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367 Cards in this Set
- Front
- Back
What are the 4 primary functions of the kidneys?
|
1. Excretion of end products of bodily metabolism
2.Control of constituents of body fluids (filtration/ reabsorption) 3.Secrete hormones such as renin and erythropoetin 4.Metabolism of hormones (such as insulin) |
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What is the functional unit of the kidney?
How many are there in each kidney? |
The nephron
1.2 million in each kidney |
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What are the components of the nephron?
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Glomerulus, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct
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How much of the cardiac output goes to the kidneys?
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20%
|
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Between what MAPs does auto regulation of blood flow and glomerular filtration take place (in an adult)?
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80-180 (remains constant)
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Renal blood flow is strongly influenced by ____ and _____.
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SNS and renin
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What do the kidneys manufacture in response to systemic hypotension and renal ischemia?
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Prostaglandins
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What do prostaglandins do?
What purpose does this serve in the kidneys? |
Vasodilate
Vasodilates to allow more blood flow to the kidney |
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What tests help you evaluate the GFR?
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BUN- elevation can be related directly to GFR or to protein catabolism
Creatinine: directly related to muscle mass, indirect indicator of GFR Creatinine clearance (derived from a formula accounting for age, weight, sex, etc) |
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What tests help you to evaluate the function of the renal tubule?
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Urine dip (proteinuria, urine specific gravity), urine osmolarity, 24 hour urine collection
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What is a normal GFR?
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About 120 ml/minute
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A BUN >____ indicates impairment of GFR
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50
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Urine that is positive for protein should be evaluated by what further test?
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24 hour urine collection
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What two anesthetic agents may cause direct nephrotoxicity?
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Methoxyflurane
Sevoflurane (Compound A) |
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How do anesthetics indirectly affect the kidneys by way of the cardiovascular system? The SNS?
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Anesthetics may cause hypotesion which can lead to decreased GFR and decreased UOP; Regional anesthetics cause a decrease in sympathetic tone, leads to vasodilation and hypotension, again decreasing GFR and UOP
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Catecholamines and Angiotensin II lead to ____
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Fluid retention
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What are the 4 stages of renal impairment?
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1. Decreased Renal reserve
2.Renal insufficiency 3.End Stage Renal Disease 4. Uremia (dialysis dependent) |
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Chronic renal disease may lead to______.
Why? |
Anemia
Decreased erythropoetin production |
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Chronic renal disease may have this affect on cardiac output:
Why? |
Increased cardiac output
Decreased oxygen carrying capacity d/t anemia |
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Chronic renal disease does this to platelets:
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Reduces platelet adhesiveness
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Renal failure leads to ___kalemia
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Hyper
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When a person is in chronic renal failure, their intravascular volume is_____.
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Unpredictable
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Chronic renal failure leads to what type of pH?
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Metabolic acidosis
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Chronic renal disease leads to this type of blood pressure
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Systemic hypertension
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Chronic renal disease makes patients more at risk for ____
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Sepsis
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ESRD patients should undergo ____ within 24 hours prior to surgery
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Dialysis
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What lab values to you want to know about your ESRD patient prior to surgery?
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K (especially related to succinylcholine administration); BUN, Creatinine,
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Antihypertensive medications should be _____ prior to surgery.
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Continued (D/C may lead to rebound hypertension)
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What are good alternative medications to succinylcholine if your patient's potassium is elevated?
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Cisatracurium, Atracurium (because they are not metabolized by the kidneys)
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Is it ok to give sucinylcholine to ESRD patients?
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Only if their potassium is ok
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Why would an end stage renal disease patient exhibit an exaggerated response to IV induction agents?
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Decreased protein binding (more free drug floating around)
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You would not want to give Atracurium or Cisatracurium to your patient if they have a history of ____.
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Seizures
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Why might your ESRD patient exhibit an exaggerated decrease in BP?
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May reflect ANS dysfunction or a impaired baroreceptor mediated reflex response
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Do you want to maintain general anesthesia with short or long acting opiods in your ESRD patient? Why?
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Short acting, because of duration of effect with renal clearance
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Normocarbia is especially important in your ESRD patient Why?
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acidosis increases potassium level
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What piece of equipment might you use to keep close track of fluid administration in the OR for your ESRD patient?
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A buretrol
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meticulous attention to fluid balance is especially critical in patients with ESRD. What fluid do you want to replace intravascular volume with? Which do you specifically want to avoid, and why?
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NS,
Avoid LR because it contains about 4meq K/L |
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AV shunts must be carefully protected inraop. What piece of documentation is imperative in these patients?
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Presence of bruit both before and after surgery
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Which opiod might you specifically want to avoid in ESRD patients?
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Morphine; metabolites can accumulate
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What type of block might be useful for placement of an AV graft?
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Brachial plexus block
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The duration of a block in an ESRD patient might ____ by as much as ___%. Why?
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Decrease, 40%, d/t increased cardiac output and increased tissue blood flow
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Co-existing neuropathies in ESRD might ____ seizure threshold for local anesthetics
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Decrease
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Before selecting regional route of anesthetic for your ESRD patient, you should check ____ and document ______.
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Coags, Uremic neuropathies
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Many NDMR undergo extensive ____ in the _____.
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Excretion from the kidneys
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In your ESRD patient, you would want to _____ the dose of NDMR and _____.
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Decrease, monitor
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Causes of 'pre renal' ARF:
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1. Hypovolemia
2. Decreased renal blood flow d/t decreased cardiac output |
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Acute renal failure caused by acute tubular necrosis can be caused by:
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1. Nephrotoxins
2. renal ischemia 3. Circulating myoglobin (crush injuries) |
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Post-renal causes of ARF are:
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urinary Obstruction
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Signs and symptoms of acute renal failure:
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Elevated BUN/creatinine, fluid retention, sodium and water retention, acidosis, hyperkalemia, nausea/vomiting, easy bruising/bleeding, decreased UOP, changes in mood/mental status
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Pre-renal oliguria is indicated with______ urine with a _____ sodium content
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Concentrated, low sodium content- indicates renal function is intact, body is trying to preserve water and sodium through reabsorption to increase intravascular volume
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Oliguria is defined as:
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less than 0.5 ml/kg/hr or 400 ml/day in adults, <1 ml/kg/hr pediatrics
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What are the goals of therapy in treating pre renal oliguria/ARF?
What is the first thing you would do to accomplish this? |
Limit the duration and magnitude of reduction in Renal Blood Flow
Volume! (crystalloid) |
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A fluid challenge to confirm a diagnosis of pre-renal ARF would consist of:
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3-6 ml/kg
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If oliguria is due to decreased cardiac output, _____ might be considered
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Dopamine 3-5 mcg/kg/min
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In establishing a diagnosis of pre-renal ARF, a 0.1mg/kg dose of Lasix would improve symptoms if_____, but not if______.
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oliguria is due to ADH, but not if it is due to decreased RBF
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What is the first thing you should do if you are suspecting that your patient has new onset oliguria?
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Check the patency of your catheter
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Does administering diuretics in oliguric ARF prevent the development of tubular necrosis
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Evidence in support of this theory is lacking, controversial. Does cloud picture of sodium reabsorption from urine for about 6 hours (making diagnosis more difficult)
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You must restore _____ before giving a _____ to a patient in pre renal ARF
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Intravascular volume, diuretic;
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Fluid volume in ARF is best assessed with
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CVP or PCP
|
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Is urine sodium excretion increased or decreased in patients with ATN?
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Increased (>40 meq/L)
|
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Urine is ____ concentrated in ATN
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poorly
|
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What lab level must you carefully monitor in ATN?
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Potassium, hyperkalemia may result
|
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Residual Volume
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The amount of air remaining in lungs after forced expiration
|
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Expiratory reserve volume:
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Amount of air that can be expired after normal tidal volume
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Tidal Volume
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Volume of air inspired and exhaled on each regular breath
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Inspiratory Reserve Volume
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Max additional volume that can be inhaled above normal tidal volume
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Inspiratory Capacity
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Max volume of air inspired from end expiratory level
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Vital Capacity
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Max capacity of air that can be expired following a maximal inhalation
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Functional Residual Capacity
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Volume of air remaining in lungs after at end expiratory level
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Total Lung Capacity
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Volume of air in lungs after maximal inhalation (5800 ml)
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Functional residual capacity is influenced/determined by what factors?
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Body habitus (height, obesity), sex, posture, positioning (supine vs. upright), lung disease, diaphragmatic tone
|
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What effect does lying supine have on functional residual capacity?
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Decreases
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Can the residual volume of air be exhaled voluntarily?
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No
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Vital Capacity is influenced/determined by:
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Body habitus (height), respiratory muscle strength, lung compliance
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What is a normal vital capacity for an adult?
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60-70 ml/kg
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Induction of anesthesia has what effect on your diaphragm?
What effect does this have on lung volume and chest wall compliance? |
Loss of diaphragmatic tone
Decreased lung volumes and decreased compliance |
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What effect will Trendelenberg positioning have on lung volumes?
HOB elevation? |
Decreased
Increased |
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Do NMB agents affect lung volumes?
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No
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How long after anesthetic agents are turned off will poor diaphragmatic tone persist?
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Can last for hours after agents off
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What are 6 common causes of obstructive pulmonary disease?
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Asthma, Chronic Bronchitis, Emphysema, cystic fibrosis, bronchiectasis, bronchiolitis
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What do all obstructive lung diseases have in common?
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Resistance to airflow
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In obstructive lung diseases, increased resistance to flow leads to...
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Air trapping (increased residual capacity), increased WOB, VQ mismatch
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Wheezing is caused by
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Turbulent flow
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VQ mismatch and resistance to airflow can lead to____
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Abnormal oxygen exchange and arterial hypoxemia
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What is FEV1
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Amount of air that can be exhaled in 1 second
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A FEV1/FVC of less than ____ is diagnostic for obstructive respiratory disease
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<70%
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MMEF (maximal mid-expiratory flow) less than ____ is indicative of COPD.
When does this value begin to change? |
<70?
Begins to decrease before demonstratable symptoms of COPD begin |
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COPD generally has what effect on lung volumes?
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Increased Total Lung Capacity and Residual Volume
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What are two common respiratory finding in COPD?
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Wheezing and dyspnea
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Asthma is characterized by ______ and ______ in response to various stimuli
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Bronchiolar inflammation and hyperactivity
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Asthma attacks are manifested by:
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Episodic attacks of wheezing, dyspnea, and cough (with increased mucous production)
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Early uncompensated acute asthma attacks lead to what three 'value' changes?
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Hypoxia,
Hypocapnia (from hyperventilation) Respiratory Alkalosis (from blowing off CO2) |
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What lab values increase your level of concern in an asthmatic in acute distress?
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Normalizing or elevated CO2, normalizing or decreasing pH
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What happens to the airway during an asthma attack?
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Reduction in airway diameter, inflammatory thickening of bronchial mucosa, accumulation of tenacious secretions
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With asthma, what chronic changes can take place in the lungs and airway over time?
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Lung hyperinflation, pulmonary hypertension, loss of elasticity
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What effect does Asthma have on the heart?
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Strain on R. and L. heart, increased lung volumes can cause pulsus paradoxus, EKG changes
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What EKG changes might you see in an acute asthma exacerbation?
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ST segment changes
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What questions do you want to make sure to ask in a preoperative assessment of a patient with a history of asthma?
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Previous hospitalizations for asthma, date of last attack, wheezing or SOB, cough/sputum production, allergy history, treatment regimen, EKG, CXR, and eosinophil count (may increase preceding attack)
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When would regional anesthesia not be a good choice for patients with Asthma, COPD or other lung disease?
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Spinal block that might travel high enough to impede respiratory muscle strength or weaken diaphragm
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Is regional or general anesthesia a better choice for someone with asthma (or other lung disease)?
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Neither method is inherently superior; situational
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Why might you encourage your patient to quit smoking for even 12-14 hours before surgery?
|
Reduces carboxyhemoglobin
|
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What airway device might you use in a patient with asthma?
What is it? |
LTA (Laryngeal tracheal anesthetic)
Tube inserted into airway that releases a circumferential spray of lidocaine to the larynx and trachea just prior to intubation to decrease risk of airway irritation and bronchospasm |
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What other elements might you want to consider in your differential diagnosis of intraop bronchospasm?
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Kink in tube, inadequate concentration of anesthetic drugs, Aspiration, pneumothorax, pulmonary embolism
|
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What are the first three things you want to do if your patient experiences an intraoperative bronchospasm?
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1. Increase volatile agent
2. Albuterol MDI 3. Corticosteroids (consider theophylline if these do not work, but be aware of very narrow therapeutic index) |
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What is the best choice of volatile agent in your patient with Asthma?
Which volatile might you want to avoid? |
Sevoflurane
Desflurane |
|
Can you give succinylcholine to asthmatics?
|
Yes, despite Histamine release.
|
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What drugs do you want to avoid giving Asthmatics?
|
Aspirin, NSAIDs, Tagamet, Beta Blockers
|
|
Cromolyn Sodium
|
Mast cell stabilizer, used to prevent asthma exacerbations
|
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When are corticosteroids used with asthmatics?
|
Can be used for both acute and chronic treatment
|
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What do beta sympathomimetics do in the treatment of asthma?
|
Causes bronchodilation
|
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Ipratroprium Bromide is useful for:
|
exercise or irritant triggered asthma
|
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Chronic bronchitis: diagnostic features?
Pink Puffer or blue bloater? |
Productive cought on most days of a three consecutive month period every year for 2 years
Blue Bloater |
|
What happens to the Residual Volume and Total Lung Capacity in someone with Chronic Bronchitis?
Is dyspnea an early or late sign? |
RV increases, TLC remains the same; often have significant disease before dyspnea begins to occur
|
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What effect does Chronic bronchitis have on the heart?
|
RV failure and Cor Pulmonale
|
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Emphysema is characterized by
Pink Puffer or blue bloater?: |
Loss of elastic recoil of the lungs, collapse of airways during exhalation
Pink Puffer |
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What spirometric changes would you expect in a patient with emphysema?
|
Increased RV, TLC, FRC, RV/TLC ration
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Dominant feature of COPD is:
|
Progressive airflow obstruction
|
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Typical appearance of someone with chronic bronchitis:
|
Overweight, dusky/cyanotic, pronounced cough, large sputum production, likely to have cor pulmonale, more cough than dyspnea, 40-55 years of age, frequent URI
|
|
Typical appearance of someone with emphysema:
|
Thin, pursed lip breathing, anxious, Non-cyanotic, pronounced dyspnea, minimal cough, low sputum production, infrequent URI, 50-75, Cor Pulmonale Rare
|
|
Pre-op management of someone with COPD should be aimed at:
|
determining the severity of disease, identifying treatments to decrease airway inflammation, treating infection, and increasing the size of small airways (reverse hypoxia, hydrate to decrease secretion tenacity)
|
|
Preoperative education for a patient with a history of COPD undergoing a thoracic or upper abdominal surgery should include:
|
Likelihood of post-op ventilation
|
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What might Nitrous Oxide cause in a patient with COPD?
|
Increased air-trapping and potential for pneumothorax
|
|
Can you use PEEP in a patient with COPD
|
Yes, in moderation
|
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Patients with COPD might be very _____ to narcotics
|
Sensitive to respiratory depressant effects- use caution and moderation so that you don't knock out their respiratory drive
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If a COPD patient has and FEV <_____ and an upper abd or thoracic procedure, they are likely to _____.
|
50, remain intubated postoperatively
|
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Name 6 examples of acute intrinsic restrictive lung disease
|
1. Pulmonary Edema
2. Opioid overdose 3. ARDS 4. Aspiration 5. High Altitude 6. CHF |
|
Name 2 examples of chronic intrinsic restrictive lung disease
|
1. Sarcoidosis (cause uncertain, perhaps autoimmune and treated with steroids)
2.Drug induced pulmonary fibrosis |
|
If a patient has sarcoidosis, they may need:
|
Stress dose steroids intraoperatively (especially if they have been treated with steroids in the past 6 months)
|
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Name 10 examples of extrinsic restrictive lung disease
|
1. Obesity
2. Pregnancy 2. Kyphoscoliosis 4. Mediastinal mass 5. Chest wall or sternal deformities 6. Flail Chest 7. Pneumothorax 8.Pleural effusion 9. Neuromuscular disorders 10. Ascites |
|
Preoperative management of a patient with acute intrinsic lung disease should include:
|
Maximize oxygenation and ventilation, treat volume overload
|
|
Intraoperative ventilator management of a patient with acute intrinsic lung disease might include
|
High FiO2, high PEEP, PC mode might be preferred (or VC with decreased TV and compensatory increase in rate)
|
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Pre-operative assessment and management of a patient with chronic intrinsic or extrinsic lung disease might include:
|
Determine level of pulmonary impairment and dyspnea with exertion
|
|
Patients with restrictive lung disease are prone to ______ hypoxia
|
Very rapid onset, low pulmonary reserve before decompensation takes place
|
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What 6 risk factors highly predispose postop respiratory complications (including post-op mechanical ventilation)?
|
1. Pre-existing pulmonary disease
2. Smoking 3. Upper abdominal or thoracic surgery 4.Obesity 5. Age > 60 6. Prolonged General anesthesia (case >2.5 hours) |
|
the absorption, distribution, metabolism and excretion of inhaled or injected drugs
|
Pharmacokinetics
|
|
Volume of Distribution (Vd)
|
Dose of drug administered IV divided by the plasma concentration
|
|
Vd does not refer to absolute anatomic volumes. What does it represent?
|
the compartments that constitute the compartment model for that drug
|
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Drugs with high concentrations in the central compartment have a _____ volume of distribution
|
low
|
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Drugs with a high concentration in the peripheral compartment have a _____ volume of distribution
|
high
|
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What two factors make a drug have a low volume of distribution (stay in central compartment)
|
Low lipid solubility, high degree of ionization
|
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If a drug has a low volume of distribution, its concentration in the plasma will be _____.
|
High
|
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Drugs that are lipid soluble and not ionized have a _____ volume of distribution, and therefore ______.
|
High, readily move into the peripheral compartment
|
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Drugs that have a high volume of distribution have a ____ concentration in the central compartment, and a high concentration in the peripheral compartment.
|
Low in central, high in peripheral
|
|
Pharmacodynamics
|
the responsiveness of receptors to drugs and the mechanism by which these effects occur (what the drug does to the body)
|
|
Receptors
|
Specific macromolecules in cell membranes, "lock and key" mechanism that causes a reaction to take place
|
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The number of receptors is ____ and can be _____ or _____ depending on stimuli.
|
Dynamic, can be upregulated or downregulated
|
|
Receptors work by ____
|
1. regulating production of cAMP
2. Opening or closing ion channels 3. Causing enzyme production |
|
Patients on longstanding blood pressure medications have_____ receptors
|
More (due to upregulation)
|
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If patients on long term blood pressure medications do not take these medications before surgery, they will have an _________ due to________
|
Exaggerated Response and become exceedingly hypertensive, due to up regulation of these receptors
|
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IV drips are designed to maintain a _____ of drug filling receptors
|
steady state; plasma concentration is proportional to amount of drug at receptors
|
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Factors (pharmacodynamics) that influence plasma concentrations of the drug will also influence the ______. This means that if drug delivery exceeds ______ the drug will accumulate
|
concentration at receptors; of delivery exceeds clearance, drug will accumulate in the body
|
|
volume of plasma cleared of drug by renal excretion and/or metabolism in the liver or other organs
|
Clearance
|
|
Most important organs for clearance of unchanged drugs and their metabolites
|
Kidneys; excrete water soluble drugs and/or their metabolites
|
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Lipid soluble drugs must be____ before being excreted by the kidneys
|
Metabolized into water soluble drugs for excretion
|
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Microsomal Enzymes to metabolize drugs are located in ______
|
hepatic smooth endoplasmic reticulum
|
|
The p450 enzyme system is important because
|
It can be excited or ramped up by having to clear chronic meds like dilatin, and can then metabolize other drugs more rapidly than usual
|
|
Elimination Half-Time
|
Time necessary for the plasma concentration of drug to decline 50% during the elimination phase
|
|
_____ elimination half-times are necessary for almost complete excretion of drug
|
Five
|
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_____ drug is pharmacologically active and lipid soluble
|
Non-ionized
|
|
_____ drug is pharmacologically inactive and water soluble'
|
Ionized
|
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Degree of ionization of a drug in the body is determined by its ___ and the ___ of the surrounding fluid
|
pKa, pH of the body or surrounding fluid
|
|
Changes in body ___ can effect the way drugs act within the body
|
pH
|
|
Oral drugs undergo a ____. What does this mean?
|
First-pass effect; oral drugs are metabolized extensively by the liver before having a chance to act upon the body
|
|
Redistribution
|
Transfer of drug to inactive tissue sites such as skeletal muscle
|
|
MAC
|
Minimum alveolar concentration (partial pressure) of an inhaled anesthetic at 1 atmosphere that prevents skeletal muscle movement in response to a noxious stimulus (surgical skin incision) in 50% of patients
|
|
Factors that reduce the number of MAC the patient will require
|
Most things that slow your brain down or make patients have altered LOC
Age extremes •Hypothermia •Metabolic acidosis •Hypoxemia •Hypotension •Preoperative Medications •IV anesthetics •Alpha-2 agonists, Lithium, Opioids •Cardiopulmonary bypass •MAP <40 mmHg •PaO2 <38 mmHg •Hypothyroidism •Pregnancy – Postpartum (<72 hours) •Acute ethanol consumption |
|
Factors that increase the number of MACs the patient will require
|
Pretty much anything very stimulating
•Hyperthermia •Hypernatremia •Chronic alcohol consumption •Infants •Drugs that increase CNS catecholamines (MAOI, tricyclic antidepressants, cocaine, acute amphetamine ingestion) |
|
MAC
|
Minimum alveolar concentration (partial pressure) of an inhaled anesthetic at 1 atmosphere that prevents skeletal muscle movement in response to a noxious stimulus (surgical skin incision) in 50% of patients
|
|
Factors that have no effect on the MAC that the patient will require
|
•Duration of anesthesia
•Gender •Hypo or hypercarbia •Hypertension •Anesthetic metabolism •Thyroid gland dysfunction •Hypo or hyperkalemia •PaO2 >38mmHg •Spinal cord transection/removal of forebrain in animals |
|
The Myer-Overton Theory (or Critical Volume Hypothesis)
|
Anesthesia occurs when a critical volume of anesthetic molecules dissolve in crucial lipid soluble (hydrophobic) sites such as cell membranes, resulting in external pressure on ion channels necessary for sodium movement across membranes
|
|
Factors that reduce the number of MAC the patient will require
|
•Increase in age- Most things that slow your brain down or make patients have altered LOC
•Hypothermia •Metabolic acidosis •Hypoxemia •Hypotension •Preoperative Medications •IV anesthetics •Neonates •Alpha-2 agonists, Lithium, Opioids •Cardiopulmonary bypass •MAP <40 mmHg •PaO2 <38 mmHg •Hypothyroidism •Pregnancy – Postpartum (<72 hours) •Acute ethanol consumption |
|
Factors that increase the number of MACs the patient will require
|
Pretty much anything very stimulating
•Hyperthermia •Hypernatremia •Chronic alcohol consumption •Infants •Drugs that increase CNS catecholamines (MAOI, tricyclic antidepressants, cocaine, acute amphetamine ingestion) |
|
Factors that have no effect on the MAC that the patient will require
|
•Duration of anesthesia
•Gender •Hypo or hypercarbia •Hypertension •Anesthetic metabolism •Thyroid gland dysfunction •Hypo or hyperkalemia •PaO2 >38mmHg •Spinal cord transection/removal of forebrain in animals |
|
The Myer-Overton Theory (or Critical Volume Hypothesis)
|
Anesthesia occurs when a critical volume of anesthetic molecules dissolve in crucial lipid soluble (hydrophobic) sites such as cell membranes, resulting in external pressure on ion channels necessary for sodium movement across membranes
|
|
Which is more potent, a lipid soluble inhaled anesthetic, or a water soluble anesthetic?
|
Lipid- high degree of correlation between inhaled anesthetic potency and lipid solubility (part of Myer-Overton Theory)
|
|
What three molecular mechanisms are believed to be responsible for the action of general anesthetics?
|
•Bind directly to proteins
•Selectively target synaptic ion channels or the systems that regulate them •Enhance the response evoked by GABA |
|
What effect do inhaled anesthetics have on respiratory patterns?
|
Breathing will be rapid, shallow, regular, and rhythmic
|
|
Do inhaled anesthetics increase or decrease respiratory rate? What effect do they have on Tidal Volume?
|
Increase rate (dose dependent), decrease Tidal Volume
|
|
What effect do inhaled anesthetics have on PaCO2? What other factor influences this intraoperatively?
|
Increase PaCO2; surgical stimulation also influences this
|
|
Inhaled anesthetics cause a _________ to the effects of increased CO2?
|
Decreased response; increased CO2 level does not make anesthetized patients increase their rate or depth of breathing
|
|
Anesthetic concentrations of _______ will completely eliminate the regular respiratory response to _______.
|
1 MAC, eliminate normal response to hypoxemia
|
|
sub anesthetic concentrations of inhaled anesthetics (less than 1 MAC) have what impact on the normal response to hypoxemia?
|
Decreased, but not obliterated response to hypoxemia
|
|
How long might the decreased ventilatory response to hypoxemia caused by inhaled anesthetics last?
|
Well into their time in the PACU
|
|
What effect to inhaled anesthetics have on bronchial smooth muscle?
|
Relaxes, causing Bronchodilation
|
|
What two anesthetic agents are known to be more airway irritating?
|
Forane and desflurane
|
|
What are the inhaled anesthetic drugs held to be the standard for being non airway irritating?
|
Sevoflurane, halothane, and N2O
|
|
Under the effects of inhaled anesthetics, is the pulmonary vasoconstriction response to hypoxemia preserved?
|
Yes, pulmonary arterioles will still vasoconstrict in response to hypoxemia
|
|
What effect do inhaled anesthetics have on blood pressure?
What can attenuate this response? |
Decreased blood pressure; surgical stimulation and addition of N2O decrease this response
|
|
Why do inhaled anesthetics cause a decrease in blood pressure?
|
Decreased SVR
|
|
Normally a decrease in BP will stimulate _________ resulting in an increase in heart rate.
|
Carotid sinus baroreceptors
|
|
What effect does Sevoflorane have on heart rate?
|
No effect
|
|
N2O results in a _____ in heart rate
|
Mild increase
|
|
At levels less than 1 MAC, what effect does desflurane have on HR?
|
No effect
|
|
At levels greater than 1 MAC, what effect does desflurane have on HR?
|
Increases
|
|
In response to a decrease in blood pressure, Halothane _____
|
Blocks the normal carotid sinus baroreceptor response that increases HR- i.e. HR not responsive to hypotension
|
|
With sevoflurane, does the heart rate increase in response to hypotension? With N2O?
|
No,
N20 causes minimal increase |
|
What effect does decreasing blood pressure have on heart rate when using desflurane?
|
No effect at concentrations less than 1 MAC, Heart rate increases at greater MAC concentrations
|
|
What effect does decreased blood pressure have on heart rate when using isoflorane?
|
Increases 20%
|
|
Halothane causes a dose dependent _____ in cardiac output
|
Decrease
|
|
Desflurane and Isoflurane have ______ effect on cardiac output
|
No effect
|
|
What inhaled anesthetic will support cardiac index the best?
|
Desflurane
|
|
What effect does N20 have on cardiac output? What effect does it have on stroke volume?
|
Increases it slightly, no effect on stroke volume
|
|
Agents other than N20 cause a_______ on stroke volume
|
Dose dependent decrease in stroke volume
|
|
Considering the decrease in stroke volume, does using isoflurane or desflurane result in decreased cardiac output?
|
No; increase in heart rate compensates for decrease in stroke volume, and CO is unchanged
|
|
Is a direct decrease in myocardial contractility with inhaled anesthetics seen in practice?
|
No, not consistently seen in reality, although it is theoretically possible
|
|
What inhaled agent has the least effect on myocardial contractility?
|
N20
|
|
Right Atrial Pressure _____ in a dose dependent manner when using inhaled anesthetics
|
Increases- d/t myocardial depression
|
|
The increase in R. Atrial Pressure d/t myocardial depression is _____ by any peripheral dilating effect caused by inhaled agents
|
attenuated/offeset
|
|
_____ and ____ (agents) cause a decrease in SVR
|
Isoflurane and Desflurane
|
|
Halothane and N20 have ___ effect on SVR
|
No effect
|
|
Addition of N20 to ___ and ____ results in less decrease in ___
|
Isoflurane and Desflurane results in less reduction in SVR
|
|
______ selectively dilates coronary arteries in animal studies
|
Isoflurane
|
|
Coronary Steal Syndrome:
What is it, and what agent is thought to cause it? |
Coronary dilation causes a decrease in blood flow through narrowed coronary arteries (which are attempt to compensate by always being maximally dilated); could possibly be caused by Isoflurane (this could result in ischemia, although autoregulation seems to compensate)
|
|
Anesthetics sensitize the myocardium to the effects of ____
|
Epi (use less epi than in ICU setting)
|
|
______ rhythm is common during administration of inhaled anesthetics
|
Junctional rhythm
|
|
Which agent causes the least effect on cardiac rhythm?
|
Sevoflurane (Halothane causes most, followed by ethrane, isoflurane, desflurane, and finally sevoflurane)
|
|
You should not administer N20 to a patient with this type of pulmonary blood flow
|
Pulmonary hypertension- N20 increases Pulmonary vascular resistance and can worsen pulmonary HTN
|
|
________ ventilation favors venous blood return to the heart
|
spontaneous
|
|
Increased duration of anesthetic administration results in _____ depressant effects with which agents
|
less, halothane, ethrane, desflurane
|
|
Patients with ____ will have increased anesthetic induced myocardial depression
|
CHF
|
|
_____ and _____ will produce myocardial depression
|
CAD and N20
|
|
_______ will exaggerate the magnitude of circulatory effects produced by inhaled anesthetics
|
Altered SNS/prior drug therapy (for example beta blockers, other blood pressure medications)
|
|
Surgical stimulation causes _____
|
SNS activation
|
|
What is a potential side effect caused by Halothane? Why did it have this effect?
|
Halothane Hepatitis; halothane metabolized by liver, thought to be autoimmune caused by circulating IGG antibodies
|
|
Isoflurane, desflurane, and enflurane may cause
|
Hepatotoxic metabolites in susceptible individuals (such as those with previous exposure to halothane)
|
|
Methoxyflurane and ____ could cause_____ if metabolism leads to a serum fluoride level greater than 50 mcmol/L
|
Sevoflurane, Fluoride induced nephrotoxicity- leads to inability to concentrate urine
|
|
Is there any evidence that anesthetic administration during pregnancy is teratogenic?
|
No evidence for most agents, avoid N2O d/t concerns of teratogenicity
|
|
Pbr =
|
partial pressure of inhaled agent in brain = input (into alveoli) - uptake (lost into arterial blood)
|
|
Input (of agent into alveoli) is dependent on what 3 factors?
|
•Inspired partial pressure of the anesthetic (PI)
•Alveolar ventilation (VA) •Characteristics of the anesthetic breathing system |
|
Uptake from alveoli into blood is dependent on:
|
•Solubility of the agent
•Cardiac output •Alveolar to venous partial pressure difference (A-vD) |
|
Does metabolism or percutaneous loss impact PA of inhaled anesthetics?
|
No
|
|
Second Gas Effect:
Is this impacted by concentration effect? |
The ability of the large volume uptake of one gas (first gas) to accelerate the rate of rise of the PA of a concurrently administered companion gas (second gas); independent of concentration effect (probably not clinically significant)
|
|
What effect does increased alveolar ventilation have on input of inhaled agents?
|
Increased alveolar ventilation increases input of agents; increases PA of inhaled agents and promotes more rapid induction of anesthesia (hypoventilation has opposite effect)
|
|
What effect does hyperventilation have on input of anesthetics?
|
Increases input, but decreases cerebral bloodflow and therefore offsets effect by decreasing delivery to brain
|
|
Partition Coefficient
|
Solubility; Distribution ratio describing how the inhaled anesthetic distributes itself between two phases at equilibrium
|
|
What factor affects partition coefficient?
|
Temperature dependent
|
|
High blood solubility (blood partition coeffient) means that a _____ amount of agent needs to be dissolved in blood before equilibrium is reached (works _____)
|
Large, slowly
|
|
Drugs with a high blood solubility take a ______ time for patient to go to sleep and wake up
|
Long
|
|
Low blood solubility means that ____amount needs to be dissolved in blood before equilibrium is reached (works _____)
|
small, fast
|
|
Drugs with a _____ blood gas partition coefficient will take less time for the anesthetic concentration in the brain to reach the concentration of anesthetic in the alveoli
|
Low
|
|
maintaining the pressure in the alveoli for volatile anesthetics constant for about ______ will assure an equal concentration in the brain
|
15 minutes (predicted by tissue blood coefficients)
|
|
N20 has a lower blood gas partition coefficient than Nitrogen. Therefore, N20 can _____ air filled spaces faster than Nitrogen can leave, resulting in an increased ____ or ____ in air filled cavities
|
Enter, causing increase in volume or pressure
|
|
The magnitude of volume or pressure increase is influenced by the _____, ______, and the ____ of nitrous oxide administration
|
Alveolar pressure of N20, blood flow to air filled space, and duration of N20 administration
|
|
Cardiac output influences _____. Therefore, patients with high cardiac output will go to sleep ____than patients with low cardiac output
|
Slower
|
|
A right-to-left intracardiac or intrapulmonary shunt _____ the rate of induction of anesthesia. Why?
|
Slows; dilutional effect
|
|
Highly perfused tissues _____ with the arterial concentration of the volatile anesthetic
|
equilibrate rapidly
|
|
Skeletal muscle and fat receive less cardiac output than highly perfused organs, and serve as a ______ for volatile agents
|
Inactive reservoir
|
|
What three things are produced in response to stress (such as surgery?)
|
Glucagon, catecholamines, Cortisol
|
|
What is the primary and most important regulatory mechanism of hormone secretion?
|
Feedback mechanisms (others are biorhythms and neural controls, but less important)
|
|
The pituitary gland is enclosed in the _____ and connected by the _______.
|
Sella Turcica, hypophyseal stalk
|
|
Hormones of the anterior pituitary
|
FLAGTOP
Follicle stimulating Luteinizing ACTH Growth hormone thyroid stimulating hormone MelanOcyte stimulating hormone Prolactin |
|
Patients with Acromegaly are at high risk for
|
difficult airway and post-op airway obstruction- consider awake fiberoptic intubation/glidescope
|
|
Posterior pituitary hormones
|
ADH (vasopressin) and oxytocin
|
|
DI is caused by ____ and leads to _____
|
Lack of ADH (damage to pituitary) or kidney not responsive to ADH; leads to excessive diuresis of straight water and hypernatremia
|
|
SIADH is caused by _____ and leads to______. Treated by:
|
Overproduction of ADH, straight water retention, dilutional hyponatremia. Treat with fluid restriction, diuretics, hypertonic saline
|
|
4 functions of the thyroid:
|
1.carbohydrate and lipid metabolism
2. maintain metabolism 3. stimulate oxygen consumption 4.secrete calcitonin |
|
Which is more active, T3 or T4?
|
More T4, but T3 more potent
|
|
Hyperthyroidism: _____ disease
|
Graves disease
(exopthalmos, increased metabolic rate with associated S/S) |
|
Graves disease treatment:
|
radioactive iodine, thyroidectomy, beta blockade (to block extra SNS stimulation)
|
|
NEM tube:
|
monitors if surgeon is too close to recurrent laryngeal nerve
|
|
In a patient with hyperthyroidism, you want to avoid_______
|
Ketamine (SNS stimulant)
|
|
For a hypotensive patient with hyperthyroid, you want to give
|
Direct acting vasoconstrictors
|
|
Close airway assessment of a patient with hyperthyroid may be very important due to
|
Goiters
|
|
Thyroid surgery can result in
|
Recurrent laryngeal nerve damage (vocal cord paresis)- may want to use NIM tube to monitor, or tracheal compression
|
|
Patients may have what airway complications after thyroid surgery?
|
Stridor and laryngospasm
|
|
Differential diagnosis for intraoperative thyroid storm would include:
How would you treat it? |
Malignant hyperthermia (s/s very similar); hyperthermia, tachycardia, dysrhythmias, CHF; give anti-thyroid meeds, fluids, control temperature, control HR (esmolol)
|
|
In hyperparathyroidism, iCa is usually ______
|
very high; want to normalize pre-op with fluids and diuretics
|
|
Hypoventilation should be avoided in patients with hyperparathyroid because_____
|
Hypercarbia can increase calcium level
|
|
Response to NDMR in hyperparathyroidism?
|
Unpredictable (based on calcium levels)
|
|
Aldosterone (mineralocorticoid):
What causes its release |
regulation of extracellular causes potassium excretion and sodium retention; results in increased blood volume and fluid retention
|
|
Adrenal cortex releases:
|
mineralo and corticosteroids (aldosterone and cortisol) and androgens
|
|
Adrenal medulla releases
|
Catecholamines (epi, norepi, dopamine)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Strict aseptic technique is especially important for patients with:
|
Cushing's disease (immunocompromised)
|
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Strict aseptic technique is especially important for patients with:
|
Cushing's disease (immunocompromised)
|
|
Conn's Tumor
|
Primary aldosteronism- causes excess effect (HTN, hypokalemia, fluid retention); give spironolactone,
NDMB can be unpredictable because of hypokalemia |
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
Proper positioning of a patient with Cushing's disease is especially important because:
|
of risk for osteoporosis
|
|
Strict aseptic technique is especially important for patients with:
|
Cushin's disease (immunocompromised)
|
|
Addison's Disease:
|
Adrenal corticoid deficiency (hypovolemia, hyponatremia, hyperkalemia, hypoglycemia, hypotension)
|
|
Any patient who has received steroids for more than 2 weeks out of the last 12 months should receive
|
Stress dose steroids (Addisonian crisis can result if not given)
|
|
How would you treat Addisonian crisis?
|
Rapid administration or D5NS
Hydrocortisone bolus Hydrocortisone q6 |
|
Pheochromacytoma
|
Catecholamine secreting tumor
|
|
Pheochomocytomoa: order of adrenergic blocking
|
Block alpha before beta adrenergics (otherwise, can increase BP even further)
|
|
After ligation of vasculature feeding pheo, blood pressure:
|
Falls rapidly (due to down regulation of adrenergic receptors), and not likely to normalize for 10 days
|
|
Patients with DM are at increased risk for:
|
Undiagnosed cardiac issues
Also may have TMJ, gastroparesis (at risk for aspiration) |
|
Sulfonylureas: what do they do?
|
Decrease insulin resistance and increase release from the pancreas for 8-24 hours
|
|
Sulfonylureas should be _____ on the day of surgery
|
Held
|
|
Diabetic autonomic neuropathy puts patients at increased risk for:
|
(silent) MI, ischemia, labile BP, cardiomyopathy
|
|
What is a reliable indicator for autonomic neurophathy in diabetic patients?
|
Orthostatic hypotension
|
|
Diabetics are more likely to have a _____ allergy
|
Protamine (d/t long term exposure to NPH insulin)
|
|
Management goal for blood sugars intraoperatively is
|
below 180
|
|
Why are patients prone to hyperglycemia intraoperavtiely?
|
Decreased insulin release, increased catecholamines, increased cortisol. glucagon, and growth hormone
|
|
S/S of diabetic autonomic neuropathy:
|
early satiety, impotence, night time diarrhea, peripheral neuropathy, loss of beat to beat variability in HR, orthostatic hypotension, unexplained tachycardia
|
|
Myocardial O2 demand is most significantly affected by:
|
Heart rate
|
|
What types of surgery put patients at highest risk of cardiac event?
|
Major abdominal, thoracic, and emergency surgeries
|
|
Blood pressure should be maintained within _____ of baseline values?
|
20%
|
|
What is one treatment goal for patients with cardiac disease during induction?
|
Blunt the sympathetic response to DL (narcotics, LTA, IV lidocaine, esmolol)
|
|
What is a good combination for cardiac anesthesia?
|
Opioid and Nitrous
|
|
What anesthetic technique should be avoided with critical aortic stenosis?
|
regional anesthesia
|
|
What NDMB might cause increased HR and BP?
|
Pavulon
|
|
Risk of re-infarction after MI remains for ____ months and is highest for the first ____ months
|
6 months; highest risk for first 3 months
|
|
Patients with drug eluting stents must not stop plavix for the first ____, and elective surgeries should be delayed
|
12 months
|
|
Patients with bare metal stents should not have elective surgery in the first____ after placement
|
6 weeks
|
|
Cystoscopy is performed in what position? What impact does this have on your FRC?
|
Lithotomy, decreases FRC
|
|
TURP (transurethral resection of prostate): why is so much fluid instilled?
|
To provide visualization through cystoscope
|
|
If you have a perforation of your bladder or urethra during a TURP procedure, where would pain be referred to?
|
Shoulder
|
|
What are the risks of TURP procedure?
|
◦Intravascular absorption of irrigating fluid.
◦Hemorrhage ◦Perforation of bladder or urethra. |
|
Why does a patient absorb irrigation fluid in a TURP procedure?
|
Opening of venous sinuses allows entry into the vascular system
|
|
The amount of fluid absorbed during a TURP procedure is dependent on:
|
◦ Height of irrigating fluid
◦Number and size of venous sinuses opened. ◦Duration of resection |
|
What fluids are used for irrigation in a TURP procedure?
|
Glycine and Cytal
|
|
Why is it important to monitor the instilled versus drained irrigation fluid in a TURP procedure?
|
dilutional hyponatremia can result; if patient is awake (regional), monitor LOC closely (headache, loopy,
|
|
Glycine toxicity in a TURP procedure causes:
|
Glycine is broken down to ammonia, which can act as a CNS depressant; glycine is also a neurotransmitter in the retina, so glycine toxicity can also lead to transient blindness
|
|
An early sign that you might be getting into trouble during a TURP (except LOC changes)
|
Hypertension and reflex bradycardia
|
|
Resection time for a TURP should be limited to
|
1 hour
|
|
Fluid can be absorbed during a TURP at a rate of
|
20ml/min
|
|
What is one consideration regarding airway issues during robotic prostatectomy?
|
Extreme trendeleberg- can cause ETT migration (high or out) so make sure taped super securely; can cause difficulty ventilating
|
|
Extreme head down positioning can cause:
|
initial increase in cardiac output followed by decreased cardiac output, edema to head, face, and airway (laryngeal edema, post-op stridor) risk of pneumothorax, carbon dioxide embolism (from insufflation),
|
|
co2 insufflation in the peritoneum may result in:
|
hypercaria, acidosis if not compensated for by respiratory system, hypertension (from SNS stimulation and Aldosterone release); increased intraabdominal pressure
|
|
In mitral stenosis, you want the heart rate to be ____, SVR to be ____, preload _____, and contractility ______
|
low HR, SVR maintained, preload maintained to slightly increased, contractility maintained
|
|
Mitral regurg- memory aid
|
Fast, full, and forward
|
|
What vasopresor might you want to use in a patient with mitral regurg and hypotension
|
Ephedrine is better choice than phenylephrine because it increases HR
|
|
In Aortic stenosis, the stroke volume is _____
|
fixed
|
|
Heart rate in aortic stenosis should be _____, preload should be ____, and after load should be_____
|
Heart rate low (70-80), preload and after load maintained or increased, and contractility maintained
(Neo is good vasopressor in this disease) |
|
Aortic Regurg:
|
Fast, full, and forward (HR 80-100, increase preload, decrease after load)
|
|
With hypertrophic cardiomyopathy, what would be the best agent to use in the case of vasodilation?
|
Phenylephrine (pure alpha 1 agonist)
|
|
Would you do a spinal in a patient with hypertrophic cardiomyopathy?
|
No, d/t too much change in preload and after load
|
|
Patients with artificial valves, shunts, or a history of endocarditis should receive _______
|
prophylactic antibiotics for any procedure where bleeding is anticipated
|
|
Where should the bovie ground pad be placed on a patient with an AICD?
|
As far from the AICD as possible
|
|
AICD should be _____ prior to surgery because
|
turned off, d/t potential interference from bovie
|
|
Placing a magnet over the AICD
|
Disables the ICD, and paces at a set rate; resumes to normal when magnet removed
|