pts with difficult respiratory secretions, or hypothermic pts see use often
  • Passes a stream of gas in various ways: Bubble or cascade, Pass-over
    Counter-flow, Inline
  • May be heated or unheated
  • Placed in inspiratory limb downstream of unidirectional valve
  • Heated humidifiers should not be placed in expiratory limb
  • Condensation can decrease delivered Vt
  • Water traps - change frequently to decrease risk of contamination and infection
46
Q

OPAs

A

Lifts tongue and epiglottis away from posterior pharyngeal wall

Decreases work of breathing during SV (when used with face mask)

Size by measuring corner of mouth to angle of jaw/earlobe

47
Q

NPA use, C/Is, Proper seating

A

-use to dilate nasal passage prior to nasal intubation
-tolerated in pts w/ intact airway reflexes (awake)
-used when loose teeth, oral trauma, gingivitis, limited mouth opening
C/I in basilar skull fx, nasal deformity, hx epistaxis, pregnancy, coagulopathy

Design: shortened tracheal tube
-flange at outer end to prevent complete passage

-less stimulating than OPA (better tolerated)
-sized by outer diameter in French scale  Insertion: sized bony mandible or nostril to external auditory meatus (earhole)

** -bevel of NPA rests above epiglottis**
-insert parallel to inferior nasal floor

48
Q

LMA Classic shape, location when in use and materials

A

Shaped like a TT proximally
Elliptical mask distally
Sits in hypopharynx and surrounds the supraglottic structure
An inflatable cuff
Latex free, reusable, disposable

49
Q

LMA Insertion

A

Well lubed
hold like a pencil
press upward against hard palate
follow posterior pharyngeal wall, pressing backward in a smooth motion
should feel it curve around and downward in airway, advance until resistance felt
When balloon inflated, neck bulged and LMA may “rise” slightly indicating it is seated

50
Q

LMA Advantages

A

Ease of insertion
quick to place
improved hemodynamic stability(not as stimulating with induction drugs)
reduced anesthetic requirements
no paralytics needed
avoids some ETT risk such as trauma/bronchospams

51
Q

Mac Blade Points

A

Tongue has gentle curve
#3 and #4 useful for adults
Has been shown to cause greater cervical spine movement than with Miller
Makes intubation easier because blade requires adequate mouth opening due to blade size

52
Q

Miller Blade Points

A

Miller blades
Tongue is straight with slight upward tip
#2 and #3 for adults
less Force, less head extension, and cervical spine movement
Great for smaller mouths and longer necks
LIfts epiglottis

53
Q

Miller Blade view

A

Blade lifts epiglottis

If blade inserted too far, it elevates larynx or esophagus

If withdrawn too far, epiglottis flips down and covers glottis

Can use like a Macintosh to insert into the vallecula

54
Q

Rigid Indirect Laryngoscopes

A

Stainless steel, lighted stylet with malleable distal tip; design utilizes eye piece

Oxygen port for oxygen insufflation

Neutral position, inserted midline; available in adult and peds sizes

Stylet advanced into trachea; light pressure and tip anterior at all times to avoid injury

Can be used as a light wand, check ETT placement, or placement of double-lumen ETT

55
Q

Optical Stylet Pros

A

Easy to use for routine and difficult intubations(ala fiber optic scopes)

Trachea is visualized, esophageal intubation should not occur
Decreased incidence of sore throat
Results in less c-spine movement over conventional laryngoscopy

56
Q

Optical Stylet Cons

A

Longer intubation time
Cannot be used with nasal intubation
Cannot be adjusted into a precise direction compared to a traditional malleable stylet

57
Q

Video laryngoscope pros

A

Magnified anatomy
Some scopes have curved/straight blades to mimic laryngoscopes
Operator and assistant can see
May result in decreased c-spine movement
Further distance from infectious patients
Demonstrates correct technique in legal cases

58
Q

Video laryngoscope cons

A

Requires video system
Portability varies
Strongest predictors of failure: altered neck anatomy with presence of a surgical scar, radiation changes, or mass

59
Q

Laryngoscopy Complications

A

Dental injury Most frequent anesthesia-related claim
Most likely damaged teeth, Upper incisors (9, 10, 8) and left more likely than right
Restored or weakened teeth
Tooth protectors
Placed on upper teeth during DL
Protects from the blade causing direct surface damage
Does not guarantee safety from dental trauma

60
Q

ETT Design

A

Internal and external walls circular
Decreases kinking
Can be shortened at machine end
Patient end has slanted bevel
Helps view larynx
Murphy eye
Provides an alternate pathway for gas flow

61
Q

Laser-Resistant ETT

A

Metallic or silicone and metal mixture
Reflects laser beams-CO2 or KTP laser
Cuffs contain methylene blue crystals
Saline-Not laser resistant

Double cuffs-Fill with methylene blue saline solution to detect laser biffs
**Distal cuff first, then proximal cuff **

62
Q

ETT Markings

A

On bevel side above the cuff
Read from pt side to machine side
Safety standards
The word oral or nasal or oral/nasal
Tube size in ID in mm
Name of manufacturer
Graduated markings in centimeters from patient end
Cautionary note… single use only if disposable
Radiopaque marker at patient end

62
Q

ETT Cuffs

A

Inflatable balloon near patient end of tube
Strong, tear-resistant, thin, soft, and pliable
Must not herniate over murphy eye or bevel of tube
wCuff pressure = 18 - 25 mm Hg; usually 8 - 10 mL of air
Monitor cuff pressure frequently if using nitrous as this causes cuff inflation/expansion

63
Q

ETT Complications

A

Vocal cord granuloma (mass that results from irritation
Common in adults; females
Trauma, ETT too large, infection, and excessive cuff pressure
S/S: Persistent hoarseness, fullness, chronic cough, intermittent loss of voice
Treatment: laryngeal evaluation, voice rest

64
Q

Airway Bougie

A

Polyester base with resin coating
Distal end angled 30-45 degrees
Introduced with anterior positioning of the tip
Blind intubation if glottic exposure is absent
ETT passage is difficult

Advance gently
Feel clicking sensation across tracheal rings

65
Q

Right Mainstem Points

A

Shorter, straighter, larger diameter
25 degree takeoff from trachea
RUL tracheal takeoff very close to origin
Avg length 2.5 cm from carina to take-off

66
Q

Left Mainstem Points

A

45 degree takeoff from trachea
LUL tracheal takeoff more distal
Avg length 5.5 cm from carina to take-off

67
Q

Double Lumen Tube Insertion

A

-left DLT primarily used (to avoid blocking RUL bronchus)
-right DLT for left lung surgeries (eg: transplant)
Insertion:
Placed similarly as a standard ETT-more difficult due to stiffness and size
Advance through the larynx with angled tip anterior into the trachea
Bronchial cuff passes the cords, the tube is turned 90 degrees
Bronchial portion points toward the appropriate bronchus
Verification of the location of the bronchial port with an fiberoptic scope
Blue bronchial cuff is just below the carina in the appropriate bronchus
Inflate bronchial balloon under direct visualization to verify proper placement
Ensure bronchial cuff does not herniate over the carina
Isolate a lung by clamping either the tracheal or bronchial connector

68
Q

Indications For Bronchial-Blockers

A

When DLT is not advisable, can block a segment of lung without isolating the whole thing
Nasal intubation
Difficult intubation
Patients with tracheostomy
Subglottic stenosis
Need for continued postoperative intubation
If a single-lumen tube is already in place
Critically ill pts

69
Q

Resistance of ETT is determined by whut

A

Length, and internal diameter of tube (config and connectors)
Jean Poiseuille has entered the chat

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