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Anatomoy 3 > Principles 4 > Flashcards

Principles 4 Flashcards

1
Q

How does vapor pressure vary with temp?

A

VP increases w temp

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2
Q

What are 3 fxns of interlocks?

A

Prevents the operator from delivering more than one VA simultaneously

  • only one vaporizer, seated correctly
  • must be on for carrier gas to enter
  • no trace output from other vaporizers
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3
Q

Classification of variable bypass vaporizers

A
  • flow over
  • temp compensated
  • agent specific
  • out of circuit
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4
Q

What is splitting ratio?

A

The gas entering the vaporizing chamber divided by the fresh gas flow. Controlled by concentration control dial and temperature compensation valve

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5
Q

What effect does flow have on vaporizer design?

A

FGF okay btw 0.2-10 L/min

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6
Q

What effect does temp have on vaporizer design?

A

Okay btw 20-35 C

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7
Q

What effect does the pumping effect have on vaporizer design?

A

Oscillating pressures distal to outlet cause exited vaporizer gas to reenter, so delivered vapor is higher than dialed… so check valves at outlets and inlets to vaporizers are used.

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8
Q

Classification of the tec 6 vaporizer

A
  • Heated, dual circuit
  • Pressurized
  • gas/vapor blender (FGF never comes into contact or flows over the liquid agent)
  • no output during warm up or if power lost
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9
Q

Checkout routine for the Tec 6

A 
Mute buttons (check lights, alarms)
w 1% on dial, unplug (checks battery power)
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10
Q

Correct procedure to fill vaporizer

A

*Turn off
*Watch the liquid level indicator as to not overfill
*Must be in horizontal position
Funnel-type and keyed-filler

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11
Q

Hazards of contemporary vaporizers

A
  • Awareness or hypoxemia d/t leaks or empty vaporizers (prevent w negative pressure check)
  • Incorrect agent
  • Overfilling
  • Electronic failure
  • tipping
  • reliance on breath by breath gas analysis rather than preventive maintenance
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12
Q

What are the fnxs of the breathing circuit?

A
  • deliver oxygen and anesthesia

* eliminate CO2 (by washout w adequate FGF or chemical absorption)

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13
Q

Open circuit

A

Open drop or NC

  • no reservoir (aka breathing bag)
  • no rebreathing
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14
Q

Semi-open circuit

A

Non rebreather or FGF > VE (high FGF)

  • reservoir (aka breathing bag) present
  • no rebreathing
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15
Q

Semi-closed circuit

A

Circle (FGF < VE)

  • reservoir present
  • partial rebreathing
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16
Q

Closed circuit

A

Circle (APL closed) (little to no FGF)

  • reservoir present
  • complete rebreathing
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17
Q

What is rebreathing and how is it used in anesthesia?

A

Rebreathing of exhaled gases
*increased as FGF is decreased
Advantages:
*cost reduction
*increase is tracheal warmth and humidity
*decrease staff exposure to VA
High FGF and low rebreathing during induction and emergence - Low FGF and high rebreathing during maintenance

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18
Q

How is CO2 rebreathing prevented in conventional circuit and non-rebreathing circuits?

A
  • Washout w adequate FGF

* absorption by granules

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19
Q

What is dead space and where does it end?

A

Ends where inspiratory and expiratory gas streams diverge (Y-piece in circle systems)
Increase VD = increase chances of rebreathing
exhaled CO2

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20
Q

Vd/VT ratio in spontaneous, intubated, and FM

A 
Vd/VT = dead space / tidal volume
spontaneous = 0.33
intubated = 0.46
FM = 0.64
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21
Q

Advantages of circle breathing systems

A
  • constant inspired concentrations
  • conserve respiratory heat/humidity
  • useful for all ages
  • useful for closed systems or low flow
  • low resistance (< ETT but > NRB)
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22
Q

Disadvantages of circle breathing systems

A
  • Increased VD (dead space)

* Malfunctions of I/E unidirectional valves

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23
Q

Considerations for children

A

*compliance
*barotrauma
*weak
*uncuffed ETT (leak)
Use NRB circuits
*no unidirectional valves or absorbent
*low resistance
*FGF determines amt of rebreathing, >5

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24
Q

Mapleson D and F circuits

A

gas escapes via tail of bag (bag-tail valve), IPPV, resp mvmts easily seen

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25
Q

Bain circuit

A

inner tube inside outer tube
hazards:
*increased dead space
*unrecognized disconnection or kinking causing complete rebreathing

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26
Q

What do you do when changing from one circuit to another on AGM?

A
  • Repeat compliance/leak check

* Repeat auto vent check (allows machine to compensate for different compliance and deliver accurate VT)

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27
Q

What specific changes must you make when using the ADU AGM?

A
  • use small spirometry sensor (effect VT)

* choose Peds sensor in monitor setup

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28
Q

Baby < 10 kg

A

Hand bag and use precordial

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29
Q

Fabius breathing system

A

*FGF decoupling - bag not still, it moves opposite
of bellows, in sync w chest
*Piston driven vent - very quiet, no gas needed
*FGF enters behind insp unidirectional valve
*No bag/auto switch in breathing circuit

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30
Q

ADU breathing system

A

*Vertical check valves - less resistance
*Breathing bag at end of hose - no fixed position
*Checked for leaks/compliance - part of electronic
checklist
*Optimized for low flow

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31
Q

What is the size of CO2 absorbent?

A

4 - 8 mesh

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32
Q

What is the main constituent of absorbent?

A

Calcium hydroxide - CA(OH)2

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33
Q

What is the final product of absorbent?

A

Calcium carbonate - chalk - CaCO3

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34
Q

What is the amt of water content in soda lime?

A

15 - 20%

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35
Q

What is the first neutralization rxn in CO2 absorption?

A

formation of carbonic acid

CO2 + H2O → H2CO3

36
Q

What is the second rxn?

A

Carbonic acid and Lye produce sodium carbonate, water and heat
H2CO3 + NaOH → Na2CO3 + H20 + heat

37
Q

What is the final rxn (second neutralization rxn) in CO2 absorption?

A

Sodium carbonate and calcium hydroxide produce chalk (calcium carbonate) and lye
Na2CO3 + Ca(OH)2 → CaCO3 + NaOH

38
Q

What are the recommended practices for safety in handling soda lime?

A

*Check color at the end of the case
*Change on a regular basis (q 48 hrs)
*Do not assume that lack of color change means
granules are intact

39
Q

How do you change Aestiva prefilled canisters?

A

Discard top canister, promote bottom to top, and put fresh one on the bottom

  • wear gloves/mask
  • remove plastic wrap before
  • check for leaks after
  • don’t change mid case, convert to semi-open circuit (FGF to > 5 L/min)
40
Q

How do you change ADU CO2 absorber?

A

*Quick release can change during ventilation
*smaller canister (good bc avoids dry granules, des
produces carbon monoxide, sevo produces
compound A, bad bc freq change $)
*Alarms when inspired CO2 > 3
If no replacement, turn up FGF

41
Q

What is a toxic product of sevo?

A

Compound A

*Keep flows > 1 L/min (for not > 2 MAC hr)

42
Q

What situations would cause inspired CO2 to increase?

A
  1. Malfunctioning unidirectional valve

2. Exhausted absorbent

43
Q

What is the management plan when inspired CO2 increases?

A
  1. Increase FGF 8-10 L/min ( > VE) = semi-open,
    almost no rebreathing
    *if CO2 returns to normal, than its exhausted
    granules, if CO2 remains high…
  2. Inspect unidirectional valves
44
Q

What are the toxic breakdown products of current VA?

A

Sevo → Compound A

Des → Carbon monoxide

45
Q

What causes this toxic breakdown?

A

Degradation of VA by the activator KOH (a strong
base)
*take out activators (NaOH and KOH)
*do not use Sevo at FGF < 1 L/min for more than
2 MAC hours
Dry absorbents also cause breakdown

46
Q

What is the indicator used for changing absorbent?

A

Ethyl violet ~ indicates when absorbent pH has reached 10.3 (alkaline), but there maybe color reversion

47
Q

Classify mechanical ventilators by power source:

A
  • Electric (Piston ventilator)
    • just controls or piston-driven motor
  • Pneumatic (Gas-driven bellows)
    • if dual circuit bag-in-bottle - gas powered
    • if pipeline lost, hand ventilate!
48
Q

Classify mechanical ventilators by drive mechanism:

A
  • Pneumatic, double circuit - O2 or air drives bellows

* Electric motor drives bellows

49
Q

Classify mechanical ventilators by cycling:

A

Time cycled, electronically controlled
*volume mode - flow stops when set VT delivered
OR when max pressure reached
*pressure mode - flow generated to maintain set
pressure, no guaranteed volume

50
Q

Classify mechanical ventilators by bellows type:

A 
Gas-driven:
     * Ascending - standing (most common - PEEP) 
     * Descending - hanging (datascope)
Piston driven 
     (Divan and Fabius)
51
Q

Why would hanging bellows be less safe than standing bellows?

A

The bellows will still fill (with RA) in the event of a disconnect
Water can gather in the bellows (decreasing VT
and increasing risk of infection
Note: decoupling - bag remains in circuit

52
Q

How do you choose safe initial ventilator settings?

A

Are they breathing spontaneously, is there a reason to have limited pressure, do they need a certain amt of volume (limited).

53
Q

How do the bag-in-a-bottle ascending bellows and relief valve work?

A

The bellows is like an anesthetist squeezing the bag, within the bellows is the gas insp and exp by the pt.
With the addition of FGF, there must be a spill valve or barotrauma would result
Gas is released to the scavenger in an equal amt of FGF per minute (exp only)
Note: when switching from bag to vent or auto, removes bag and APL valve from breathing circuit

54
Q

How is 2 to 3 cm H2O of PEEP implicated in all standing bellows?

A

During early exp, a weight w/in the VRV (APL)holds pathway to scavenger closed until bellows have filled

55
Q

What is VCV?

A 
Volume controlled ventilation setting:
*desired VT delivered at constant flow (unless 
     excessive pressure is reached)
*time cycled (you set resp rate)
*PIP uncontrolled
Adjust VT to prevent atelectasis, adjust RR for
     desired CO2 level
I:E ratio 1:2
56
Q

What is PCV?

A

Pressure controlled ventilation:
*PIP limited
*cycle controlled by time
*decelerating flow pattern
*VT uncontrolled - increase if compliance increases or PIP decreases
*High flow needed at first, then less to maintain
*Target pressure is adjusted for the desired VT
Set pressure limit to 20 cc H2O, adjust RR for
desired CO2 level
I:E ratio 1:2

57
Q

Indications for PCV:

A

If high insp pressure is dangerous - LMA, neonates,
emphysema
Low compliance - obesity, pregnancy, ARDS
Compensates for leaks - LMA, uncuffed ETT

58
Q

What is PCV-VG?

A

Pressure controlled ventilation with volume guarantee:
Basic controls are target pressure and RR, AND a
desired VT is also set.
*decelerating flow pattern at a constant pressure
(just like PCV)
*BUT the insp pressure is adjusted to deliver the
desired VT
This compensates for changes in the pt’s lung
characteristics

59
Q

What is SIMV?

A

Synchronized intermittent mandatory ventilation:
*Full to partial support of ventilation
*Can be PCV or VCV
*Intermittent mandatory breaths delivered in
synchrony and triggered by the pt’s
spontaneous efforts
*Settings include: volume or pressure, rate, trigger
window and sensitivity

60
Q

What is PS?

A 
Pressure support:
*Pressure targeted mode
*Rate of ZERO - only for spontaneously breathing
     pts!
*Thus, no minimum minute ventilation 
*Start at 10 cm H2O and adjust as needed
61
Q

How do modern vents accomplish VT compensation?

A

Accuracy at lower VT - compensating VT for
compliance and leak testing, and changes in
FGF (use smaller circuits and change D-lite,
don’t forget to change settings, and repeat leak
and compliance tests)
Enter pt’s wt and it will select VT and parameters

62
Q

What are signs of carbon monoxide poisoning during anesthesia?

A

*

63
Q

Why is des compensation used on the Fabius GS?

A

*

64
Q

What is the proper procedure for denitrogenation?

A
  • FGF 4-6 L/min
  • APL valve open fully
  • *TIGHT MASK FIT**
65
Q

What should flows look like during induction?

A

High MAC, High FGF (5-8 L/min) = overpressure

when end-tidal agent @ MAC, turn down VA to MAC w high flows OR leave VA high and turn down flows

66
Q

What should flows look like during maintenance?

A

Low flows = 1 L/min, to conserve heat/humidity

67
Q

What should flows look like during emergence?

A

High FGF w NO VA (washout)

68
Q

Avoid low flows if…

A

High VO2 needed or toxic gases to washout
*MH, smoke inhalation, sepsis
*necessary equipment broken/missing
-O2 analyzer, agent analyzer, absorbent
Relative
*case < 15min
*leaks to expected (older machine, FM, uncuffed
ETT, rigid bronchoscopy

69
Q

What are the s/sx of MH?

A

Tachycardia
Tachypnea
Elevated pETCO2

70
Q

List the differential diagnosis’s of MH:

A

Ventilator problems, unidirectional valve malfunction, exhausted granules, pneumoperitoneum

71
Q

What are the triggers of MH?

A

Succs and VA

72
Q

What is the definitive treatment for MH?

A

Dantrolene 2.5 mg/kg (up to 10 or more)

73
Q

What is safe supportive treatment for MH?

A

Cooling, NaHCO3 for acidosis, treat high K+
gas machine: Stop VA and succs, High FGF,
hyperventilate, charcoal filters, change soda lime
and circuit

74
Q

What is the set up for managing known MH pt?

A 
Avoid triggers
*use TIVA, N2O
*Roc instead of Succs
Gas machine
*Remove vaporizers
*change granules and breathing circuits
*Flush (FGF 10 L/min for 20 min)
75
Q

What are the most common problem areas of the old vents?

A
  • lack PCV (used in children/obese/ARDS)
  • lack VT precision (neonates = nonrebreather)
  • lacks adaptive ventilation (no compensation)
  • lacked integrated PEEP
  • no electronic checklist
  • limited low flow capability
76
Q

How do you choose new vent modes for maximum pt safety?

A

Think of Peds, barotrauma, etc…

77
Q

VCV: salient characteristics/settings -

A

*VT 8-10 ml/kg - prevent atelectasis
*RR 6-12 (titrate to ETCO2)
can add in PEEP, FIO2, I:E ratio

78
Q

VCV: indications -

A

*

79
Q

VCV: controls -

A

Tidal volume and RR

80
Q

VCV: caveats -

A

VILI - ventilator induced lung trauma

no support for spontaneous ventilation

81
Q

VCV: contraindications -

A

Obese, neonates, pneumoperitoneum, steep trendelenberg

82
Q

PCV: characteristics/settings -

A
  • P insp set: 15-20

* RR (titrate to ETCO2)

83
Q

PCV: indications

A

COPD, LMA, uncuffed ETT, emphysema, neonates, pregnancy, obesity, ARDS

84
Q

PCV: contraindications

A

spontaneous breathers

85
Q

SIMV: characteristics/settings -

A

senses insp effort and delivers breaths in sync,
no breath stacking, can breath spontaneously in btw vent breaths
Based on VOLUME
Set VT and RR
can add PEEP, change I:E ratio

86
Q

Trigger window

A

for SIMV mode on ADU - the fraction of expi cycle sensed - default is 50-70%
more = stacking
less = no sync breaths delivered

87
Q

Sensitivity

A

for SIMV mode on ADU - how much negative pressure is needed before a breath is triggered
- default is -1 cm H2O

Anatomoy 3 (9 decks)

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