Welliver Paper Questions-Josh Flashcards
Discuss the goals associated w/ anesthestic management that is associated w/ intracranial tumor debulking:
what are the 2 main goals to optimize cerebral circulation and Oxygenation?
- maintain or acheive normal ICP
- Maintaining CPP at minimum 70 mmHg
Discuss the goals associated w/ anesthestic management that is associated w/ intracranial tumor debulking:
why would you want to avoid narcotics preop?
- depress respiratory fxn and raise PCO2 causing cerebral vasodilation and thus increased ICP
List the S/S of elevated ICP:
- H/A
- Difficulty concentrating
- Memory disturbances
- Vision Disturbances
- Vertigo
- Syncope
- Nausea
- Vomiting
- Cushing Reflex
- Cushing Triad
- Sz
- Coma
Do all Intracranial tumors increase ICP
- Nope
The location of most neurosursical procedures for tumor resection is ____-tentorial and involes the ____ _______
- Supratentorial
- Cerebral Hemisphere
the cerebral hemispheres are divided by the _____- ______ fissure
(not on test per se but just in case)
Medial longitudinal
the right and left hemispheres are connected by a bundle of nerve fibers called the ______ _____
Corpus Callosum
The cerebral Cortex is compromised of the _______, ______, ______, and _______ lobes
- Frontal
- Parietal
- temporal
- occipital
_________ refers to the location of the brain stem
Infratentorial
Infratentorial consist of the ______, ______, _______, and _____ and is the major motor and sensory pathways and the cranial nerve nuclei
- Midbrain
- Medulla
- Cerebellum
- Pons
Positioning:
Infratentorial usually require a ___ or ____ position
- Prone
- Lateral
Positioning:
the Sitting position is associated w/ increased risk of _____ and excessive neck flexion
VAE
what are the 4 primary concerns during induction
Hypoxia
Hypercarbia
HTN
Hypotension
___-tension decreases CBF and risk further ischemic injury to the brain tissue
HYPOtension
____-tension risk increasing ICP ompedind adequate cerebral circulation
HYPERtension
what are the 3 primary intraoperative goals of anesthesia care fro the pt w/ elevated ICP?
- Decreasing intracranial volume to prevent further increase in ICP
- Maintaining adequate CPP (by manipulating BP)
- Decreasing CMRO2
what are 3 ways you can lower CMRO2?
- IV agents
- VAAs
- Temperature
CMRO2: IV agents
The IV agents _____, _____, and _____ all lower CMRO2
- Thiopental
- etomidate
- propofol
CMRO2: IV agents
how do the IV agents lower CMRO2?
- The mdulation of GABA receptors lowers neuronal activity whch corresponds w/ lower Cerebral O2 consumption
CMRO2: IV agents
____ coma is sometimes induced to maximally supress CMRO2 and is reflected by an isoelectric EEG
Barbiturate
CMRO2: VAA
VAAs decrease _____ and increase _____
CMRO2
CBF
CMRO2: VAA
how do VAAs lower CMRO2
- they decrease neuronal activity which lowers O2 and Glucose consumption by brain tissue,
- the Vasodilatory effects provide additional O2 to the brain
CMRO2: Temperature
Some CRNA’s allow a mild _____ in body temperature to help lower CMRO2
decrease
CMRO2: Temperature
Each __C in body temp corresponds to a __-__% decrease in CMRO2
- 1
- 7-8%
CMRO2: Temperature
what is the rational for the hyPOthermia
- to lower CMRO2 and metabolite formation in order to protect brain tissue, but this remains controversal
CMRO2: Temperature
there is no conclusive objective data stating that supports the use of HYPOthermia as an independent varible that decreases morbidity and mortality for a pt w/ space occupying lesions. This being said _______ should be avoded as it has been found to be detrimental
Hyperthermia
Explain the word “Coupling” in relationship of CMRO2 to CBF
- coupling is the direct relationship of CMRO2 and CBF
- an INCREASE in one corresponds to an INCREASE in the other.
- thus during normal activity increases in cerebral metabolic activity will corrolate w/an increase in CBF
“Coupling”
_____, _____, and ____ all decrease CMRO2 and allow normal regulatory decreases in CBF (aka Coupling)
Hint answers are meds
- Benzo
- Barbs
- Prop
“Coupling”
what and how does VAAs do to Coupling
- Uncouple
- they disrupt or “uncouple” this relationship by decreasing CMRO2 while increasing CBF
- Basicallly change the direct relationship of CMRO2 and CBF to an inverse relationship
If VAAs decrease CMRO2 why do we only ise 1/2 MACs?
- A decrase in CMRO2 is beneficial to ischemic brain tissue , but increases in CBF may cause detrimental increases in ICP and possibly divert blood flow away from ischemic areas to non-ischemic areas. AKA Steal phenomenon
Methods used to lower intracranial pressure address the need to decrease one or more of the 3 components of the Cranial Vault producing ICP. what are those 3 components?
- Brain
- Blood
- CSF
________ the volume of any of the 3 components reduces intracranial pressure
- Decreasing
what is 3 ways to decrease the brain component to lower ICP
- Diuretic (loop/mannitol)
- Hypertonic saline (3%)
- Corticosteroids
whata re 3 ways to lower the Blood component to decrease ICP
- Hyperventilation
- Limit IV fluids (<1L)
- Elevate the HOB (30 degrees)
What is 3 ways to decrease the CSF component of ICP
- Ventriculostomy
- Subdural drain
- Lumbar Drain
how do diuretics decrease brain size to lower ICP
- decrease blood and brain volume
- Shrink the brain size
- Lasix- lowers blood volume
- Mannitol- extracts fluid from brain tissue
- HYpertonic NS- Osmotically decreases brain water w/o causing hypovolemia
*
how do corticosteroids decrease Brain size to lower ICP
- bnloock inflammatory responses and may prevent further brain edema
How does hyperventilation decrease blood in the brain?
- decreases PaCO2 causing cerebral vasoconstriction
- PaCO2<30mmHg - the vasoconstriction lowers the amount of blood within the vault
How does limiting fluids decrease blood in the brain?
- prevents increases in IV volume
How does CSF drainage decrease CSF in the brain?
- removes volume from the cranial vault
HYPERventilation is a universal treatmetn for acute increase in ICP, so Describe why HyPERventilation is beneficial for pt’s w/ increased ICP
- b/c hypocarbia causes cerebral vasoconstriction which decreases the amount of blood w/in the cranial vault.
- Vasoconstriction is though to occur in areas of the breain that ARE NOT ISCHEMIC
- the ischemic areas contain mediated vasodilator substances and are not likely to respond to hyperventilation and vasoconstriction
- provide robinhood effect or reverse steal- whereas CBF is diverted toward ischemic areas of the brain and away from adequatly oxygenated areas.
PaCO2 is usually __-___mmHg higher then EtCO2
5-10 mmHg
what fluids are good
NS or LR
why shoulf you avoid dextrose solutions?
- metobolism of the glucose will lower teh osmotic pressure of the fluid
- also they oppose the goal f decreasing cerebral metobolism
Risk associated w/ head in prongs
- excessive flexion
- airway swelling
- cervical cord compression
- decreased outflow
Risk associated w/ head in prongs
what crainial nerves are at risk which control airway patency, respiration, and hemodynamics
- IX
- X
- XI
- XII
CN IX
- glossopharyngeal
- tongue, larynx
- swallowing, larynx elevation
CN X
- Vagus
CN XI
Accessory nerve
CN XII
Hypoglossal
Risk associated w/ VAE in what position
fucing sitting (this better be a mother fucking question for as mouch as Ive seen the mother fucker)
Risk associated w/ VAE, as the air enters the Venous system it travels to the ___ ___ and ___ _____ entering the pulmonary arterioloes
Right atrium
Right Ventricle
Risk associated w/ VAE, once in the pulmonary arterials a ___ ____ ___ is created and can cause hypoxia, CO2 retention, decrease EtCO2, and heart failure
Right Ventricular Airlock
Risk associated w/ VAE, additionaly to the right ventricular airlock, the reflec pulmonary and bronchial constriction occurs d/t release of endothelial mediators causing _____ ___ and increased ___ ___ ___
- Pulm HTN
- Peak Inspiratory Pressures
list the Most sensitive to least sensitive monitoring tech used to detect VAE (9)
- TEE
- Precordial doppler
- EtCO2
- Pulmonary artery cath
- CO
- CVP
- ECG changes
- BP
- Precordial stethoscope
when air is present in the right atrium the sound is described as a ____ murmur and it is distinctly different from baseline Heart sounds
Millwheel
treatment for VAE
steps
- Notify surgeon
- Flood area w/NS bone wax on bone edges
- lower pt head
- immediatly aspirate blood and air w/60mL syringe
- d/c N2O use 100% O2
which is not considered a component of the cranial Vault?
- Blood
- Brain
- Bone
- CSF
3.Bone
whch factor can decrease ICP?
- Hypoxia
- Hyperventilation
- Delivery of VAAs
- Hypercarbia
2.Hyperventilation
Which is not a potential consequence of elevated ICP
- Confusion or lethargy
- Cushing Response
- Cushing Syndrome
- Cushing Triad
3.Cushing Syndrome
Which is the mechanism of action by whoch mannitol protects brain tissue?
- Venous engorgement and increased permeability
- Osmotic Diuresis and Free radical scavenging
- Hypotension and decreased tissue perfusion
- Osmotic diuresis and decreased CMRO2
4.Osmotic diuresis and decreased CMRO2
Which events Cause physiologic stimulation during a tmor debulking procedure?
- Induction, Intubation, skin incision, bone sawing, brain tissue resection
- Intubation, skin incision, skull peristeal scraping, brain resection
- Intubation, skin incision, skull periosteal scrapping, emergence
- All events during tumor debulking are equally stimulation
- Intubation, skin incision, skull periosteal scrapping, emergence
(this is the answer I think.. there is no key but thats what I would saw)
Guess what chicken butt….. you done!!!
