sept viva Flashcards
intralipid contents
Intralipid, which is an emulsion of soy bean oil, egg phospholipids and glycerin,
LA tox risk
LA drug factors Pr B and affinity to NaCH and pregame’s, acid, renal, hep
prev LA tox
USS
monitor
awake
test dose
AFOI blcok
Glossopharyngeal not oropharyngeal.
LA tox ecg
sinus bradycardia, intracardiac conduction defects (prolonged PR & QRS complex), ventricular arrhythmias, cardiac arrest.
Desc pain
PAG–>RVM–>DH
LC–>DH
Rexed Laminae
The Rexed laminae comprise a system of ten layers of grey matter (I–X),
P+H
Adelta–>laminae 2,5
C fibers–>2
The substantia gelatinosa is one point (the nucleus proprius being the other) where first order neurons of the spinothalamic tract synapse. (laminae II)
Many μ and κ-opioid receptors, presynaptic and postsynaptic, are found on these nerve cells;
gate theory
Ab touch and desc inhib in SUBSTANTIAL GENATINOSA (lamina II of DH)
glucose uptake
Glut1 the 1 most important thing so brain
Glut 2 food panc and hep
Glut 4 is lock in door (insulin dep)
BMR measurement
heat or indirect calaromitery
atp production cellular respiration
google
atp production cellular respiration
RB pyruvate oxidation CO2 prod
fatty acid
Fats into fatty acids and glycerol
ketogen
Fatty acid–>acetylcoa (b oxidation)
aceytl coa–>acetone, acetoacetate and betahydroxybutyrate via 3 steps including HMG coa synthase
When the body has no free carbohydrates available, fat must be broken down into acetyl-CoA in order to get energy. Under these conditions, acetyl-CoA cannot be metabolized through the citric acid cycle because the citric acid cycle intermediates (mainly oxaloacetate) have been depleted to feed the gluconeogenesis pathway. The resulting accumulation of acetyl-CoA activates ketogenesis.
Ketone bodies are produced mainly in the mitochondria of liver cells,
The production of ketone bodies is then initiated to make available energy that is stored as fatty acids. Fatty acids are enzymatically broken down in β-oxidation to form acetyl-CoA. Under normal conditions, acetyl-CoA is further oxidized by the citric acid cycle (TCA/Krebs cycle) and then by the mitochondrial electron transport chain to release energy. However, if the amounts of acetyl-CoA generated in fatty-acid β-oxidation challenge the processing capacity of the TCA cycle; i.e. if activity in TCA cycle is low due to low amounts of intermediates such as oxaloacetate, acetyl-CoA is then used instead in biosynthesis of ketone bodies via acetoacetyl-CoA and β-hydroxy-β-methylglutaryl-CoA (HMG-CoA). Furthermore, since there is only a limited amount of coenzyme A in the liver, the production of ketogenesis allows some of the coenzyme to be freed to continue fatty-acid β-oxidation.[8] Depletion of glucose and oxaloacetate can be triggered by fasting, vigorous exercise, high-fat diets or other medical conditions, all of which enhance ketone production
The three ketone bodies, each synthesized from acetyl-CoA molecules, are:
Acetoacetate, which can be converted by the liver into β-hydroxybutyrate, or spontaneously turn into acetone. Most acetoacetate is reduced to beta-hydroxybutyrate, which serves to additionally ferry reducing electrons to the tissues, especially the brain, where they are stripped back off and used for metabolism.
Acetone, which is generated through the decarboxylation of acetoacetate, either spontaneously or through the enzyme acetoacetate decarboxylase. It can then be further metabolized either by CYP2E1 into hydroxyacetone (acetol) and then via propylene glycol to pyruvate, lactate and acetate (usable for energy) and propionaldehyde, or via methylglyoxal to pyruvate and lactate.[10][11][12]
β-hydroxybutyrate
R quotient
CO2/R=0
CO2/O2=R
fat is .7 pr .8
feed COPD fat
stomach consumes CO2
lattent heat of…
melting
lattent TB= hidden
nicotine
Acute exposure to nicotine – HD effects last 1hr Abstinence cigarettes 12hrs – 10 - 20% increase in physical work capacity T ½ COHb 4 - 6hrs so overnight abstinence helpful (10hrs in men) Peak benefit re: upper airway irritability at 10 days (effects start at 48hrs)
Autonomic ganglia (N1 receptors) – blocked by hexamethonium 2. NMJ (N2 receptors) – blocked by tubocurarine 3. CN
Initial stimulation then persistent depression of autonomic ganglia
CNS stimulant
–
tremor
Increased ventilation v
ia nicotine stimulating aortic/carotid body chemoreceptors
CVS: tachycardia, hypertension, increased SVR (via SNS increase)
Resp: initial stimulation of saliva/bronchial secretions then inhibition
GI: PNS activation causing vomiting, diarrhoea
ADrenal medulla ADr release
sweat glands ANS
In sweat glands the receptors are of the muscarinic type.
isometric isotonic
ismetric–>nil external work–>100% energyoutput as heat
isotonic–>some external work–>50% heat loss
brown fat
uncouples oxidative phosphorylation
not dep on consumption of ATP for ATP
heat produced through chemical reaction without ATP needing to be utilised
COX pathway
Sm muscle–>PG
cycloendoperoxidase
nerve twitch face
orbicularis occuli
nerve monitory placement
Typically smaller muscle groups are more sensitive
The positive (red) lead is placed proximal
Ulnar nerve
Electrodes are placed along the ulnar border of the wrist at the flexor crease, and thumb adduction is assessed.
Facial nerve
The positive electrode is placed at the outer canthus, and the negative electrode is placed anterior to the tragus. Eyebrow twitching is assessed. orbicularis occuli
Posterior tibial nerve
Electrodes are placed posterior to the medial malleolus, and plantar flexion is assessed. posterior tib
r vs s
rectus right clock
sirrius anticlock
levo vs dextro
A dextrorotatory compound is a compound that rotates the plane of polarized light clockwise as it approaches the observer (to the right)
Dr X
stereoisomer
diff 3d orientation same bonds
diastereioismer
non enantiomers
- ->geo (cis)
- ->configurational (cant rotate around single bond)
thio tautomerism
So, as demonstrated by the diagram I nabbed from the net above, the ketone form C=O* is lipid soluble and is favoured in acidic environments. The enol form is favoured in alkaline environments and is water soluble.
Enol forms for barbiturates are water-soluble at pH 10-11at 6% sodium carbonate
valsalva phase 3
BP drops as LV afterload worsened with release and prelead reduced
Valsalva quantification
highest HR in phase 4 over lowest in phase 4
ANS dx vasovagal
Figure 4.49 The Valsalva response in autonomic
dysfunction: excessive fall in blood pressure
in Phase II and absence of overshoot and
bradycardia in Phase IV.
NSAID SE
CCF and fluid and salt rention
NSAIDs promote sodium and water retention, and this has generally been explained by a reduction in prostaglandin-induced inhibition of both renal chloride reabsorption and the action of antidiuretic hormone
3 phases of heat loss
Rapid reduction
Core temperature falls by 1-1.5°C in the first 30 minutes.
Predominantly due to vasodilation, which is due to:
Reduction in SVR, with generalised vasodilation and increased skin blood flow
Heat redistribution is the major initial factor (rather than heat loss), as vasodilation leads to increased heat content of peripheries.
Impairs thermoregulatory vasoconstrictive responses
Inter-threshold range is widened to 4°C (up from 0.4°C)
Gradual reduction
Further drop in core temperature of 1°C over following 2-3 hours.
humidity
evernote
preg ABG
26-32mmHg CO2
pO2 → essentially unchanged 100-105mmHg
resp drive preg
Hyperventilation centrally stimulated by
progesterone
preg CO
O2 Flux
Measured as the product of blood O2 content and CO
- ↑CO (30%)
normal HCT
40%
CVS changes preg %s
all about 25% except CO=50% and BV=50%
https://primarysaqs.files.wordpress.com/2009/12/makeup-describe-the-cardiovascular-changes-that-occur-in-pregnancy.pdf
thyroid anatomy
inf to cricoid caritlage
ext branch of sup laryngeal
recurrent laryngeal
thyroid production
In follicular cells
Iodine from basement memebrane
Iodination of tyrosyl residue of thyroglobulin
Lysosomal enzymes cleave T4 from iodinated thyroglobulin
T4 cross into blood
thyroid effect
physiocal vs chemical
catachol and insulin sens due to B rec upreg
hypothyroidism and GA
Hypothyroidism may result in depression of myocardial function, decreased spontaneous ventilation, abnormal baroreceptor function, reduced plasma volume, anaemia,82 hypoglycaemia, hyponatraemia and impaired hepatic drug metabolism
Preventative measures should be adopted to protect against hypothermia. Because of an increased incidence of adrenocortical insufficiency and a reduced adrenocorticotropic hormone response to stress, hypothyroid patients should receive hydrocortisone cover during periods of increased surgical stress.
Hyperthyroidism
Of importance to the anaesthetist are the cardiovascular effects of hyperthyroidism including atrial fibrillation, congestive cardiac failure and ischaemic heart disease.4
In an attempt to prevent the dreaded complication of ‘thyroid storm’, patients should be euthyroid before surgery.4286 This is achieved by the use of antithyroid drugs, commonly carbimazole or propylthiouracil. These drugs block the synthesis of thyroxine but take 6–8 weeks to work. Beta‐blockers, particularly propranolol, are used to ameliorate the effects of thyrotoxicosis13 and are effective in the acute preoperative phase. Longer‐acting beta‐blockers such as atenolol or nadolol may achieve better control of symptoms.2736 Anaesthetic drugs may be affected by the hypermetabolic state of hyperthyroidism. For example, the clearance and distribution volume of propofol are increased in hyperthyroid patients. When total intravenous anaesthesia is used, propofol infusion rates should be increased to reach anaesthetic blood concentrations.9
Bohr effect
boring is stable #evernote and eqn
Bohr eqn
a-E/a
as a is higher than e
humidity
renaults!!!!!
propofol infusion rate and CSHT
6mg/kg/hr bristol final stage
onset 30s
CSHT at infinity is 10min MILLERS
CSHT 5hrs is 5min
THio presentaion
NaCO3
NaTP
2.5%
stable 24 hrs
thio doa
10min
thio CVS
CORE
neg ino with CO decrease 20%
some VD
compensatory tachy!!!!!!
thio resp
BC
thio hep
inducer of CYP450
thio other
arterial injection
porporia
porphyria
Porphyric crisis due to build up of porphyrins—>skin and nervous system effects
- abdo and chest pain
- vomiting fever
- HTN tachy
- Confusion
- Blisteres
Complication
- seziure
- Paralysis
- Fatal
Rx
* IV haem or glocuse—>decreased haem synth—>less precursor accumulating
intraarterial injection thio
alpha antag
anticoag
analgesia
block
alpha anatag
phenoxybenzamine non selctive for pheochromocytoma
phentolamine
neo vs edro vs other
evernote
muscurinic antag
eyedrop to dilate
SE of neostig
CLINICAL FEATURES
confusion CNS depression weakness salivation urinary and faecal incontinence GI cramping vomiting sweating muscle fasciculations pulmonary oedema miosis brady or tachycardia seizures
QT prolonged
1,3
sux, volatile, low K, low Mg
NO moa
Activates gyanalate cyclase
Oxytocin se
Phtn and coronary spasm ci in congenital hear tdx
Misoprostol
Pge1 analogue
Diarrhoea in the bum
Carbeprost
F2alpha
BC and pulm HTN
DIARHOEA VOMIT
central vs mixed venous
superior vena cava and proximal pulmonary artery,
reticulocytes
Like mature red blood cells, in mammals, reticulocytes do not have a cell nucleus. They are called reticulocytes because of a reticular (mesh-like) network of .
RBC production
rbc met
everntoe Bile secretion bilirubin
whole blood
Whole blood is typically stored under the same conditions as red blood cells and can be kept up to 35 days if collected with CPDA-1 storage solution or 21 days with other common storage solutions such as CPD.
double if PRBC
PRBC additives
CONTINUED PROF DEV
CPDA
SAGM
Sodium Chloride 0.92g
• Adenine 0.02g
• Dextrose Monohydrate 0.95g
• Mannitol 0.55g
storage lesion
Blood can be stored for up to 35 days, which corresponds to 70% survival
Hyponatraemia
oxy dose post infusion
> Prolonged use of oxytocin induces oxytocin receptor desensitisation and larger doses of
oxytocin may be required to prevent or treat uterine atony and PPH 3
levosimendine
sensitizes Ca
milronone
Milrinone, commonly known and marketed under the brand name Primacor, is a medication used in patients who have heart failure. It is a phosphodiesterase 3 inhibitor that works to increase the heart’s contractility and decrease pulmonary vascular resistance.
pulm HTN
Pulmonary Vasodilaters (generally referring to chronic Mx but some acute: http://www.rcjournal.com/contents/07.07/07.07.0885.pdf
- O2—>reverse HPVC
- CCB—>VD eg nifedipine and diltiazem
- Nitric Oxide Gas
- Low-dose intravenous sodium nitroprusside causes pulmonary vasodilation and reduces PAP, PVR, and right-ventricular afterload, but is not selective.
- Nitroglycerin is another NO donor that has selective pulmonary vasodilation effects when delivered via aerosol
- In vascular smooth-muscle cells, prostacyclins stimulate soluble adenylate cyclase and convert adenosine triphosphate to cyclic adenosine monophosphate (cAMP). In turn, protein kinases mediate a cAMP-induced decrease in intracellular calcium and produce relaxation and vasodilation (see Fig. 3).99,100 Prostaglandin I-2 and prostaglandin E-1 are both potent pulmonary vasodilators and inhibitors of platelet aggregation
- -Epoprostenol, a short-acting prostaglandin I-2
- -Aerosolized epoprostenol is an effective alternative to INO in the acute care setting
- Sildenafil, a phosphodiesterase type 5 inhibitor, approved for the treatment of erectile dysfunction, has been shown to be an effective treatment for PAH in several randomized controlled trials in adult patients154 –156 and was approved by the FDA in June 2005 as an oral PAH therapy.
- -Phosphodiesterases are enzymes that inactivate cGMP and cAMP. Use of phosphodiesterase inhibitors to prevent the breakdown of cGMP and cAMP in vascular smoothmuscle cells can augment or prolong the vasodilator signaling pathways of both NO and prostacyclin
23dpg weeks
consumed–>increased sats in pRBC
5% left at 4 weeks
storage lesion
K 28 at 28 days
ph 6.7
PRBC 75% at 28 days
dex CVS
BRADY–>DEATH
Dex CNS
less deleirum
Dex PK
high Prb
extensive hep with nil minimal renal dep vs clonidine 50% peed out unchanged
affect Pulm VR
Factors which influence pulmonary vascular resistance
Pulmonary blood flow:
Increased blood flow results in decreases pulmonary vascular resistance in order for pulmonary arterial pressure to remain stable
This is due to:
Distension of pulmonary capillaries (mainly), and
Recruitment of previously collapsed or narrowed capillaries
Lung volume:
Relationship between lung volume and PVR is “U”-shaped
Pulmonary vascular resistance is lowest at FRC
At low lung volumes, it increases due to the compression of larger vessels
At high lung volumes, it increases due to the compression of small vessels
Hypoxic pulmonary vasoconstriction
A biphasic process (rapid immediate vasoconstriction over minutes, then a gradual increase in resistance over hours)
Mainly due to the constriction of small distal pulmonary arteries
HPV is attenuated by:
Sepsis and pneumonia
hypothermia
iron infusion
Metabolic and endocrine factors:
Catecholamines, arachidonic acid metabolites (eg. thromboxane A2) and histamine increase PVR
Hypercapnia and (independently) acidaemia also increase pVR
Alkalaemia decreases PVR and suppresses hypoxic pulmonary vasoconstriction
Hypothermia increases PVR and suppresses hypoxic pulmonary vasoconstriction
Autonomic nervous system:
α1 receptors: vasoconstriction
β2 receptors: vasodilation
Muscarinic M3 receptors: vasodilation
Blood viscosity
PVR increases with increasing haematocrit
Drug effects:
Pulmonary vasoconstrictors: Adrenaline, noradrenaline and adenosine
Pulmonary vasodilators: Nitric oxide, milrinone, levosimendan, sildenafil, vasopressin, bosantan / ambrisantan, prostacycline and its analogs, calcium channel blockers and ACE-inhibitors.
Stomache secretion
Stomache secretion evernote
g cells enterochroffin like cells
H2 blockers
H2 blockers are available by prescription or over-the-counter, and include ranitidine, famotidine, cimetidine
Hypothal thermo reg parts
anterior hypothalamus is sensitive to
local warming of blood, which increases the ring rate, producing sweating and vasodilatation.
e posterior hypothalamus responds to cold
Cutaneous responses to heat 383
aerent impulses from the peripheral temperature
receptors and causes increased shivering thermogenesis.
layers of adrenal medulla
zona glomerulosa: The outermost layer of the adrenal cortex, responsible for producing mineralocorticoids such as aldosterone. zona fasciculata: The middle layer of the adrenal cortex, responsible for producing glucocorticoids such as cortisol.
magnesium level vs side effects
magnesium level vs side effects google
5 SA AV
10 weak
15 AV block and resp paralysis
20 Arrest
ANS strucutre
ANS
- SNS-efferent cell bodies in lateral grey column and in peripheral ganglion of T1-L2
- PSNS-efferent Brainstem CNs 3,7,9,10 and sacral primary rami—>pelvic splanchnic nerves
mass effect SNS
SNS-mass effect
- exit lat grey column—>white rami communicans 3 options in the Sympathetic trunk
1. Synapse at that ganglion in white rami communicans
2. Travel upon down trunk to ganglions above # cervical ganglion
3. Pass through and synapse with a more distal ganglion - therefore blocking or stimulating one white rami communicans segment—>wide effect on many organs at many levels above and below
eqipment class
Class I
Equipment that has an earth wire connected to its outer metal casing
This protects against shock in case a fault causes the active wire to contact the outer case
eg refrigerator, electric kettle
Class II
Double insulated equipment
Has a plastic outer case in addition to the normal internal insulation
An earth wire is not required as the outer casing is non-conductive
eg hair dryer
Class III
Extralow voltage (< 40V) or battery powered equipment
Doesn’t require an earth wire, even if it has a metal case because the voltage is low so that the risk of macroshock is negligible
eg mobile phone
avoid electricution
(i) general measures; (ii) equipment design; (iii)
equipotentiality; (iv) isolated circuits; and (v) circuit breakers.
warfarin MoA
inhibits reduction of vit K by inhibiting vit K epoxide reductase
recuded form required as a coenzyme for carboxylation of glutamic acid residue
sux arrhythmias
Bradycardia
due to direct action on muscarinic ACh receptors in SA node
o sinus brady, junctional/ventricular escape rhythm, asystole
worse if high vagal tone
o children, blocked, hypoxic, laryngoscopy
more commonly if repeat dose given
can be offset by co-administration of atropine
Tachycardia / Hypertension
“large” / second dose of sux can directly stimulate nicotinic ACh receptors in sympathetic ganglia
o SNS nerve activity
o catecholamines released from adrenals
tachycardia, hypertension
ventricular arrhythmias
o2 storage in blood calc
150.1X1.34=200g
so 1L of O2 in blood
preoxygenation
PAo2=110/176 ie 13%
13% of 2.1L is 275ml
3.5ml.70 is 245ml
fuel cell vs other
clarke
HME
During expiration, the HME picks up some of the moisture from the expired humid air.
These water droplets retain some of the heat from the gas which has carried them.
During inspiration, the incoming torrent of air collects these warm water droplets, and carries them as vapour into the lungs of your patient.
Laplace
T=p.r/2
Tension is equal to TMP.RADIUS IN heart
P=2T/R
Pressure to collapse alv=ST/r to collaps
Surfactant
1.compkiance
2.oedema
3 stabilises
Surfactant oedema
Less ST so less oedema
Hb structure
4 heam
4globin polypeptide chains 2a 2b
Methhb
Fe3+
Prilocaine nitrites
Less able to bind O2 and less able to offload
Treat with methelene blue and vit c
hep BF calc
Like CO AUC (ficks prinicple is more complex with a fixed infusion)
ICG has a known HER 0.74
AUC (measured)=x (known)/cl
AUC=x/(Q.0.74)
HER is 0.74 for ICG
Cl is vol cleared per min=Q.HER ie Q.0.74
renal BF calc
PAH is filtered at the glomerulus, and any remaining in the peritubular capillaries is secreted into the lumen by proximal tubules. When the PAH concentration is low, all the plasmaperfusing, -filtering and -secreting parts of the kidney (the effective renal plasma flow is 85%–90% of the total renal plasma flow) are completely cleared of PAH. The renal clearance of PAH is therefore equal to the effective renal plasma flow, from which the effective renal blood flow can be calculated: = − Effective renal blood flow Effective renal plasma flow 1 Blood haematocrit
PaO2 at altitide
0.21(380-47)-50
=19mmHg (5x worse)
neuropathic pain def
x
niceception def
x
neuropathic pain mech peripher
increased Na ch perm. microanatomical change-cross connection and sprouting central -migroglial activation -ca ch sens due to over expression -loss of large fibre inhibition -anamotical reorg (brain and SC)
cross and SC
decussate
paracetamol MOA
evernote
paracetamol met
evernote
NSAID flow chart
CORE
endoperoxidase
NMDA coagonist
Glycine is NMDA coagonist
NMDA rec
xenon NO2 ketamine methadone
post pit
ADH oxytocin
adrenaline secretion
enterochromafiin cells
COMT effect
The enzyme introduces a methyl group to the catecholamine, which is donated by S-adenosyl methionine (SAM).
phenylephrine dose
Initial dose: 50 to 250 mcg by intravenous bolus (most common doses: 50 to 100 mcg)
1ml is 100 microg
hep BF calc
INDOCYNIN GREEN
PLACENTA HORMONES
e placenta acts as an endocrine organ as it
produces both peptide (human chorionic gonadotrophin [HCG] and human placental lactogen
[HPL]) and steroid hormones (oestrogen and progesterone).
uterus blood supply
uterine and ovarian–>arcuate–>radial–>basal and spiral
uterine unit
chorionic villi
fetal villi with chorioic external 2 layers
-syncitiotrophoblast and cytotrophopblast (cyto near cytoplasm)
intervillous space-maternal blood (YES)
MEAC
x fent is 3mcg/ml
uterine BF determ
alpha stim and uterine artery pressure
t.f in uterus
diff
facilitated-glut1
active-Fe vit C
endocytosis IgG
Selegiline
PDx Selegiline acts as a monoamine oxidase inhibitor,
nonobstetric anaesthetic
Neostigmine crosses the placenta and fetal bradycardia can occur, while glycopyrrolate does not. !!!!
Non-steroidal anti-inflammatory drugs in early pregnancy may be associated with increasing fetal loss12 and in the third trimester may cause the premature closure of the ductus arteriosus. Single doses are unlikely to be harmful. T
All volatile agents up to an MAC of 1.5 dilate uterine arteries and increase uterine blood flow, but at higher concentrations, this is offset by decreases in maternal arterial pressure and cardiac output. Volatile agents also reduce uterine tone. Nitrous oxide is avoided during the first trimester (see the Anaesthetic drugs and teratogenicity section). Light anaesthesia and pain are avoided to prevent maternal catecholamine release and consequent reduced uteroplacental perfusion.
Droperidol PK
extensive liver met 1% renal unchanged
acinus
The centre of the acinus is formed by the
portal triads consisting of portal vein, hepatic
artery and bile duct. The acinus is supplied by
terminal branches of the hepatic artery and portal veins, which drain into sinusoids. The blood
in the sinusoids drains into hepatic venules. The
hepatic acinus may be divided into three functional zones: (1) periportal, (2) mediolobular and
(3) centrilobular zones (Figure 6.1). Periportal
hepatocytes (zone 1) receive blood with the highest
oxygen content and have the highest metabolic rate
and are especially involved in protein synthesis.
Centrilobular hepatocytes (zone 3) receive the
least oxygen but contain high concentrations of
cytochrome P-450 and therefore are important
sites for drug biotransformation.
NAPQI
phase I
glutathion mop–>cysteine
Nociception
Nociception (also nocioception, from Latin nocere ‘to harm or hurt’) is the sensory nervous system’s process of encoding noxious stimuli.
sevo SVP
20kpa
158mmHg
2% with 90% bipass
artline MAP
AUC per cardiac cycle
SE RE
SE max 91=awake
Evoked potentials (EP)
Evoked potentials (EP) Evoked potential monitors measure electrical activity in certain areas of the brain in response to stimulation of specific sensory nerve pathways.
entropy CI
patient-brain dead neonat
Surgical-MRI
Drug-ket, N20
entropy
entropy, freq, time
bis
freq, phase, duration
doppler shift
shift=v/c x freq0. cos theta
measure BF
tracer uniquely handled by organ and doesnt change BF itself
innate vs adaptive
nonspec vs targetted protein triger
Anaphylaxis def
Anaphylaxis is an acute severe type I hypersensitivity reaction affecting multiple organ systems (there is currently no consensus definition)
adaptive immune
Over next 10 – 14 days produces IgE specific to the antigen
late anaphylaxis
TNF-α with a cumulative mean difference of 22.81 ng/ml is also an inflammatory soluble mediator and is released as both pre-formed and late-phase mediator and has the ability to activate neutrophils, recruits other effector cells and enhances the synthesis of chemokine
normal ICP
ICP is defined as 5 to 15 mm Hg
MAP to CBF linear
TBI
altered Ach at NMJ
sux, NDMR
producution blocked with Hemi
release blocked with Bot
LA blocks post synaptic
Volatile blocks positive feedback and Ca and Nach res and Na Ch
aminoglyco blocks presynaptic ca
frusemide blocks camp for less release.
gibbs donan
uneven distribution of permiable charged ions on either side of SPM due to distribution of impermiable charged ions
“The Gibbs-Donnan effect describes the unequal distribution of permeant charged ions on either side of a semipermeable membrane which occurs in the presence of impermeant charged ions. “ derranged phys
AFOI
internal of sup laryngeal is sens (inside)
m. of larynx
intrinsic m-
CT is sole adductor ext sup lary n.
laryngeal cartilage
evernote
AP tissues
In physiology, an action potential occurs when the membrane potential of a specific cell location rapidly rises and falls:[1] this depolarization then causes adjacent locations to similarly depolarize. Action potentials occur in several types of animal cells, called excitable cells, which include neurons, muscle cells, endocrine cells, glomus cells, and in some plant cells.
pain in elderly
evernote
Conc effect
In the study ofinhaled anesthetics, theconcentration effectis the increase in the rate that the Fa (alveolar concentration)/Fi (inspired concentration) ratio rises as the alveolar concentration of that gas is increased. In simple terms, the higher the concentration of gas administered, the faster the alveolar concentration of that gas approaches the inspired concentration. In modern practice is only relevant fornitrous oxidesince other inhaled anesthetics are delivered at much lower concentrations due to their higher potency.
remi pka onset t/2
7.1 so 68% unionized at 7.4
onset 90s
t/2 5min so doa 10min or so.
clearance ++ fast 5l/min
clearance remi>morp>fent>alfent !!
why does morph have a longer t/2 vs fent
fent bolus offset is due to redistribution!!
why does alfent have a smaller t/2 vs fent
t/2=vd/cl
as Vd is smaller t/2 is shorter
why does remi have fast onset
pka 7.1
lipid sol
why does remi have short doa
non spec plasma and tissue esterase hydrolysis
t/2=Vd/Cl
vd small and clearance large
FGF req for T piece
2.5xMV
MV of 30kg=300mlx20=6L–>15L/min FGF
he dilution
V1.C1=C2.(V1+V2)
V2=TLC!!!!!
then with TLC known spirometry can determine FRC
mole
The mole (symbol: mol) is the unit of measurement for amount of substance in the International System of Units (SI). A mole of a substance[1] or a mole of particles[2] is defined as exactly 6.02214076×1023 particles, which may be atoms, molecules, ions, or electrons.[1] In short, for particles 1 mol = 6.02214076×1023
Avogadro’s law
Avogadro’s law states that “equal volumes of all gases, at the same temperature and pressure, have the same number of molecules.”[1]
1mole=22L at STP
gas cylinder size
E=emergency
J=juganaut
vol in anaesthetic clinder
V1.P1=V2.p2
O2
4.7x137/1=629L from size E bottle
NOTE N20 is a vapour so not applicable
-it is stored at 44bar and produces 1800L (as liquid can produce a shit tone of gas)
137 bar for air, o2, entenox
VIE figures
VIE figures BP=-180 Crit temp -118 VIE -150C
psuedocrit temp
at 147 bar is -5.5
at 4 bar (ine pipeloine is-30C)
partician coeff
x
USS limitations errors
x
APL pos
distal to Bag to avoid PTx!
scavenging
- Active or passive systems are incorporated to collect gas waste.
- This method consists of a collecting and transfer system, a receiving system and a disposal system.
- Both excessive positive and negative pressure variations in the system are limited.
- Other methods are used to reduce theatre pollution: theatre ventilation, circle system, total intravenous and regional anaesthesia.
sample line vol
120ml/min O2 consumption 3.5ml/kg/min= 250
hence 350ml min.
la place
To appreciate the afterload on individual muscle fibers, afterload is often expressed as ventricular wall stress (σ), where AL=2.r.p/thickness
In alv P to collapse= T/r
contractility factors
The Frank-Starling law holds that increased stretch on the myocytes (to a point) increases the force of their contraction.
(indep of preload-simple stretch in a lab)
afterload
Afterload can be defined as the resistance to ventricular ejection - the “load” that the heart must eject blood against. It consists of two main sets of determinant factors:
Myocardial wall stress, which represents intracardiac factors
Input impedance, which represents extracardiac factors
Wall stress is described by the Law of Laplace ( P × r / T)
and therefore depends on:
P, the ventricular transmural pressure, which is the difference between the intrathoracic pressure and the ventricular cavity pressure.
Increased transmural pressure (negative intrathoracic pressure) increases afterload
Decreased transmural pressure (eg. positive pressure ventilation) decreases afterload
r, the radius of the ventricle
Increased LV diameter increases wall stress at any LV pressure
T, the thickness of the ventricular wall
A thicker wall decreases wall stress by distributing it among a larger number of working sarcomeres
Input impedance describes ventricular cavity pressure during systole and receives contributions from:
Arterial compliance
Aortic compliance influences the resistance to early ventricular systole (a stiff aorta increases afterload)
Peripheral compliance influences the speed of reflected pulse pressure waves (stiff peripheral vessels increase afterload)
Inertia of the blood column
Ventricular outflow tract resistance (increases afterload in HOCM and AS)
Arterial resistance
Length of the arterial tree (the longer the vessels, the greater the resistance)
Blood viscosity (the higher the viscosity, the greater the resistance)
Vessel radius (the smaller the radius, the greater the resistance)
what changes contractility
homeometric-frank starling
heterometric-HR bowditch and Anrep (AL)
HR, preload, afterload
drugs, electoolytes, disease.
anrep
AL
Sustained myocardial stretch activates tension dependent Na+/H+ exchangers, bringing Na+ ions into the sarcolemma. This increase in Na+ in the sarcolemma reduces the Na+ gradient exploited by sodium-calcium exchanger (NCX) and stops them from working effectively. Ca2+ ions accumulate inside the sarcolemma as a result and are uptaken by sarco/endoplasmic reticulum Ca2+-ATPase (SERCA) pumps. Calcium induced calcium release (CICR) from the sarcoplasmic reticulum is increased upon stimulation of the cardiac myocyte by an action potential.
bainbridge
The Bainbridge reflex, also called the atrial reflex, is an increase in heart rate due to an increase in central venous pressure. Increased blood volume is detected by stretch receptors (Cardiac Receptors) located in both sides of atria at the venoatrial junctions.
bezold jarish
The Bezold–Jarisch reflex (also called the Bezold reflex, the Jarisch-Bezold reflex or Von Bezold–Jarisch reflex[1]) involves a variety of cardiovascular and neurological processes which cause hypopnea (excessively shallow breathing or an abnormally low respiratory rate), hypotension (abnormally low blood pressure) and bradycardia (abnormally low resting heart rate) in response to noxious stimuli detected in the cardiac ventricles
CO autoregulation
Golden
heterometric-HR,AL–>contract. Pressure–>HR
homeometric-FS–>cont
40-180 CO indep of HR in vitro
what makes prop good for TCI
t/2=vd/cl
relatively predictable vd, cleara,ce redistribution, and half time
CVP information
ΔCVP = ΔV / Cv
end-expiration,
PEEP — PEEP of 10 cmH20 usually results in increase of CVP by ~3 cmH20
swan ganz
evernote
GABA rec
CORE AF
aa,bb,g
ab x2=GABA binding site
ag=modulatory allosteric BNZ binding site (increased activation)
b= propofol, volatile site, barbituates (increased duration)
Although benzodiazepines and barbiturates produce the same electrophysiological action (increase in chloride conductance) at the macroscopic level, studies of channel kinetics indicate that benzodiazepines act primarily by increasing channel activation/ reactivation whereas barbiturates act by increasing the duration
allosteric
relating to or denoting the alteration of the activity of an enzyme by means of a conformational change induced by a different molecule.
how do drugs works
CORE
1) PC
2) rec
a) LGIC
b) second messenger
- GPCR, TKR, GCyclase
c) steroid
3) enzymes
4) VGIC
DV
UV–>IVC and liver the shunt is the DV
umbi vein artery Po2
verin 28 artery 18
max MV
30xnormal
cardiac output not even close
Resp exchange ratio
CO2 EXPIRED/O2 CONSUMED. varies dep on metabolic and non metabolic facotrs.
RQ is fixed and simply reflects substrate.
In the body, the volume of CO2 expired and
the volume of O2 consumed vary with metabolic,
as well as non-metabolic, factors. During exercise, the RER approaches a value of 2 because a
greater volume of CO2 is expired due to hyperventilation. In metabolic acidosis, the RER increases
because the respiratory compensation for acidosis
causes the amount of CO2 expired to increase,
whereas, in contrast, the RER decreases in
metabolic alkalosis as the hypoventilatory compensatory response reduces the amount of CO2
expired.
anaesrobic threshold
e workload above which the blood concentration of lactic acid rises is called the ‘anaerobic
threshold’.
pasteurs point
The Pasteur point is the partial pressure of oxygen at which oxidative phosphorylation ceases, and is ~1mmHg
measure CO2
ABG: Carbon dioxide tension is measured with a Severinghaus electrode, which is based on the pH electrode, as PaCO2 is related to [H+]. The Severinghaus electrode consists of:
expired IR
mass spec
ramand spec
anaesthetic gas measurement
evernote
phase capno
1,2,3,4
beerlambert
absorpptoin=molarabcoeff.c.l
NSAID SE
rash, allergic,
AKI–>heartfailure, hyperkalaemia, HTN
double bohr
so easy to get wrong
mum gives freely
fetus clings
metabolic role placenta
COMT, MAO, butylcholinesterase
long term potentiation
In neuroscience, long-term potentiation is a persistent strengthening of synapses based on recent patterns of activity.
central sens
glutamate, NO, glia
sensitization of wide dynamic range neurons
wind up is short term and progresses if sustained to long term potentiaion #sdney
Expansion of receptive field size
Increase in magnitude and duration of response to stimuli
Reduction in threshold of firing
picco vs swancanz
Picco: if swan canz CI
PICO
insert a central line
place PiCCO into a large artery, usually the femoral (axillary is an alternative)
CO and pulse contour analysis
RMP def
The resting membrane potential of a cell is defined as the electrical potential difference across the plasma membrane when the cell is in a non-excited state. Traditionally, the electrical potential difference across a cell membrane is expressed by its value inside the cell relative to the extracellular environment.
Vapour pressure =fi.barometroc pressure
Vapour pressure
CSHT definition
Context-sensitive half time is the time required for a 50% decrease in the central compartment drug concentration after drug administration has ceased; where the “context” is the duration of a “BET” (bolus, elimination, transfer) infusion that maintained a steady concentration in the central compartment.
Ka
Law of mass action: Rate of reaction is proportional to conc of reactants A+R—>AR V1=V2 at equillibrium V1=D.R.k1 V2=DR.k2 So DR/D.R=K1/K2=Dk Kd=dissociation constant inverse of Ka Ka= K2/K1=A.R/AR KA=association constant and is reciprical (strenght of sticking on once bound)
starling forces numbers and principle
MAP=60
PBC=15
oncCap=21
loosely 60-20-20=20
filtration coef=SA.p
reflection coef=1/proptein perm=glycocalyx function
steroids dose potency
dex 4=pred 25=hydrocort 100
dex spec glucocort!!
Moa Dex
increased enceph–>eat
decreased sub P
decreased 5HT
decreased PG
getn
positive effect-conc dep, post Abx and small degree time above MIC
SE determined by time above crit level.
block ribosome s30–>mistranslate tNRA–.weak protein–>wall breaks –>cidal –>synergistic with b lactams
SE nephrotox ATN reversible, Dx ototoxicity
not met–>excreted unchanged kidneys +water sol.
muscle weakness
prolonged block
Patient: PK, PD
drug: choice
Anaesthetic: intereactions
2006a(6): Explain the possible mechanisms for prolonged neuromuscular blockade after a 4hr procedure using a non-depolarising muscle relaxantGeneral: Non-depolarising muscle relaxants work by competitively antagonizing ACh at the nAChR on the motor endplate of the NMJ. Prolonged blockade after 4 hours can be due to:Pharmacokinetics- AbsorptionoRepeated administration of NMBD during the case oAccidental administration of long-acting NMBD during the case Drug error- DistributionoInfusion (eg of vec which is lipid soluble) would lead to accumulation in lipid rich tissue without monitoring level of blockadeoInappropriately large doses→ high conc in synaptic cleft- MetabolismoImpaired metabolism: Hepatic failure preventing the metabolism of active drug into less active/inactive metabolites (eg pancuronium)o↓T°C if Pt not adequately warmed during the case: slows down drug metabolism- EliminationoRenal failure:↑ amount of active drug remaining in the body PancuroniumoRenal failure: active metabolite (vec) not eliminated fast enoughoHepatic failure: ↑ active drug remaining Vecuronium, Rocuronium, pancuroniumPharmacodynamics - Electrolyte disturbances:o↓K+, ↑Mg2+(competes w Ca2+), ↓Ca2+- ↓pH: ↑affinity of non-depolarising NMBDs (except gallamine) for nAChRo↑risk during a long case- Drugs:oVolatiles (prolonged exposure during a long case)- ↓ACh release at NMJoLithium -↓Na+ transmission at NMJoAminoglycosides - ↓ACh releasedby ?competition w Ca2+oLA – may block Na+ channel at NMJ (variable)oDiuretics – may effect cAMP production (variable)oCa2+ blockers - ↓ACh releaseoMg- Neuromuscular abnormalityomyasthenia gravis→ defective nAChRoEaton-Lambert → impaired Ca reuptake
Define the term “hepatic extraction ratio”
Define the term “hepatic extraction ratio”
“Hepatic extraction ratio … is the fraction of the drug entering the liver in the blood which is irreversibly removed (extracted) during one pass of the blood through the liver”.
determinants of HER
BF, uptake, enzyme capacity
HER drug types
high HER–>BF is relevant. Prb and HF not
low HER
->low Prb–>protein binding irrel
–>high Protein binding–>protein binding change–>toxicity
nerve test palcement
Typically smaller muscle groups are more sensitive
The positive (red) lead is placed proximal
Ulnar nerve
Electrodes are placed along the ulnar border of the wrist at the flexor crease, and thumb adduction is assessed. Facial nerve orbicularis occult The positive electrode is placed at the outer canthus, and the negative electrode is placed anterior to the tragus. Eyebrow twitching is assessed. Posterior tibial nerve Electrodes are placed posterior to the medial malleolus, and plantar flexion is assessed. post-tibial nerve-flexor hallucis brevis
onset of different muscle group block
onset is determined by BF
since larynx and diaphragm equal and larynx more sens order is L, D
adductor has poor BF and as a peripheral muscle group is most sensistive
offset is determined by resistance
D>L>Adductor
Orbicularis occuli corresponds well with larynx but depth of block can be underestimated by direct stim of muscle anddecause facial nerve is quite reistant
clinical imp: AD is safe indicateor of when to tube and extubate
diaphragm recovery is not equal to larynx recovery which is not equal to upper airway muscle tone. (wait for adductor)
venous drainage brain
dural venous sinus–>IJV
CSF foramen
foraemen of munroe
aqueduct of silvia
goes to arachnoid villi outpouches from dura in sagital sinus
arachnoid villi
Arachnoid granulations (also arachnoid villi, and pacchionian granulations or bodies) are small protrusions of the arachnoid mater (the thin second layer covering the brain) into the outer membrane of the dura mater (the thick outer layer).
coricoid plexus
in ventricles
ultrafiltration glucos facilitated Na actively transported Cl fo;llows
hi HER
prop, GTN, ketamine #only IV or +++ dose
low HER
methadone, roc, phenytoin, thio
nerve fibre types
A alpha somatic motor beta touch delta cold sharp B preganglion ANS C post gang ANS and pain and temp
resistance unit
dyne.s/cm^5
or mmHg.Min/Lx80
normal is 100
muscle of artery
media=muscle
PVR factors
luminal-r4
intraluminal-PAP
extraluminal-lung vol, PEEP
PTC
It consists of applying a 50-Hz tetanic stimulus to the ulnar nerve for 5 s, followed by single twitch stimulation at 1 Hz. The number of twitches observed in the period of post-tetanic facilitation, the post-tetanic count, correlates inversely with the degree of neuro- muscular blockade.
PTC to TOFC
TOFC 1=PTC of 9
PTC of 2–>10min until TOFC of 1
rec occupancy for depression
75% NDMR, depol is only 20%
placenta
IgG
ketamine bidning site
Phencyclidine (PCP
preg and prB
α1‐acid glycoprotein decreased during pregnancy with the lowest value around week 30
changes in preg
peaks:
map 20
CO30
https://primarysaqs.files.wordpress.com/2009/12/makeup-describe-the-cardiovascular-changes-that-occur-in-pregnancy.pdf
roc met
CORE
NIL!!!
VEC
CVS SE: nil P+H (NIL BRADY)
active met with short half life peed out
also bile out
panc
active met with half potency
unchanged peed
mets in bile
Atrac met
hoffman hydrolysis–>lordenosine
nonspec esterases–>ludenosine
Cisat met
hoff–>nonspec esterases
miv
isomers
histamine release
ED 95
CORE AF
In anaesthesia, the term ED95 is also used when referring to the pharmacology of neuromuscular blocking drugs. In this context, it is the dose which will cause 95% depression of the height of a single muscle twitch, in half of the population.
secondary immune response
2nd time seen it ++ quick 1 vs 5 days
opiate terms
phenanthrene
thebaine
phenylpiperadine
opiate receptors
all act suprasinally, SC and peripherally
yet predominate at
mu-supraspinal #Morphine
delta-spinal
kappa-spinal
NOP-supra and spinal
GqpCR
evernote
CYP450
3A4 is midaz and alfent and warf
2D6 is codeine tramadol
dabagat vs riva #evernote
Dabagatran Double DURATION +Double action + DIALYSIS proDRUG. Min prB
Thrombin inhibitor #coag cascade and PL agg
ropivocaine strucutre
propyl group on its piperadine nitrogen
S enantiomer
less lipid sol–>more discriminatory block
elim half life 150min 2.5hrs
AchEi
physiostigmine crossed BBB to treat central antichol Sx
neostig-reacts with amide site to cause conformational change alowing esteratice site to forma covalent bond #carbamylated
micromacro
0.01ma ie 10microamp vs 100ma
earthing
completes circuit when fault–>trip and path less resistant than through you.
in powerlines –>escape
aladin caseete
electrical injection of liquid (doesnt change volume with temp much.)
flow meteres viscosity density
- At low flow rates, the clearance is longer and narrower, thus acting as a tube. Under these circumstances, the flow is laminar and a function of gas viscosity (Poiseuille’s law).
- At high flow rates, the clearance is shorter and wider, thus acting as an orifice. Here, the flow is turbulent and a function of gas density.
mannitol end point
should be discontinued if Na+ > 160 or osmolarity > 320mosmol/kg
hypertonic salien end point
end point of therapy Na+ 145-155
STP
NaCO3
propofol contains
benzyl alcohol
NaOH ph 7.4
TEG
What is r?
r = reaction time (normally <6 minutes)
Measured from sample placement until the amplitude reaches 2 mm
Represents activation of the coagulation cascade (intrinsic)
Prolonged with heparin, coagulation factor deficiency
If abnormal, consider FFP
Initiation
What is k?
k = clot formation time (normally <6 minutes)
Measured from r until the amplitude reaches 20 mm
Represents fibrin formation
Requires normal intrinsic clotting factors, fibrinogen and platelets
Amplification
What is the α angle?
Measured from the top of r to the k value
Normally 60 degrees
Represents the rate of clot propagation
If abnormal, consider fibrinogen = cryoprecipitate
What does the maximum amplitude represent?
Represents clot strength
Normally 60 mm
Significantly disturbed by platelet abnormalities
midaz
0.5mg/kg PO 0.1mg/kg IV
flumazenil
0.5mg ie 1ml
naloxone
50-100mcg Q5min
