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Semester 3 TxWes > Principles of Anesthesia Practice I Unit IV > Flashcards

Principles of Anesthesia Practice I Unit IV Flashcards

1
Q

Why was ultrasound initially used in the OB population?

A

It provided visualization without exposure to radiation

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2
Q

Primary advantages of the use of ultrasound?

A

Identify anatomical structures, you can see where the needle is going (and the spread of LA), may decrease time and/or complications

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3
Q

At what frequency does ultrasound travel at? Normal audible sound?

A

Ultra = 2 - 20 MHz
Normal sound = 20 - 20,000 Hz or 0.002 - 2.0 mHz

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4
Q

What creates the “picture” when using ultrasound?

A

The sound waves interfacing with a surface and either; transmitting, reflecting or something in between

The sound waves that are reflected back to crystals create impulse recorded by the computer

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5
Q

Sound transmits through what in the body?

A

Fluid, which creates no signal and is anechoic/dark

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6
Q

Sound is in between transmission/reflection through what in the body?

A

Soft tissue/muscle/fat, creating Iso/hypoechoic pattern, or rather, the various shades of grey

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7
Q

Sound is reflected through what in the body?

A

Bones/stones which creates lots of signal = hyperechoic or brightness

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8
Q

Solid tissues create what pattern on ultrasound? Soft/hollow?

A

Solid = hyperechoic
Soft/hollow = hypoechoic

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9
Q

What is inside the head of the transducer probe?

A

Piezo electric crystals

they change shape with electric impulse and vibrate to generate sound waves

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10
Q

What frequency does each ultrasound probe operate at?

A

Linear = 7 - 15 MHz
Curvilinear = 2 - 5 MHz
Phased array = 1 - 3 MHz

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11
Q

What is the relationship of MHz to resolution?

A

The higher the MHz, the higher/better the resolution

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12
Q

Describe static vs dynamic approach using ultrasound

A

Static = identify the target vessel/assess patency, mark site and insert blind

Dynamic = perform the procedure in real time and visualize the needle puncturing the vessel wall

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13
Q

How do you hold the transducer proble?

A

Like a pencil

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14
Q

What is gain and depth?

A

Gain = brightness/signal quality (goal is fluid is black, soft tissue is mid grey)

Depth = fairly self explanatory, start at a high depth then work to bring object of interest into the middle of the screen

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15
Q

Describe in plane and out of plane?

A

In plane = the probe is parallel to the needle
Out of plane = the probe is perpendicular to the needle

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16
Q

In plane is primarily used when inserting a needle, why is out of plane still a necessary view?

A

You can still be behind or in front of the vessel which you can’t see on an in plane view, whereas an out of plane view can tell you if you are behind or in front of the vessel

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17
Q

What is the primary disadvantage of out of plane view?

A

Unclear where the tip of the needle is

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18
Q

What is the only contraindication to ultrasound for IV access?

A

An emergency situation; it takes too long. Get an IO first

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19
Q

When would you use a curvilinear probe to obtain IV access rather than a linear?

A

If the patient is obese

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20
Q

Primary goal of a FAST exam?

A

To identify the presence of free fluid in the abdomen

there are virtually no contraindications to this exam. A few studies have linked it to pressure-related injuries but this is not a confirmed issue

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21
Q

During a FAST exam, what are you examining in the R/L upper quadrant?

A

RUQ = Morison’s pouch (intraperitoneal space between the right live and the right kidney)
LUQ = Peri-splenic view

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22
Q

Describe “heeling” when using ultrasound

A

A unique strategy used primarily in peripheral nerve blocks. You want the probe to be parallel to the nerve you are wanting to access, so you may need to dig in the “heel” of the probe to get it parallel to the nerve

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23
Q

What is a key safety step to take when you have the needle in the approximate space to inject LA?

A

Verify the nerve doesn’t move with the needle - you don’t want to inject LA directly into a nerve

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24
Q

What would a gastric antrum look like if NPO, clear liquid and solid food?

A

NPO = small, empty thick walls
CL = rounder/distended, “starry night” thinner walls
Solid food = hyperechoic and even thinner walls

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25
Q

Indications for central access?

A

Monitoring central venous pressure
Infusion of caustic drugs
Administration of TPN
Aspiration of air emboli
Insertion of transcutaneous pacing leads
Venous access for people with poor peripheral veins
Dialysis access

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26
Q

Contraindications to central access?

A

Renal cell tumor extending into right atrium, tricuspid valve vegetation, site infection and site specific issues (like a femoral line on a patient on tube feed - too much, uh, “rectal flooding”)

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27
Q

Complications of attempting central access?

A

Pneumo/hemo, line infection, carotid puncture, dysrhythmias, trauma to nearby nerves

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28
Q

What anatomic structures help guide IJ line placement?

A

A triangle in the neck made by the sternocleidomastoid and the scalene muscle

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29
Q

Ideal position for IJ central line insertion?

A

Trendelenburg (increase venous return and reduce risk of air embolism)

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30
Q

What area of the body should be prepped for IJ CVC insertion?

A

Chin to sternum to shoulder to neck to ear

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31
Q

What do you drape prior to CVC insertion?

A

Head to foot and side to side

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32
Q

What is the purpose of the seeker needle?

A

A small 25 gauge to need to identify if you are in a vein/artery using a small needle so that if you puncture an artery it should self seal

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33
Q

Describe the needle with catheter technique

A

(this is what you commonly saw in the ICU) you hit the desired vessel with the needle, once in, you removed the needle and left the catheter behind to then insert a guidewire (older techniques have you hook up a tube to identify venous vs arterial cannulation)

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34
Q

Basic way to identify an artery vs a vein on ultrasound?

A

A vein is compressible, thinner walled, and generally larger

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35
Q

What type of wire is the guide wire?

A

A J-wire

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36
Q

What is the most important step regarding use of the guidewire?

A

Never let go of the guide wire (J-wire)

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37
Q

Why do you try to insert a CVC using a twisting motion?

A

It helps “screw” itself into the vascular wall

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38
Q

What must be done to allow removal of the wire after the catheter has been advanced?

A

Remove the cap on the CVC

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39
Q

What vessel is 14 cm away from the cavo-atrial (costo-phrenic) junction?

A

RSC

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40
Q

What vessel is 15 cm away from the cavo-atrial (costo-phrenic) junction?

A

RIJ

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41
Q

What vessel is 18 cm away from the cavo-atrial (costo-phrenic) junction?

A

LIJ

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42
Q

What vessel is 17 cm away from the cavo-atrial (costo-phrenic) junction?

A

LSC

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43
Q

What 3 factors are you evaluating on CXR after CVC insertion?

A

Catheter tip position, presence of a wire, and no pneumo/hemo

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44
Q

Where has the CVC been inserted?

A

RIJ

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45
Q

Where has the CVC been inserted?

A

LIJ

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46
Q

What complication has occurred here?

A

Pneumo

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47
Q

What complication has occurred here?

A

Hemo

note how there is still viable lung tissue above, and the loss of the lower quadrant sharp notch. There is also a solid white mass where lung tissue should be. Those details differentiate this from a pneumo

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48
Q

What is the definition of cutanenous?

A

Something that is sensory and peripheral

peripheral motor conduction is different than cutaneous innervation

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49
Q

What is a bundle of neurons/axons in and outside the CNS called?

A

In the CNS = tracts
Outside the CNS = nerves

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50
Q

What is the term for a bundle of cell bodies in the CNS vs the PNS called?

A

CNS = nuclei
PNS = ganglia

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51
Q

Describe how neurons organize themselves as they exit the CNS

A

They form rootlets, which then come together and form an anterior/posterior root (which may include ganglia, usually in the dorsal root), both roots come together and form a spinal nerve. From that nerve, various other smaller nerves can branch out

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52
Q

What is the basic function of the anterior/posterior spinal cord

A

Anterior = efferent motor function
Posterior = afferent sensory function

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53
Q

What is generally the first branch points of the spinal nerve?

A

It will branch into a posterior and anterior ramus (anterior is bigger)

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54
Q

What are the basic functions of the anterior/posterior rami?

A

Posterior = sensory innervation to the posterior side of the body (it does have some minor motor innervation as well, but is almost exclusively sensory)
Anterior = mixed motor and sensory function for the anterior aspect of the body

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55
Q

How does information from the ANS get to the SNS?

A

Via the pathway that connects the anterior ramus to the sympathetic chain via small projections called the rami communicans

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56
Q

What are the types of rami communicans?

A

White and grey

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57
Q

What important structure runs parallel to the spinal cord and connects to the ANS via the rami communicans?

A

The sympathetic ganglionic chain

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58
Q

What is the basic difference between the L/R sympathetic ganglionic chain?

A

The left chain is more posterior and lateral than the right because the aorta forces the left chain to be more posterior/lateral

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59
Q

What branches of the posterior ramus tend to stay midline and provide cutaneous innervation to the back?

A

The medial branches of the posterior ramus

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60
Q

What branches of the posterior ramus are further out to the side of the body?

A

The lateral branches of the posterior ramus

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61
Q

What does the anterior ramus form at the sternum?

A

It branches out at the sternum creating the anterior cutaneous branches

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62
Q

What branch of the anterior ramus covers the sides of the body (think ribs)?

A

The lateral branches of the anterior ramus

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63
Q

What is the other name for the anterior ramus at the thoracic level?

A

The intercostal nerve (1 per level of the spinal cord)

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64
Q

The 3rd rib would have what intercostal nerve associated with it?

A

The 3rd intercostal nerve

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65
Q

How many cervical dermatomes are there?

A

7

C1 does NOT have any sensory function, so it does not have a dermatome associated with it

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66
Q

What general region do the clunial nerves innervate?

A

The lower back and to top of the butt

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67
Q

What are the 3 primary thoracic dermatome landmarks Schmidt mentioned in lecture?

A

T4 = nipple line
T6 = xiphoid
T10 = umbilicus

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68
Q

The phrenic nerve arises from what vertebrae?

A

C3 - 5 (they are all anterior rami as well)

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69
Q

How does breathing change with a high T-spine lesion?

A

Phrenic nerve is still intact; so you would lose respiratory accessory muscle function. You could still breath, but your ability to increase respiratory effort would be impaired

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70
Q

Describe the location of the lesser occipital nerve relative to the greater occipital nerve

A

It is a smaller nerve and is positioned lower and slightly more lateral than the greater occipital nerve

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71
Q

What level does the greater occipital, suboccipital and 3rd occipital nerve emerge from?

A

GO = C2
3rd = C3
Sub = C1 (purely motor)

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72
Q

Primary function of the trapezius muscle?

A

Assist with ventilation

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73
Q

What is the name of the posterior ramus of C1?

A

The suboccipital nerve - innervates motor function of deep muscle packages

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74
Q

What is the highest dermatome in the body?

A

The C2 dermatome = innervated by the greater occipital nerve

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75
Q

What area does the greater occipital nerve innervate?

A

It innervates the area around/down from the ear

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76
Q

What are the anterior rami nerves that branch off of C2 - 4?

A

Lesser occipital, greater auricular, transverse cervical and supraclavicular nerve

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77
Q

What anterior rami emerges from C2?

A

Lesser occipital nerve

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78
Q

What anterior rami emerges from C2/3?

A

The great auricular and transverse cervical nerves

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79
Q

What anterior rami emerges from C3/4?

A

Supraclavicular nerve

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80
Q

What are the 4 nerves of the cervical plexus?

A

The lesser occipital, greater auricular, transverse cervical and supraclavicular nerves

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81
Q

Of the cervical plexus, what nerve(s) contributes to the phrenic nerve and innervates the diaphragm and pericardium?

A

Supraclavicular nerve

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82
Q

Of the cervical plexus, what nerve(s) form the motor part of the cervical plexus and innervate the infrahyoid muscles except the thyrohyoid muscle?

A

The lesser occipital, great auricular and transverse cervical nerves

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83
Q

What muscle does the phrenic nerve sit on?

A

The anterior scalene muscle

per lecture, it “rides” next to the middle scalene muscle

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84
Q

What levels of the spine contribute to the brachial plexus?

A

C5 - T1

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85
Q

What type of nerves exclusively make up the brachial and cervical plexi?

A

Anterior rami

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86
Q

What muscles create the interscalene space?

A

The middle scalene and anterior scalene muscle

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87
Q

What structures do the rami combine to form as you go further and further down a plexus?

A

Rami -> trunks -> divisions

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88
Q

What levels does the upper trunk emerge from?

A

C5/6

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89
Q

What levels does the middle trunk emerge from?

A

C7

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90
Q

What levels does the lower thoracic trunk emerge from?

A

C8/T1

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91
Q

Describe how the nerves branch off the trunks of the brachial plexus

A

Each trunk creates 2 divisions, an anterior and posterior division

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92
Q

What brachial plexus divisions make up the posterior cord?

A

The 3 posterior divisions of each trunk

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93
Q

What brachial plexus divisions make up the lateral cord?

A

The 2 anterior divisions of the upper/middle trunk

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94
Q

What brachial plexus divisions make up the medial cord?

A

The anterior division of the lower trunk

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95
Q

After the divisions of the brachial plexus become cords they become what?

A

The infraclavicular branches of the brachial plexus

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96
Q

What are the terminal branches of the posterior cord?

A

The axillary and radial nerves

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97
Q

What does the lateral cord divide into?

A

The musculocutaneous nerve and lateral root

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98
Q

What structures combine to form the median nerve?

A

The lateral root of the lateral cord and the medial root of the medial cord

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99
Q

What does the median cord divide into?

A

The ulnar nerve and a portion of the median nerve

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100
Q

What level(s) does the radial nerve originate?

A

C5 - T1

101
Q

What level(s) does the axillary nerve originate?

A

C5/6

102
Q

What level(s) does the ulnar nerve originate?

A

C7 - T1

103
Q

What level(s) does the median nerve originate?

A

C6 - T1

104
Q

What level(s) does the musculocutaneous nerve originate from?

A

C5 - 7

105
Q

What does the axillary nerve cutaneously innervate?

A

The lateral deltoid

106
Q

What does the radial nerve provide cutaneous innervation to?

A

Anterior = The lateral/anterior biceps/triceps of the upper arm and a small part of the lateral wrist

Posterior = the thumb and index/middle finger and much of the middle posterior arm

107
Q

What sensory area does the ulnar nerve primarily innervate?

A

The medial wrist and pinky/ring finger

108
Q

What does the median nerve primarily innervate?

A

Anterior = the palm and pads of the thumb and first 3 fingers

Posterior = the middle 3 fingertips

109
Q

What does the anterior thoracic rami branch into?

A

The anterior and lateral cutaneous branches

110
Q

What are the nerves that branch off anteriorly off the T-spine that do not directly run in line with the ribs?

A

The subcostal nerves (though they are still technically intercostal nerves)

111
Q

What parts of the spine contribute to the lumbar plexus? Sacral plexus?

A

L = L1 - 4
S = L4 - S4

112
Q

What thoracic nerve(s) may be able to connect to the lumbar plexus?

A

T12 (connecting to the iliohypogastric nerve)

113
Q

How many nerves make up the lumbar plexus?

A

6

114
Q

List the lumbar plexus nerves from top to bottom

A

Iliohypogastric
Ilioinguinal
Genitofemoral
Lateral cutaneous
Obturator
Femoral nerve

I I Get Leftovers On Fridays

115
Q

What spinal level(s) contribute to the iliohypogastric nerve?

A

L1

116
Q

What spinal level(s) contribute to the ilioinguinal nerve?

A

L1

117
Q

What spinal level(s) contribute to the genitofemoral nerve?

A

L1 - 2

118
Q

What spinal level(s) contribute to the lateral cutaneous nerve of the thigh?

A

L2 - 3

119
Q

What spinal level(s) contribute to the obturator nerve?

A

L2 - 4

120
Q

What spinal level(s) does the femoral nerve originate from?

A

L2 - 4

121
Q

What is the primary function of the Psoas major?

A

Helps with posture

122
Q

What muscle does the iliohypogastric, ilioinguinal and genitofemoral all run in close to proximity to?

A

The Psoas major muscle

123
Q

What do the branches of the iliohypogastric innervate?

A

The lateral cutaneous branch innervating the lateral hip
The anterior cutaneous branch follows the inguinal ligament and borders the reproductive organs

124
Q

What is the motor function of the iliohypogastric?

A

It innervates the transversus abdominis and the internal abdominis (primary one is the transversus)

125
Q

What are the sensory branches of the ilioinguinal nerve?

A

One heads inferiorly to cover a small patch of the medial upper thigh, the other provides sensory innervation to the reproductive organs

126
Q

What is the motor function of the ilioinguinal nerve?

A

Innervates the internal oblique

127
Q

What are the 2 branches of genitofemoral nerve?

A

Femoral and genital

Femoral = upper part of the thigh

Genital = provides sensory innervation to the reproductive organs

128
Q

What does the genitofemoral nerve uniquely innervate in men?

A

It provides a motor connection to the cremasteric reflex (stroking the upper/inner thigh causes the cremaster muscle to contract)

129
Q

What anatomic structure surrounds the obturator foramen?

A

The ischial tuberosity

130
Q

What muscles make up the femoral triangle?

A

The sartorius, iliopsoas pectineus and the adductor longus

131
Q

What nerve branches off the femoral nerve that contributes to the majority of sensory innervation to the lower extremity?

A

The saphenous nerve

132
Q

What muscles surround the adductor canal?

A

The sartorius muscle, adductor longus and the vastus medialis

133
Q

What nerve are we targeting in the adductor canal?

A

The saphenous nerve

134
Q

What is the primary function of the LCA (lateral cutaneous nerve of the thigh)?

A

Sensory innervation of the anterior/lateral thigh

135
Q

What is the basic function of the obturator?

A

Primarily motor in function

136
Q

What is the area of sensory innervation of the obturator?

A

A small cutaneous branch that covers a small part of the medial thigh

137
Q

What muscles does the femoral nerve innervate?

A

Iliopsoas, pectineus, sartorius and quadriceps femoris

138
Q

What are the sensory branches of the femoral nerve?

A

Anterior cutaneous = innervates the medial thigh
Saphenous nerve = medial side of the lower leg and part of the posterior thigh

139
Q

What levels does the superior gluteal nerve emerge from?

A

L4 - S1

140
Q

What levels does the inferior gluteal nerve emerge from?

A

L5 - S2

141
Q

What levels does the posterior cutaneous nerve of the thigh emerge from?

A

S1 - 3

142
Q

What levels does the sciatic nerve emerge from?

A

L4 - S3

143
Q

What levels does the pudendal nerve emerge from?

A

S2 - 4

144
Q

What muscles does the superior gluteal nerve innervate?

A

The gluteus medius, tensor fasciae latae and the gluteus minimus

145
Q

What muscle does the inferior gluteal nerve primarily innervate?

A

The gluteus maximus

146
Q

What nerves provide sensory innervation to the gluteal region?

A

The superior/middle/inferior clunial nerves and the lateral branch of the iliohypogastric nerve

147
Q

What nerves combine to make the sciatic nerve?

A

The tibial nerve and the common fibular nerve

148
Q

What is the other/older name of the common fibular nerve?

A

Peroneal nerve

149
Q

What is the largest diameter nerve in the body?

A

Sciatic nerve

150
Q

What are the branches of the common fibular (peroneal) nerve?

A

Lateral sural cutaneous (sensory innervation of the lateral and back of calf and part of the lateral front of the shin)

Superficial fibular nerve (innervates the top of the foot and has it’s own 2 branches: the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve)

Deep fibular nerve (innervates the space in-between the big toe and index toe via 2 branches, the lateral cutaneous and medial cutaneous nerve)

151
Q

What are the 4 branches of the tibial nerve?

A

Medial sural cutaneous, medial calcaneal, lateral calcaneal and lateral dorsal cutaneous branch

152
Q

What does the medial sural cutaneous branch innervate?

A

Sensory innervation to the back part of the leg

153
Q

What does the medial calcaneal branch innervate?

A

Innervates the heel and bottom of the foot

154
Q

What does the lateral calcaneal branch innervate?

A

Innervates the lateral side of the foot

155
Q

What does the lateral dorsal cutaneous branch innervate?

A

Covers a portion of the back of the leg

156
Q

Primary functions of the pudendal nerve?

A

It has sensory function in the pelvis, rectum/colon and reproductive functions of men

157
Q

What does the posterior cutaneous nerve of the thigh innervate?

A

It takes care of of the sensory innervation of the superficial hamstring, mostly pain

158
Q

What cranial nerves are primarily motor?

A

Oculomotor (III)
Trochlear (IV)
Abducent (VI)
Accessory (XI)
Hypoglossal (XII)

159
Q

What cranial nerves are pure sensory?

A

Olfactory (I)
Optic (II)
Vestibulocochlear (VIII)

160
Q

What cranial nerves are primarily involved with ocular motor function?

A

The oculomotor (III), trochlear (IV) and abducent (VI)

161
Q

What cranial nerve controls 4/6 muscles of the eye?

A

Oculomotor

Trochlear controls the superior oblique of the eye and the abducent controls the lateral rectus

162
Q

What muscle(s) does the accessory (XI) nerve innervate?

A

sternocleidomastoid and the trapezius

163
Q

What areas does the hypoglossal (XII) innervate?

A

Motor innervation to the tongue and floor of the mouth

164
Q

What is the primary function of the vestibulocochlear (VIII) nerve?

A

It assists with our hearing and balance

165
Q

What type of neurons send information to the olfactory bulbs?

A

2nd order neurons - they go through the cribriform plate

166
Q

What are the bones of the eardrum?

A

Malleus, incus and stapes

167
Q

What are the mixed function cranial nerves?

A

Trigeminal (V), Facial (VII) Glossopharyngeal (IX) and Vagus (X)

168
Q

Primary innervation of the trigeminal (V) nerve?

A

Sensory to the front of the head and muscle innervation for chewing

169
Q

Primary innervation of the facial (VII) nerve?

A

Sensory for taste, salivation and crying. Motor innervation of the face

170
Q

What are the muscles of chewing?

A

Masseter and temporalis muscles

171
Q

What cranial nerve is involved with the submandibular, lingual and lacrimal glands of the face?

A

The facial (VII) nerve

172
Q

What nerve innervates the parotid gland?

A

Glossopharyngeal (IX) nerve

173
Q

What is the sensory function of the glossopharyngeal (IX) nerve?

A

Posterior 1/3 of the tongue, oropharynx soft palate, chemoreceptors of the carotid body and baroreceptors of the carotid sinus

174
Q

What is the outer covering of the nerve?

A

Epineurium

175
Q

What surrounds the nerve fascicles?

A

Perineurium

176
Q

What surrounds the individual axons?

A

Endoneurium

177
Q

What is the starting point for our high neck blocks?

A

The supraclavicular fossa

178
Q

What are the ECF compartments?

A

Interstitial: lymphatics and protein-poor fluid around cells
Intravascular: plasma volume
Transcellular: GI tract, urine, csf, joint fluid, aqueous humor

179
Q

What is the difference between diffusion and osmosis?

A

Diffusion = movement of solutes from high to low concentration across a semi-permeable membrane
Osmosis = movement of water from and area of low solute concentration to an area of high solute concentration

180
Q

What is the primary ECF cation? Primary ICF cation?

A

ECF = Na
ICF = K

181
Q

What factors can affect osmotic pressure?

A

Temperature, number of molecules and volume

P = nRT / V

182
Q

What is the difference between osmolarity and osmolality?

A

Osmolarity = number of osmotically active particles/L of solvent

Osmolality = Number of osmotically active particles per kg of solvent

183
Q

Normal osmolality range?

A

280 - 290 mOSM

184
Q

What are the primary molecules that contribute to oncotic pressure?

A

Albumin, globulins and fibrinogen

185
Q

What is the definition of oncotic pressure?

A

The component of total osmotic pressure due to colloids

186
Q

What is the average daily liquid intake from solids, metabolism and liquid intake?

A

Solids = 750 ml
Metabolism = 350 ml
Liquid = 1400 ml

187
Q

What is the average output from insensible loss, GI loss and urine output?

A

Insensible = 1000 ml
GI = 100 ml
UOP = 0.5 - 1 ml/kg/hr

188
Q

How much does urinary secretion account for total daily water loss?

A

About 60%

189
Q

What 3 hormones control our UOP?

A

ADH - renal H2O excretion in response to plasma tonicity
ANP - activated with ↑ fluid volume, so increased atrial stretch = increased renal excretion
Aldosterone - If Na+ and fluid volume ↓ aldosterone is released causing Na+ and H2O conservation

190
Q

What sensors help control our overall fluid balance?

A

Hypothalamic osmoreceptors, low pressure baroreceptors and high pressure baroreceptors

all trigger increased thirst and/or ADH release

191
Q

Where would you find high/low pressure baroreceptors?

A

High = carotid sinus and aortic arch
Low = large veins and RA

192
Q

What are some compensatory mechanisms the body can use to compensate for lost volume?

A

Venoconstriction
Mobilization of venous reservoir
Autotransfusion from ISF to plasma
Reduced urine production
Maintenance of CO…tachycardia, increased inotropy

193
Q

Where is renin released from? What does it do?

A

Released from JGA cells and cleaves angiotensinogen to make angiotensin I

AG I then turns into AG II which causes vasoconstriction and aldosterone release

194
Q

Where is aldosterone released from?

A

Adrenal cortex - retains salt and water

195
Q

Assuming no other loss of volume, how long does it take for the RAAS to restore lost volume?

A

12 - 72 hours

196
Q

How long does it take the body to restore lost RBCs?

A

Via erythropoiesis, it takes 4 - 8 weeks

197
Q

What fluids have the greatest (top 3) osmolarity?

A

Albumin, hetastarch then NS

198
Q

What fluids have the lowest osmolarity (list 3)?

A

D5, LR then plasmalyte

199
Q

What fluid does NOT have an osmolarity value?

A

Isolyte P

200
Q

How long do crystalloids stay in the ECF?

A

70% is still in after 20 minutes, only 50% after 30 minutes

201
Q

What can occur to coagulation with excess fluid administration?

A

It dilutes anticoagulant factors, making it easier to create blood clots (hypercoagulable state)

202
Q

What are some of the negative effects of NS usage?

A

Dilutes hct and albumin
Increases cl- and K+ concentrations
Late onset of diuresis
Causes hyperchloremic metabolic acidosis
Increased AKI and RRT in critical care patients

203
Q

What is the primary contraindication to LR?

A

Liver patients

LR has lactate in it as a buffer, which requires hepatic metabolism to process

204
Q

Why does LR lead to faster water excretion than NS?

A

LR suppresses ADH secretion which allows for diuresis

205
Q

What are the 2 categories of colloids we administer?

A

Semi-synthetic colloids and human plasma derivatives

206
Q

What are 2 concerns with IV colloid administration?

A

May cause hemodilution (decreasing plasma viscosity which inhibits RBCs aggregation) and may have effects on the immune, coagulation and renal systems (these uncertain effects are mitigated with strict maximum dosages)

207
Q

How long does hydroxyethyl starch stay in the ECF?

A

70 - 80% is still present at the 90 minutes mark

208
Q

Metabolism of hydroxyethyl starch is dependent on what?

A

The molecular weight of the molecules

209
Q

What are some general side effects to watch for related to the molecular weight of colloids?

A

Coagulopathy d/t dilution of clotting factors and renal dysfunction

210
Q

How long can dextran stay in the ECF?

A

6 - 12 hours

211
Q

What type of colloid is popular in microvascular surgery?

A

Dextran-40, by inhibiting clotting factors it can help keep blood flowing to small vasculature, valuable if trying to reattach small limbs

212
Q

What is the MOA of dextran-40 interfering with cross-matching?

A

By coating the RBC it can interfere with the cross-matching test

213
Q

What are the common human plasma derivatives?

A

5% albumin and immunoglobulin solution

valuable as volume replacement for trauma, sepsis or replacement s/p paracentesis

214
Q

What are the common preop and intraop causes of fluid alterations?

A

enjoy a chart

215
Q

What are some s/sx of low intravascular volume?

A

Tachycardia, decreased pulse pressure, hypotension and decreased cap refill (these generally do not occur until 25% of volume is lost), drop in UOP, decreased CVP and lab values indicating poor tissue perfusion (lactate, mixed venous)

216
Q

What are the negative outcomes of high intravascular volume?

A

↑ capillary hydrostatic pressure
Excessive fluid development in lungs, bowel, muscle
Decreased gut motility
Reduced tissue oxygenation
Poor wound healing
Hypo/hyper coagulopathy

217
Q

What are the 3 factors classic fluid therapy focuses on?

A

NPO deficit, ongoing maintenance and anticipated surgical loss

218
Q

How long do you need to be NPO for: clear liquids, breast milk, infant formula, light meal, meat/fatty fried food?

A

Clear liquids: 2 hours
Breast milk: 4 hours
Infant formula: 6 hours
Light meal: 6 hours
Meat/fatty, fried: 8 hours

ERAS is changing this, it’s starting to become more acceptable to administer carbohydrate solutions like Gatorade prior to surgery

219
Q

What is the classic approach for NPO/maintenance fluid?

A

4 ml/kg/hr for first 10kg
2 ml/kg/hr for 2nd 10 kg
Each kg over 20 kg is 1 ml/kg/hr

220
Q

Using the 4:2:1 rule, what is the hourly fluid rate for: a 160 kg patient, 120 kg patient and 55 kg patient

A

160 kg = 200 cc/hr
120 = 160 cc/hr
55 = 95 cc/hr

221
Q

What would be the total deficit if NPO for 6 hours for a 200 kg patient? 35 kg?

A

200 = 1440 cc
35 = 450 cc

hours npo x the fluid need using the 4:2:1 rule

222
Q

For a fluid deficit calculated using the 4:2:1 rule, during what timeframes would you replace each fraction of the fluid deficit?

A

½ in the 1st hour of surgery.
¼ in the 2nd hour.
¼ in the 3rd hour.

223
Q

How much blood does a lap sponge absorb? A raytech? 4x4?

A

Sponge = 100 ml
Raytech = 20 ml
4x4 = 10 ml

224
Q

How much fluid do you lose to evaporative/redistribution losses?

A

Minimal= 0-2 ml/kg/hr

Moderate = 2-4 ml/kg/hr

Severe = 4-8 ml/kg/hr

225
Q

When do you apply the parkland formula to guide burn related fluid resuscitation?

A

When 20% BSA or greater has 2nd or 3rd degree burns (LR is generally the fluid of choice)

226
Q

How much fluid do you give for a burn patient who meets the criteria for fluid based on the parkland burn resuscitation formula?

A

4 ml/kg/%BSA burned

1/2 over the first 8 hours, 1/2 over the next 16 horus

227
Q

What factors help guide goal directed fluid therapy?

A

Cvp: not super specific
Swan: use declining
Svo2: measures o2 extraction
TEE: quantify LV cavity size/EF
CO
Lactate levels: decreasing level signals successful resuscitation
SV
Svv

228
Q

Why is goal directed therapy gaining traction as a guide for fluid resuscitation?

A

It gives us a framework to decide if we need more fluid, pressors, inotropes or blood products

Studies: less AKI, respiratory failure, wound infection, and improved mortality rates

229
Q

How much fluid replacement does goal directed therapy devices assume the patient is receiving in the OR?

A

1 - 3 ml/kg/hr of crystalloid

230
Q

What are the limits to SVV mechanics?

A

LIMITS
Low hr/rr
Irregular heart beats
Mechanical ventilation (with low tidal volume)
Increased abdominal pressure
Thorax open
Spontaneous breathing

231
Q

What are the 3 types of monitoring commonly used in goal directed therapy?

A

Systolic pressure variation
Max systolic pressure - minimal systolic pressure
during one cycle of mechanical breath

Pulse pressure
Difference between systolic and diastolic BP

Stroke volume variance
The variation of SV in 30 seconds
Normal SVV is 10-15%

232
Q

List the structures in the femoral triangle from most lateral to medial

A

Femoral nerve, artery then vein

so from lateral to medial is NAV

233
Q

What nerve(s) are branches of the posterior cord?

A

Axillary and radial nerves

234
Q

What nerve(s) receive innervation from the lateral cord?

A

Musculocutaneous and median nerve

235
Q

What nerve(s) receive innervation from medial cord?

A

Median and ulnar nerve

236
Q

List the supraclavicular structures of the brachial plexus

A

The anterior rami, the trunks and the divisions

so everything from the cords and further distal is part of the infraclavicular structures of the brachial plexus

237
Q

What structure(s) is immediately proximal to the origin of the median nerve?

A

The lateral/median root

where the lateral cord and medial cord meet before combining to become the median nerve

238
Q

What nerve of the brachial plexus receives innervation from more levels of the c-spine than the other nerves of the plexus?

A

Radial nerve - receives innervation from C5 - T1

next one would be the median nerve - receives innervation from C6 - T1

239
Q

What are the motor cranial nerves of the eyes?

A

Oculomotor (III), Trochlear (IV) and Abducent (VI)

Oculomotor innervates 4 muscles, Trochlear innervates the superior oblique and the Abducent innervates the lateral rectus

240
Q

Why do signals from the olfactory system have the ability to be tied/related/combined to memories?

A

Because they are processed in the frontal cortex - where memories are also processed

241
Q

Where is sound processed in the brain?

A

Temporal lobe - the vestibulocochlear system lies close to the temporal bone

242
Q

What is the primary sensory nerve of the ophthalmic division of the trigeminal nerve?

A

The supraorbital nerve

the supratrochlear is the other and covers the top of the nose, the supraorbital has more coverage

243
Q

What is the primary sensory nerve of maxillary division of the trigeminal nerve?

A

The infraorbital nerve

The other nerve coming off this are the palatine nerves that supply innervation to the roof of the mouth

244
Q

What opening allows the primary sensory nerve of the maxillary division of the trigeminal nerve to exit the skull?

A

The infraorbital foramena - allowing the infraorbital nerve to exit

245
Q

What branch of the trigeminal nerve innervates most of the lower jaw?

A

The inferior alveolar nerve - a branch of V3

246
Q

What is the exit point for the sensory nerve covering most of the lower jaw?

A

The mental foramena - allowing the inferior alveolar nerve, a branch of V3, to exit and once it has exited it is now the mental nerve

247
Q

What nerve gives us anterior coverage of 2/3 of the tongue?

A

The lingual nerve - a branch of V3

248
Q

What is the first laryngeal branch?

A

A pharyngeal constrictor branch

249
Q

What is the layer in between the epineurium and the perineurium?

A

Inner perineurium

Semester 3 TxWes (8 decks)

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