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Quarter 4 > Principles I > Flashcards

Principles I Flashcards

1
Q

Cerebral blood flow determinants

A
  • cerebral metabolic rate
  • cerebral perfusion pressure (CPP)
  • PaCO2
  • PaO2
  • Drugs
  • intracranial pathology
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2
Q

Normal cerebral blood flow

A

50 mL per 100g brain tissue per minute [perfusion]

(over a CPP range of 50-150mmHg)

750mL/min

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3
Q

Normal cerebral metabolic rate

A

3.0 - 3.8 mL

(per 100g brain tissue per minute)

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4
Q

What can decrease cerebral metabolic rate?

A

decreased temperature and anesthetic agents

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5
Q

What can increase cerebral metabolic rate?

A

increased temperature and seizures

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6
Q

How does PaCO2 affect CBF?

A

CBR increases 1mL/100g/minute for every 1 mmHg increase in PaCO2

  • effects of hypocapnia can last 6 hours
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7
Q

How does PaO2 affect CBF?

A

Below 50mmHg cerebral vasodilation and increased CBF

  • hypoxia causes an increase in blood flow
  • <50mmHg
    • vessels maximally dilated - pressure dependent flow
  • >150mmHg
    • vessels maximally constricted - pressure dependent flow
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8
Q

Factors affecting autoregulation

A
  • chronic hypertension
    • shifts curve to the right
  • intracranial tumors
  • head trauma
  • volatile agents
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9
Q

How do volatile agents affect cerebral blood flow?

A

direct vasodilators with doses greater than 0.6-1 MAC

  • decrease CMRO2
    • uncoupling of CBF and CMRO2
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10
Q

What can happen if nitrous oxide is used after dural closure?

A

tension pneumocephalus

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11
Q

Tension Pneumocephalus

A

increased ICP secondary to pneumocephalus

  • air enters through a dural defect and is unable to escape
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12
Q

How does Ketamine affect the brain?

A

vasodilates

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13
Q

How do barbituates, etomidate, propofol, and opioids affect the brain?

A

cerebral vasoconstrictors

  • decrease CBV and ICP
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14
Q

How does Succinylcholine affect the brain?

A

increases ICP temporarily

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15
Q

Normal Intracranial Pressure

A

5-15mmHg

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16
Q

Determinants of ICP

A

brain tissue and spinal cord, blood, and CSF

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17
Q

Intracranial Elastance Curve

A

depicts impact of increasing intracranial volume on ICP

  • no volume increase from point 1 to 2 due to shift of CSF from cranium into spinal subarachnoid space
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18
Q

(6) Signs of Increased ICP

A
  • headache
  • nausea
  • vomiting
  • papilledema
  • depressed consciousness
  • coma
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19
Q

3 Methods of ICP measurement

A
  • subdural bolt
  • ventriculostomy
  • lumbar subarachnoid catheter
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20
Q

(6) Methods to decrease ICP

A
  • head elevation
  • hyperventilation
  • CSF drainage
  • ceerebral vasoconstricting anesthetics
  • surgical decompression
  • hyperosmotic drugs
    • mannitol
    • lasix
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21
Q

How should mannitol be given to decrease ICP?

A

0.25 - 0.5 g/kg IV over 15-30 minutes

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22
Q

What can be given 90s before intubation and extubation?

A

lidocaine 1.5mg/kg IV

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23
Q

Foramen Ovale

A

hole between right and left atria

  • can have a paradoxical air embolism
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24
Q

Diagnosis of Venous air embolism

A
  • precordial doppler over right sternal border
  • TEE
  • decreased etCO2
  • increase in PA catheter pressure
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25
Q

What drug is most commonly used for deliberate hypotension in neuro cases?

A

sodium nitroprusside

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26
Q

Side effects of Sodium Nitroprusside

A
  • cyanide toxicity
    • treat with thiosulfate
  • increased ICP
  • inhibition of platelet aggregation
  • increased pulmonary shunting
  • baroreceptor mediated tachycardia
  • rebound hypertension
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27
Q

“Triple H Therapy” for Cerebral aneurysm

A
  • hypervolemia
  • hypertension
  • hemodilution
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28
Q

Grading system for Cerebral Aneurysm

A

Hunt-Hess

  • grads 1 through 5
    • 1 - asymptomatic
    • 5 - deep coma
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29
Q

Rendu-Osler-Weber Syndrome

A

autosomal dominant genetic disorder that leads to abnormal blood vessel formation

  • common epistaxis episodes
  • AVMs
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30
Q

What is the leading cause of death following SAH?

A

pulmonary embolus

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31
Q

What should you give to depress vasospasms?

A

CCB

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32
Q

What separates the cerebrellum from the cerebrum?

A

tentorium

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33
Q

What % of the cardiac output does the brain recieve?

A

15%

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34
Q

Equation for cerebral perfusion pressure

A

MAP - ICP

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35
Q

Pediatric Versed dose PO

A

0.5 - 1 mg/kg

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36
Q

Pediatric Versed dose IM

A

0.1 - 0.2 mg/kg

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37
Q

Pediatric Morphine dose IM

A

0.1 - 0.2 mg/kg

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38
Q

Pediatric Ketamine dose IM

A

3 - 5 mg/kg

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39
Q

Pediatric Ketamine dose IV

A

0.25 - 0.75 mg/kg

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40
Q

Metoprolol IV push

A

2 - 15 mg

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41
Q

Neosynephrine IV push

A

50 - 200 mcg

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42
Q

Neosynephrine IV infusion

A

0.15 - 0.75 mcg/kg/min

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43
Q

Mean Arterial Pressure

A

Diastolic pressure + 1/3(pulse pressure)

normal 80-120 mmHg

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44
Q

Cardiac Index

A

CO/BSA

2.8 - 4.2 L*min/m^2

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45
Q

Meperidine dose

A

50 - 150 mg

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46
Q

Morphine dose

A

5 - 15 mg

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47
Q

Atropine pre-op dose

A

0.4 - 0.8 mg

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48
Q

Scopolamine dose

A

0.3 - 0.6 mg

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49
Q

Diphenhydramine dose

A

25 - 50 mg

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50
Q

Stroke Volume

A

CO/HR * 100

60-90 mL/beat

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51
Q

Stroke Index

A

SV/BSA

40 - 60 mL/beat/min

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52
Q

Signs of Oxygen failure

A

hear O2 failure alarm or “low FiO2” when on 100% Oxygen

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53
Q

Immediate steps in Oxygen failure

A
  1. disconnect patient from the machine and ventilate with Ambu on room air
  2. Open O2 tank and disconnect pipeline
    1. or obtain E-cylinder
  3. connect gas sampling adaptor
  4. maintain anesthesia with IV drugs
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54
Q

Signs of Venous Air Embolism

A
  • air on TEE or change in Doppler tone
  • decrease in EtCO2
  • decrease BP
  • decrease SpO2
  • rise in CVP
  • onset of dyspnea and respiratroy in awake patient
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55
Q

Treatment of Venous Air Embolism

A
  1. increase to 100% oxygen
  2. flood surgical field with saline
  3. place surgical site below heart
  4. aspirate air from central line
  5. turn down or off volatile anesthetic
  6. Epinephrine (10-100ug) to maintain CO
  7. start CPR
  8. consider TEE, left lateral decubitus, and terminating procedure
56
Q

Immediate treatment for Hypoxemia

A
  1. increase to 100% O2
  2. check gas analyzer to rule out low FiO2
  3. check vitals, PIP, pulse, and EtCO2
  4. hand-ventilate
  5. listen for breath sounds
    1. check tube position
  6. soft suction via ETT
  7. large recruitment breaths
    1. consider PEEP unless hypotensive
  8. bronchodilators
  9. increase FRC
57
Q

Differential Diagnosis for Hypoxemia

A
  • Hypoventilation
  • low FiO2
  • V/Q mismatch or shunt
  • diffusion problem
  • increased metabolic O2 demand
58
Q

Copaxone

A

treats Multiple Sclerosis

59
Q

Name (2) pathologic conditions that can lead to intracranial bleeding

A

aneurysm and AV malformations

60
Q

Rediculopathy

A

pain that is localized to a specific nerve root

  • usually from a pinched nerve or tumor
61
Q

Multiple Sclerosis

A

autoimmune disease that destroys the myelin on the nerve sheath

  • muscle weakness, parasthesia, and vision changes
62
Q

Anesthetic concerns for Multiple Sclerosis

A
  • avoid Succinylcholine
    • may produce hyperkalemia due to denervation sensitivity by upregulation of acetylcholine receptors
  • maintian lower body temperature
  • epidurals are safer than spinals
    • use a lower LA concentration
63
Q

Side effects of long-term steroid use

(prednisone)

A

may cause diabetes, edema, and fragile skin

  • more prone to osteoporosis
  • suppresses immune system
    • high risk of infection
64
Q

(3) methods to improve surgical exposure during a SAH

A
  • hyperventilate to reduce PCO2 and reduce brain size
  • diuretics
  • CSF drainage
65
Q

AV Malformations

A

abnormal connection between arteries and veins that bypass the capillary system

  • causes a “steal syndrome” and ischemia
  • intracranial hemorrhage will cause SAH
66
Q

Grading System for AV Malformations

A

Spetzler - Martin

  • based on size, eloquence, and venous drainage
67
Q

What procedures would require an awake craniotomy?

A

Deep-stimulation for Parkinson’s, epileptic foci, and treating depression and compulsive disorders

68
Q

Deep Brain Stimulation (DBS)

A

high frequency electrical stimulation

  • treatment for Parkinson’s
  • targets subthalamic nucleus and globus pallidus interior
69
Q

Dexmedetomidine for DBS

A

provides sedation and anxiolysis with minimal effect on respiration

  • alpha agonist
70
Q

Interventional Neuroradiology (IR)

A

endovascular neurosurgery to deliver drugs and devices

  • used in aneurysms, embolization of vascular tumors, AVMs, and fistulae of the brain
71
Q

ventriculoperitoneal (VP) shunt

A

relieves pressure on the brain from hydrocephalus

72
Q

Complications of INR procedures

A
  • hemorrhage
  • occlusive complications
  • contrast reactions
  • contrast nephropathy
73
Q

Concerns of patients with hydrocephalus undergoing neuroendoscopy

A
  • hypovolemia
  • sudden ICP changes
  • avoid nitrous oxide
74
Q

Cardiovascular changes with Prone

A
  • decreased:
    • cardiac index (CI)
    • venous return
    • left ventricular volume
    • compliance
75
Q

Abdominal compression in prone

A

increases pressure on vena cava

  • increases bleeding
    • due to congestion of vertebral veins
  • ischemia of spinal cord
76
Q

Respiratory changes in Prone

A

perfusion is more evenly dispersed and there is an increase in FRC

77
Q

Airway management in patients with an unstable neck injury

A
  • awake fiberoptic
  • glidescope
  • manual inline stabilization (MILS)
78
Q

Factors in Prone Vision Loss

A
  • retinal perfusion pressure
  • arterial blood pressure
  • intraocular pressure
  • anemia
79
Q

(4) visual defects associated with spine surgery

A
  • ischemic optic neuropathy
  • cortical blindness
  • central retinal artery occlusion
  • central retinal vein occlusion
80
Q

Anterior Ischemic Optic Neuropathy

A

ischemia in the anterior part of the optic nerve where the nerve enters the globe

  • can result from a low hematocrit
  • first noticed upon waking up
  • may present later with low-pressure glaucoma and optic atrophy
81
Q

Posterior Ischemic Optic Neuropathy

(retrobulbar optic neuropathy)

A

infarction of the intraorbital portion of the optic nerve

  • severe visual impairment
  • mainly caused by hypotension, anemia, and facial edema
82
Q

Cortical Blindness

A

damage to the occipital corte or optic radiation

  • ischemic or traumatic
  • may be caused by hypotension, hypoperfusion, anemia, or head position
83
Q

Central Retinal Artery Occlusion

A

caused by embolus from ipsilateral carotid artery

  • external ocular pressure with arterial hypotension
  • complete vision loss that usually improves with time
84
Q

Phenelzine

(nardil)

A

MAO inhibitor for depression

  • increases catecholamines
  • stop 2 weeks before surgery
  • avoid Demerol in patients using MAO inhibitors
    • precipitates serotonin syndrome
85
Q

Citalopram

(celexa)

A

SSRI for depression

86
Q

(4) Types of Intracranial Hematomas

A
  • epidural
  • subdural
  • subarachnoid
  • intracerebral (intraparynchemal)
87
Q

Epidural Hematoma

A

occurs when trauma causes damage to bridging arteries

  • usually meningeal artery
88
Q

Subdural Hematoma

A

between dura and arachnoid space

  • bleeding from vein rather than artery
    • slower bleed
  • commonly seen in elderly
89
Q

Subarachnoid Hematoma

A

commonly caused by an aneurysm rupture

90
Q

Glasgow Coma Scale

A

measures neurological integrity

  • eye opening, verbal response, and motor response
  • Mild 13-15
  • Severe 3-8 (3 is the lowest)
91
Q

At what % of blockge in a carotid causes concern?

A

60-70%

92
Q

What common diuretic is contraindicated in patients allergic to sulfonamide?

A

Loop Diuretics

(Lasix)

93
Q

Symptoms of Parkinson’s

A

resting tremors, instability, muscle rigidity, bradykinesia, and akinesia

94
Q

Anesthetic concerns in Parkinson’s Patients

A
  • uncertain response to central neuraxial blockade
    • autonomic dysfunction
  • high risk of aspiration
  • postoperative emergence delirium
95
Q

What type of drugs should you avoid in a person using Levodopa?

A

MAO inhibitors

96
Q

What drugs may exacerbate symptoms of Parkinson’s?

A

Phenothiazine, Butyrophenon, and Metoclopromide

97
Q

ACC

A

American College of Cardiology

98
Q

Risk factors for Artherosclerosis

A
  • men > women
  • family history
  • overweight
  • smoking
  • hypertension
  • diabetes
99
Q

Thrombus vs. Embolus

A

thrombus is a stationary plaqu, embolus is moving

100
Q

Most common cause of mortality in people undergoing intravascular procedures

A

MI

  • 40-50% of patients will get an MI
101
Q

High risk surgeries other than vascular

A
  • intraperitoneal
  • intrathoracic
  • carotid endarterectomy
  • head and neck surgery
  • orthopedic
  • prostate
  • trauma
102
Q

acute MI

A

7 days or less before examination

103
Q

recent MI

A

more than 7 days but less than 1 month

104
Q

How long after an MI should you wait before an elective surgery?

A

4-6 weeks

105
Q

Which valvular diseases are considered high risk?

A

aortic stenosis or mitral stenosis

106
Q

Types of COPD

A

bronchitis (blue bloaters) and emphysema (pink puffers)

107
Q

Difference between asthma and COPD

A

asthma is somewhat reversible, COPD is chronic

108
Q

Normal Creatinine

A

0.6 - 1.2 mg/dL

greater than 2 is significant

109
Q

Chronic Kidney Disease

A

diminished renal function without dialysis

  • based on creatinine clearance
  • 1-5 classifications
110
Q

Normal GFR

A

90 - 120 mL/min

  • a rate below 60 indicates renal damage
111
Q

Diagnostic Testing for Cardiac Function

A
  • EKG
  • exercise EKG
  • radionuclide perfusion
  • dobutamine stress test
  • TEE
  • coronary angiography
112
Q

TEE

A

echo test

  • show wall motion abnormalities
  • chambers of the heart, ejection fraction, volume status, and valve sounds
113
Q

Wait time after a bare metal stent

A

4 - 6 weeks

114
Q

Wait timea after a PTCA

A

1 year

  • dual anti-platelet therapy for a year after surgery
    • dangerous to stop treatment because they could have acute perfusion
115
Q

Benefits of shunt during a CEA

A

don’t have to rely on collateral flow

(but could create an embolus)

116
Q

Benefits of clamping during CEA

A

less risk of embolus

(potential for cerebral ischemia)

117
Q

If a patient develops ischemia, what would you see on a TEE

A

diskinetic or hypokinetic

118
Q

PAD

A

Peripheral Arterial Disease

119
Q

Peripheral Arterial Disease

A

intermittent claudication causing impaired blood flow during exercise

  • especially present in legs
  • can treat with PTA, femoral artery bypass, or aortic bi-fem bypass
120
Q

PTA

A

Percutaneous Transluminal Angioplasty

121
Q

Percutaneous Transluminal Angioplasty

A

opens up a bolcked vessel by using a small balloon catheter

122
Q

Concens with patient undergoing surgery for PAD

A
  • Coumadin (warfarin)
    • should be taken off 4-5 days before surgery
    • check PT
    • may need to switch to a heparin drip while discontinuing other meds
123
Q

Where does an AAA usually occur?

A

between renal and mesenteric arteries

124
Q

What size of AAA indicates surgical removal?

A

greater than 5 cm

125
Q

Which part of the spinal cord is at greater risk of ischemia?

A

anterior

(artery of adamowicz)

126
Q

Bair Huggers and AAA

A

upper body only

  • lower body may not be perfusing well and heating that area could cause burns
127
Q

Physiology of Cross-Clamping during AAA

A
  • increase in afterload
    • increases more the higher the clamp is placed
  • decrease in CO
  • acidosis
128
Q

Nipride

A

treatment for hypotension

1 - 10 mcg/kg/min

  • light sensitive
  • can develop tachyphylaxis and cyanide poisoning
  • typically mixed 200mcg/mL
129
Q

Nipride vs. Nitroglycerin

A

Nitroglycerin is more venodilating, Nipride is an arterial dilator

  • Nipride is quicker on and off
  • Nitroglycerin can reduce preload
130
Q

Renal Toxic Drugs

A

non-steroidals, IV contrast, vancomycin, gentamycin

131
Q

Physiology after cross-clamping during AAA

A
  • hyperperfusion to underperfused tissues
    • overal pH decreases
    • PCO2 increass
    • decrease in body temperature
  • increase in RR
132
Q

EVAR

A

endovascular aneurysm repair

133
Q

What reverses Heparin?

A

protamine

134
Q

Why should a patient be prepped and draped before induction?

A

wont have to take time while they’re asleep and risk changes in hemodynamics

135
Q

What can be done to preserve renal function during aortic surgery?

A
  • maintain blood pressure within normal range
  • avoid nephrotoxic drugs
  • Lasix or Mannitol questionable
136
Q

What should you do in anticipation of removal of the aortic cross clamp?

A
  • volume load
  • vasoconstrictors
  • Discontine nipride if using it
  • request surgeon to gradually release clamp
137
Q
A

Quarter 4 (15 decks)

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