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Test 4 Flashcards

1
Q

top 5 variables associated with 30-day mortality age > 80

A
  1. ASA status
  2. preop albumin
  3. emergency
  4. preop functional status
  5. preop renal impairment
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2
Q

frailty domains

A
  1. unintentional weight loss > 4kg past year
  2. exhausting (effort and motivation assessed)
  3. grip
  4. walking speed
  5. low physical activity
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3
Q

include in PACU handoff

A
  1. surgical/anesthetic course
  2. preop conditions warrant/influenced outcomes
  3. treatment plan
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4
Q

most common cause of airway obstruction immediately post op

A

loss of pharyngeal tone in the sedated/obtunded

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5
Q

cause of most upper AW obst

A

tongue

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6
Q

laryngospasm succs doses: IM/IV

A

IM: 2-4 mg/kg

IV: 0.1 - 0.2 mg/kg

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7
Q

PaO2/SaO2 value of hypoxemia

A

PaO2 < 50

SaO2 < 90

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8
Q

most common cause of post op hypoxemia

A

atelectasis

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9
Q

hypoxemia + hypoventilation =

A

give O2

done

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10
Q

This describes binding of O2 to Hg reducing Hg CO2 affinity.

A

Haldane effect

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11
Q

This describes process where inc concentrations of CO2 will decrease O2 affinity to Hg

A

Bohr effect

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12
Q

what is P50 on Hg Dis Curve

normal value

A

PaO2 value at which Hg is 50% saturated with O2

normal P50: PaO2 of 26-7 results in 50% of Hg saturation

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13
Q

derrangement of K+ and Mag in which directions will potential NMBAs

A

Dec K+

Inc Mag

(also hypothermia and acidosis.. ur welcome)

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14
Q

alveolar gas equation

lets hear it

A

room air

0.21 (BP - PH20) - (CO2/ 0.8)

FiO2 25% (1L O2)

0.25 (760 - PH2O) - (CO2/0.8)

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15
Q

MV increases ___ L for every ___ increase in PaCO2

A

MV increases 2 L for every 1 mmHg increase in PaCO2

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16
Q

why give narcan slow

what doses

A

pulm edema

40-80 mcg per dose give slow

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17
Q

overall, the most common cause of pulm edema perioperatively

A

laryngospasm

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18
Q

TRALI: menifestation time, signs/sx/dx/tx

A

menifestation: 1-2 hr post transfusion (can be 6 hrs)

sx:

fever, hypotension (noncardiogenic pulm edema)

leukopenia (dec WBC) sequestered in lungs

dx: bilat pulm infiltrates, inc A-a gradient
tx: O2 and diuresis

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19
Q

virchow’s triad

lets hear it

A
  1. venous stasis
  2. hypercoagulability
  3. endothelial injury
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20
Q

post op PE related to

A

surgical trauma

liberation of Tissue Factor (TF) from subendothelial tissue into blood

stimulates thrombin=> clots

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21
Q

surgical induced hemostatic changes: mostly everything increased in chart except endogenous anticoags which are what?

A

all these decrease causing risk for clots:

  1. antithrombin III
  2. heparin cofactor II
  3. tissue factor pathway inhibitor
  4. protein C
  5. protein S
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22
Q

normal aPTT

A

30-40

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23
Q

minor blood aspiration removed by

A

cough

resorption

phagocytosis

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24
Q

at risk for gastric aspiration

A
  1. obese
  2. prego
  3. hiatal hernia
  4. PUD
  5. trauma
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25
Q

chemical pneumonitis occuring during anesthesia as a result of gastric aspiration

A

Mendelson’s syndrome

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26
Q

bronchospasm associated drugs

A
  1. morphine
  2. demerol
  3. succs
  4. atracurium
  5. thiopental
  6. mivacurium

histamine related (caution w/ asthma/copd)

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27
Q

late cariac signs of inadequate oxygenation

A

bradycardia

hypotension

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28
Q

most common cause of CV complication after non-cardiac sx

A

MI

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29
Q

most common underlying cause of sudden cardiac arrest: 2 things

A

ischemia

and/or

LV dysfunction

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30
Q
A
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31
Q

In PACU: hypotension is most commonly caused by

A

hypovolemia

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32
Q

Hypotension slides

  • myocaridal dysfunction treated with
  • secondary dysfunction treated with
A

coronary vasodilators

inotropics

afterload reduction agents

secondary

stop med causing issue

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33
Q

lab confirming allergic reaction

no differentiation btw anaphhylactoid (no prior exposure required) and anaphylactic (prior sensitization necessary)

A

tryptase

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34
Q

____ is leading cause of HTN and tachycardia in PACU and produces pressor response called _________ ____.

A

pain is leading cause of HTN and tachycardia in PACU and produces pressor response called somatosympathetic reflex

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35
Q

relationship btw cooling and catecholamine system

A

hypothermia causes endocrine induced CATs

as cooling occurs vessels are more responsive to CATs

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36
Q

hypothermia effect on cardiac cycle

A

prolongs refractory period

(brady, afib)

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37
Q

pharyngeal funcition returns to adductor pollicis at what TOF ratio

A

0.9

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38
Q

ability to bite down tongue blade/ett corresponds to TOF of

A

0.85

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39
Q

alcohold withdrawal can result in ___ ____ - hallucinations, extreme combativeness, and confusion

A

delirium tremens

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40
Q

four categories of emergence delirium

A

circulation/resp (consider before others)

withdrawal

toxic

functional

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41
Q

most common electrolyte disorders contributing to delayed awakening

A

Na

Mag

Ca

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42
Q

post op pain more severe in

A

altered CYP2D6

smokers

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43
Q

Most common SE of opiods

A

bowel dysfunction

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44
Q

med tx for shivering

A
  1. demerol
  2. ketamine
  3. precedex/clonidine
  4. hydrocortisone
  5. zofran
45
Q

Apfel’s scoring

A

female, non-smoker, PONV hx/motion sickness, potop opiods. # of factors to risk

  1. 10-20%
  2. 40%
  3. 60%
  4. 80%
46
Q

Cardioplegia lowers myocardial temp to what?

A

8-12 o Celsius

47
Q

How does desaturated blood leave the patient while on CPB?

A

From one or two cannulas in RA or SVC/IVC via gravity

48
Q

Roller pumps on the console of the CPB machine serve what 3 purposes?

A

Vent the LV
Suction heart

Deliver Cardioplegia

49
Q

Roller pump, how does it work? How does it prevent RBC trauma?

A

Flow rate is determined by number of revolutions per minute Provides non pulsatile flow

Subtotal occlusion prevents excessive RBC trauma but not as well as centrifugal pump

50
Q

Centrifugal pumps are ________ sensitive?

What is a major advantage of these pumps?

A

Pressure

Unable to pump air, and advantage of less trauma to RBC

51
Q

What is a major risk if the venous reservoir on CPB becomes empty?

A

Air embolus

52
Q

Rate of venous return depends on (3)?

A

Gravity (ht above reservoir)

Intravascular volume

Proper placement of cannula

53
Q

Where are volatiles added in the CPB?

A

The membrane oxygenator

54
Q

What are some characteristics of the oxygenator?

A

High surface area and a thin film (mimics pulmonar membrane)

High resistance to flow–needs active pumping of blood

Prone to rupture w/ blood leak or air embolus

55
Q

Purpose of cardiotomy suction

A

Salvaged blood from the surgical field to reservoir; can be used for cell saver

56
Q

Purpose of LV vent? Why is there still blood even on full bypass?

A

Blood accumulates in the LV from residual pulmonary flow through bronchial arteries or aortic regurg

57
Q

How often is cardioplegia administered?

A

Q 15-30 mins

58
Q

T/F Cardioplegia arrests the heart in diastole.

59
Q

_____ mL cardioplegia to arrest the heart is used, and _____ mL before each distal graft

A

600 mL

300 mL

60
Q

T/F the CPB arterial line filter is flushed with 100% O2 for several minutes

A

False.

It is flushed with 100% CO2 b/c it is 30 times more soluble in water than air

61
Q

Prime solutions should be iso/hypo/hypertonic?

A

Isotonic or slightly hypertonic

62
Q

Goal hematocrit on bypass?

A

25%

This decreases the viscosity of blood (cold blood is more viscous) and enhances tissue perfusion at low rates

63
Q

What components are added to priming solution?

A

Abumin

Mannitol

Heparin 1k to 10k U

Bicarbonate

Blood

64
Q

Decreased BP from onset of CPB is due to what?

A

Decrease in SVR from onset of CPB

Decreased blood viscosity

D/c vascular tone d/t:

  • dilution of circulation catecholamines
  • Temporary hypoxemia
  • Low, pH, Ca++ and Mg+ in prime
65
Q

SVR increases/decreases during hypothermia?

66
Q

Why do you have a transient d/c in BP after cardioplegia?

A

It contains nitroglycerin

67
Q

During rewarming will SVR and MAP increase/decrease? After release of cross clamp?

A

Increase from 25 to 32 o

Then decline as temp >32o

After release cross clamp, will see decrease in both.

68
Q

What is goal core body temp on CPB?

A

25-32 o Celsius

69
Q

Hemodilution increases O2__________ but decreases O2 ___________?

A

Increases/improves delivery of O2

Decreases carrying capacity

70
Q

Hypothermia shifts the oxyhemoglobin curve to the ______?

71
Q

CPB activates the ________ and ________ cascade systems

A

Coagulation and fibrinolytic cascade

72
Q

MI is a rare complication of CPB but ______ and ______ is more common

A

Injury and cell necrosis

73
Q

incidence of injury or stroke on CPB?

A

2-6%

Higher risk for opened chambers such as valve sx

74
Q

Postoperative Cognitive dysfunction occurence post CPB?

75
Q

Renal failure occurence in adults and infants?

A

1% adults

2-10% in infants

76
Q

Major GI complications are rare but contribute to low/high mortality rate?

77
Q

With a severe systemic inflammatory response to CPB, how would the following factors appear: HR, SVR, and CO?

A

Tachycardia

Low SVR

Increased CO

78
Q

What is the only volatile anesthetic not recommended for patients with CAD?

A

Desflurane (From Travis’ Cardiac anesthesia notes)

79
Q

Which side is preferred for radial A line during CABG?

A

Right, b/c left is occluded by retractor for IMA

80
Q

What additive is in the ACT tubes?

A

Celite, aka diatomaeous earth (dirt)

81
Q

What is average prime volume?

82
Q

Heparin should be stopped how many hours before surgery?

83
Q

Which artery supplies leads V1-V4?

84
Q

Which artery supplies leads I, aVL, V5-V6?

85
Q

What is your goal MAC preincision?

86
Q

Heparin dose pre CPB?

87
Q

ACT levels, normal, CPB, and off pump bypass?

A

Normal 105-167

CPB >450

Off pump >300

88
Q

Heparin MOA?

A

BInds to Antithrombin III and inhibits thrombin as well as other factors IX-XIIa but mostly Xa

89
Q

If you give Heparin and ACT does not change, what should you suspect?

A

ATIII deficiency, may need FFP or synthetic ATIII concentrate

90
Q

As temp increases, gas solubility ______?

91
Q

As temp decreases, partial pressure of gas in solution _______

92
Q

Temperature, solubility, and partial pressure of a gas are related how?

A

Decreased temp=increased solubility=decreased partial pressure

Increased temp=decreased solubility=increased partial pressure

*Low PP of a gas like CO2 while hypothermic causes vasoconstriction in cerebral vessel*

93
Q

If Hgb is decreased by 50%, blood flow must ______ to maintain O2 transport

94
Q

SVR FORMULA

A

{(MAP-CVP)x80}/CO

95
Q

CPB effect on Na+K+ pump

A

Result is low extracellular K+ and higher intracellular K+ until body back to normal metabolic state and temperature

96
Q

Off Pump Cabg

Temp?

ACT?
Hemodynamics?

A

Hypothermia avoided-use fluid warmer

ACT >300

Slow HR and keep SBP >100

Low TV and increased RR

97
Q

Total circulatory arrest

Temp?

Time of procedure?

A

Temp as low as 15 o Celsius

Keep TCA time <40 mins

98
Q

2,3 DPG

Increased and Decreased Effects?

A

Increased 2, 3 DPG: releases O2, decreased affinity

Decreased 2, 3 DPG: doesn’t want to release O2, higher affinity for O2

99
Q

Bohr Effect

A

Explains the effect of CO2 concentration on O2 transport.

Occurs at tissue level; increased CO2 level causes d/c affinity for O2 and increased affinity for CO2. “Right shift”

100
Q

Haldane Effect

A

Explains effect of O2 concentration on CO2 transport

Occurs at lungs, increased O2 concentration causes d/c affinity for CO2 (wants to get rid of it) and increased affinity for O2 (pick it up to deliver to tissue)

101
Q

Minute ventilation increases by ___L for each ___mmHg increase in PaCO2

A

2L; 1 mm Hg

102
Q

What is the alveolar gas equation?

A

PAO2= FiO2(PB-PH2O)-(PaCO2/RQ)

PB=760 mmHg

PH20=47 mm Hg

RQ=0.8

103
Q

Fast administration of Narcan can cause what?

A

Pulmonary edema

104
Q

Most common cause of pulmonary edema perioperatively?

A

Laryngospasm

105
Q

TF Dysrhythmias in the PACU are typically related to myocardial injury.

A

False

Common causes include: hypokalemia, hypoxia, hypercarbia, altered acid-base, circulatory instab., pre-existing heart disease

106
Q

What TOF level is associated with pharyngeal function return?

107
Q

Aldrete score of what is adequate for PACU discharge?

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