Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
74 Cards in this Set
- Front
- Back
|
Blood Groups (ABO & RH most important)
|
ABO (3 Alleles) - A, B, AB and O – Each represents an antigen on the red cells
(type O most common 45% Caucasian 49% African American) RH – Presence or absence of Antigen D 80-85% of the population is RH positive (+D Antigen) 15-20% of the population is RH negative |
|
|
ABO/Rh test
|
most severe reactions are ABO incompatibility
-Test - pts RBC are tested with A&B antibodies which determines blood type |
|
|
Antibody screen
|
detects antibodies associated with non-ABO reaction
-Test - known as indirect Coombs (takes 45mins) |
|
|
Crossmatch
|
mimics transfusion (takes 45mins);
-Three functions of crossmatch: confirms ABO/Rh, detects antibodies to otherblood groups, detects antibodies in low titers |
|
|
In what amount of time do you have to give a blood transfusion?
|
4 hours
|
|
|
1 unit of whole blood is how many mls?
|
450-500ml Used for acute rapid bleed.
|
|
|
1 unit centrifuged WB or PRBC has how many mls and what % HCT?
|
250ml
70% HCT increases Hg 1g/dl or HCT by 2-3% |
|
|
How many cc's are in 1 unit of PLTs?
|
50-70cc
|
|
|
What is Whole Blood, PRBCs, Platelets, and FFP used for?
|
Whole Blood - For acute blood loss (has plasma which gives more volume)
PRBC - For slow blood loss, good for RBC repletion-not volume * Add NSS added for volume & decrease viscosity * LR not used due to Ca (may cause clotting) * 170 micron filter for clots/debris Should warm before infusing ~each unit has Hct of 70-80% ~each unit increases Hgb 1gm/dl & Hct 2-3% FFP - Contains all plasma proteins and all clotting factors, each unit will increase clotting factor by 2-3% * Rapid Freeze protects Factor V & VIII Slow thaw yeilds cryoprecipitate (contains von Willebrand factor and high in factors VIII & fibrinogen) ~indicated for fibrinogen levels <50-60mg/dl or active bleeding ~10 units should increase figrinogen level to >100mg/dl Platelets - For Plt count below 10-20,000 (increased risk of spontaneous bleed) *Counts below 50,000 a/w increased risk of bleeding during surgery) ~should get Plt count >100,000 ~each unit will increase platelet count 5,000-10,000 |
|
|
Name a synthetic starch and its advantages and disadvantages.
|
Hespan (Hetastarch) is an intravascular expander
*Drawback is increased bleeding ~should only give up to 20ml/kg max |
|
|
Name 4 types of Blood transfusion reactions
|
1. Hemolytic
2. Non Hemolytic 3. Anaphylatic 4. Non Cardiogenic Pulmonary Edema |
|
|
Hemolytic Reaction – Destruction of RBC by patient’s antibodies
Explain the reactions and treatment |
a. Acute (Intravascular)
Secondary to ABO incompatibility Reaction is often severe Accounts for 50% of deaths r/t transfusion (fatal 1:100,000) If <5% total blood volume given then its less severe Caused usually from misidentification of patient, specimen or unit of blood -S/S: Awake - chills, nausea, chest pain, flank pain Under Anesthesia – fever, tachycardia, hypotension, hemogloginuria, oozing, DIC, shock, renal failure -Treatment: STOP transfusion, give O2, recheck unit, blood specimen from patient for test , IV fluids, foley/Lasix/renal Dopamine, may need Plts and FFP * maintain U/O of 100cc/hr b. Delayed (Extravascular) Usually mild from antibodies It takes weeks to months to form antibodies (usually 21days after transfusion) Most commonly occurs in 4-8 days Re-exposure to same antigen Reaction occurs in 1:5,000 transfusions -S/S: malaise, jaundice, fever, decreasing Hct r/t extra-vascular destruction of transfused RBC -Diagnosis: direct Coombs test (detects the antibodies on red cell membranes) -Treatment: monitor |
|
|
Nonhemolytic - (1-3% or approximately 1:8 Transfusion)
Explain the reactions and treatment |
a. Febrile - Most common mild transfusion rxn (1-3% of transfusions); defined as increase in temp >1 degree C, usually from white cell or platelet sensitization
\-Treatment: 20-40 micron filter traps the white cells b. Uticarial – (Hives, itching) Vascular reaction of the skin marked by slightly elevated patches of redder and paler skin – (1% of transfusions), may be a/w laryngeal edema or bronchospasm -Treatment – Benadryl 50-100mg |
|
|
Anaphylactic
Explain the reactions and treatment |
Respiratory, cardio instability (hypotension, tachycardia, arrthymias), LOC, shock and death; RARE and only need a few ml of bld
-Treatment – Benadryl 50- 100mg, Epinephrine (0.1-0.5ml of 1:1000) SQ, fluids, steroids and Aminophylline 125-250mg IV slowly over 5 mins |
|
|
Non-cardiogenic pulmonary edema
|
1. ARDS - (RARE; < 1:10,000) antileukocyte antibodies in the transfusion reacts with pt.’s WBC which causes clumping in the pulmonary circulation damaging alveolar capillaries (10% mortality)
-Treatment – possibly ETT, High FiO2, PEEP or CPAP – Usually resolves in 72 Hours 2. Transfusion-related acute lung injury (TRALI) - form of noncardiac pulmonary edema, occurs w/i 2-6 hrs of transfusion (whole blood, PRBCs, FFP), total # of deaths r/t blood transfusions ’05’-’09’ in the US was 267, TRALI was 47% of all transf related deaths (6-10% morality) -S/S - dyspnea, hypoxia, hypotension, fever, b/l pulm edema, tachycardia, absence of circulatory overload (no neck vein distension, normal CVP, normal heart sounds) -Treatment - O2, mechanical ventilation, fluid support - 80% cases resolve w/i 96 hrs |
|
|
Bacterial related transfusion complications
Explain reaction and treatment |
Bacterial - may enter blood during collection or processing and can multiply during storage (staphy & citrobacter)
-S/S: hypotension, shock, fever, chills, N/V and respiratory disease -Treatment: Stop Transfusion, support CV, blood cultures, broad spectrum abx (why have to give bld in under 4 hrs) |
|
|
Graft vs. Host Disease (GVHD
Explain reaction and treatment |
T lymphocytes in bld component is transfused and reacts with recipient’s tissues
-rare but poor prognosis w/ mortality rate of 90%; recipient unable to reject the donor lymphocytes because of immunodeficiency or severe immunosuppression -a/w bone marrow transplants -can prevent by irradiating the transfusion to inactivate the lymphocytes |
|
|
Post-transfusion Purpura (PTP)
Explain reaction and treatment |
-pt. develops an alloantibody in response to platelet antigens in the transfused blood which then causes destruction of pt.’s platelets
-thrombocytopenia w/i 7-48 days after transfusion (usually) 7 days -platelet transfusion is of little help (only used if actively bleeding) Treatment -need plasmapheresis |
|
|
Problems a/w massive blood transfusion (MBT)-
|
MBT=1-2x patients BV or 10-20 units
Coagulopathy - most common cause of bleeding post MBT r/t dilution thrombocytopenia- may not occur w/ use of PRBC -FFP (after 12 units), Platelets (after 20 units) - clotting factors decreased from MBT -use of PRBC’s - fibrinogen factors decrease significantly compared to whole blood Citrate Toxicity - Ca binding in pt. from citrate in transfused blood - usually only if 1 unit q5mins or 150ml/min - S/S: decreased Ca, hypotension, increased CVP, prolonged QT, decreased Mg, decreased CO Hypothermia - core temp of 32-34 decrees C - increases morbidity and mortality - causes peripheral vasoconstriction, metabolic acidosis and impaired Hgb/O2 delivery - effects wound healing negatively - increases risk for bleeding - decreases CO, causes arrhythmias, and impaired coagulation (every 1 degree drop will DECREASE clotting factors by 10%) |
|
|
Problems with stored blood -
|
- Citrate phosphate dextrose adenine (CPDA-1) is and anticoag preservative where blood is stored at 1-6 degrees C
- citrate - anticoagulant; phosphate - buffer; dextrose - red cell energy source; adenine - allows RBCs to resynthesize ATP which extends shelf life from 21 to 35 days - can extend shelf life to 42 days if AS-1 (Adsol) is added (where 85% of RBCs are collected) Acid Base Imbalances - stored blood acidic due to citric acid anticoag - most common abnormality is metabolic alkalosis - usual K concentration <4mEq/unit, but concentration in stored blood increases with time - Treatment: Ca for cardiac symptoms |
|
|
Transfusion Associated Circulatory Overload (TACO)
Explain complication and treatment. |
increase in volume in circulation leading to pulmonary edema and decreased FRC
- S/S: increased CVP, tachycardia, SOB, hypertension Treatment: O2, support ventilation, diuretics |
|
|
Auto Transfusion
|
- 4-5 weeks prior to procedure Hgb must be >11 or the Hct > 34%
- 72 Hours between donations - Fe supplement & EPO therapy - Decreased chance of infection or reaction |
|
|
Blood Salvage
|
Blood aspirated intra-operatively with heparin added to reservoir (Cell Saver)
Need to remove1000ml, given back as RBC with a Hct of 50-60% (plasma factors washed out) *Contra-indications – contaminated wound, infection, Sickle cell disease, malignant tumor |
|
|
Normovolemic Hemodilution
|
- Decreased concentration of RBC
- will have decreased RBC loss with large amounts of blood loss during surgical procedure – Keep Hct 21-25% Technique – blood taken from patient and replaced with crystalloid or colloid - blood kept at room temperature, good for 6 hours - usually replaced after surgery |
|
|
Donor Directed
|
Family and friends donate (Need 3 days)
|
|
|
Pharmacologic Therapy-Blood related
|
Antifibrinolytics - Aminocaporic acid
- Desmopressin – for platelet dysfunction but adequate count – Increases Von Willebrand’s factor and factor 8 IV peak effect- 15-30 mins |
|
|
Name ways anesthesia can help reduce blood loss.
|
Maintain normothermia
Controlled hypotension Maintain adequate fluid volume |
|
|
Name some blood substitutes.
|
Perflurochemicals (PFC’s) - Hg based O2 carriers used when blood is unavailable (trauma & rural areas)
Fluosol-DA - Can only carry O2 if PaO2 is >300mmHg * Have solubility for O2 thats 20x that for water * Can serve as a bridge until blood is available * No T&C needed, short 1/2 life (12hrs), expensive, only used in a single low dose, 2 yr shelf - Uses: Shock, blood conservation, organ ischemia, RBC incompatibility, Sickle cell disease, blood conservation and Jehovah’s Witness - S/E: HTN, increased SVR, decreased CO, nephrotoxicity and histamine release |
|
|
Non Invasive blood pressure cuff.
|
Introduced in Italy by Riva Rocci in 1896, Cushing introduce it in the USA, Kortokopy auscultory method 1904
a. Sources of ERROR - Inappropriate cuff size and rapid deflation *Too Narrow of a cuff – False High *Too Wide of a cuff – False Low b. Correct size - Width 20-50% greater than limb diameter - 2/3 of the upper arm should be covered c. Deflation Rate- 3-5 mmHg/sec d. T-line is a non-invasive A-line (bulky, expensive) |
|
|
Automated Blood pressure cuffs
|
- Based on the principle of oscillometry
- Automated – Inflation/Deflation - Measures Systolic & Diastolic pressure - Avoid cycle times of < 2 minutes (Blood refill is insufficient) |
|
|
Invasive BP A-line
|
A-line; intravascular (Catheter) space to external transducer
* Tubing is rigid (length less then 4 feet), minimize stop cocks, flush 1.5ml/sec (faster can cause spasm or aneurysm), pressure bag at 300mmHg w/ continuous flush of 3-5ml/hour, zero at Right Atrium (Phlebostatic Axis) a. A-line indications - Critically ill, multiple lab testing, cardiac disease, controlled hypotension, major surgery |
|
|
What is the Allen's test?
|
- Test for collateral flow via the ulnar arch to make sure there is no radial artery thrombosis or occlusion
- Procedure: Apply pressure to both radial and ulnar arteries at the wrist while the patient makes a fist, have the patient open palm, release pressure over the ulnar, if patent the palm should flush (redden) in 3-6 seconds (Slow filling=7-15sec; Incomplete=>15sec) |
|
|
What is the A-line insertion technique?
|
c. Insertion
- Equipment: 20G Angio, armboard, iodine/ETOH wipe, 4x4 tegaderm, 1% Lido plain w/ TB syringe, gloves, glasses, transducer setup - Technique: dorsiflex under the wrist with a roll, palpate radial artery, iodine, inject local, glove(sterile), insert catheter at 45° angle, advance till flash then change angle to 30° and advance catheter over needle, remove needle, connect to transducer, dress site d. Complications: thrombosis (up to 50%) w/ incidence of ischemic complications <1% * Avoid vigorous flushing due to potential spasm or aneurysm * Alternate sites: femoral, brachial, dorsalis pedis, ulnar |
|
|
Lead Placement
|
V1 - 4th ICS next to right sternal border
V2 - 4th ICS next to left sternal border V3 - directly between V2 and V4 V4 - LMCL, 5th ICS V5 - horizontally level with V4 at anterior-axillary line V6 - horizontally level with V4 at mid-axillary line |
|
|
Which EKG lead is more sensitive to dysrhythmias?
|
Lead II more sensitive to dysrhythmias
|
|
|
Which EKG lead is more sensitive to ischemia?
|
Lead V5 more sensitive to ischemia
|
|
|
Whats the significance of ST elevation and depression?
|
ST depression of 1-2mm is significant for injury (subendocardial -left ventrical)
ST elevation may be ischemia or other (transmural injury) |
|
|
How does pulse oximetry work?
|
Continuous non-invasive monitoring of O2 sat utilizing spectrophotometry and Beers law
Two different wavelengths of light (oxyHgb absorbs more inrared light and deoxyHgb absorbs more red light) |
|
|
What type of light does pulse oximetry use to read O2 saturation?
|
Pulse Oximeter utilizes an LED in a sensor placed over the finger that measures the light reaching the detector, and light at detector changes with pulse
- Oximetry depends on O2; and reduceded Hgb differs on the absorption of red & infrared light * Infrared light 940 nanometers * Visible red light 660 nanometers |
|
|
What is the nanometers on the infrared and red lights of the pulse oximetry?
|
nfrared light 940 nanometers
Visible red light 660 nanometers |
|
|
What are the effects/limitations on the pulse oximetry?
|
abnormal Hgb (MetHgb, CarboxyHgb)
dyes (Indigo Carmine associated with increased BP and Methylene Blue associated with hypotension) I/C=Increase/Climbs; B=Bottom - tournequet, light, bovie, hypothermia and hypotension |
|
|
What is a precordial stethoscope used for?
|
- Weighted stethoscope used for continuous monitoring of heart & breath sounds
Detects: changes in HR, dysrhythmias, increase in airway resistance, failure to ventilate Three sizes: infant, child, adult |
|
|
Temperature Monitoring
What body organ controls temperature? What is the most accurate? |
Intrinsic regulation of hypothalamus fails with GA
Core measurement is best (ear, mid-esphagus probe, blood) *rectal is NOT reliable |
|
|
How do you prevent hypothermia?
|
increase room temp (BEST way),
warm fluids/gases, bair hugger blanket low flow Anesthesia (If gases are on high flow (8L), it can feel like being in front of a fan) |
|
|
What is capnography?
|
Evaluation of CO2 utilizing an electrically visualized wave form that measures and plots the concentration of CO2
|
|
|
What does capnography tell us?
|
Diagnostic for pulmonary, CV and metabolic status
* CO2 is the smoke of cellular metabolism * No CO2 - assume failure of the Ventilator |
|
|
Name two types of capnographs?
|
Mainstream – monitored away from the patient using a computer
Sidestream – measured hanging over the side of the circuit |
|
|
The CO2 waveform shows 5 things. What are they?
|
Height – dependent on ETO2 value
Frequency – depends of RR Rhythm – depends on respiratory center Baseline – should be zero Shape – should be normal |
|
|
What are the phases of the CO2 waveform?
|
Phase I Baseline (zero)
Phase II Expiratory (ETCO2 increases; up-sloap of expiration) Phase III Plateau Phase IV Inspiratory (CO2 being withdrawn) |
|
|
What are some problems with capnography?
|
1. Failure to maintain clinical skills
2. Misinterpret wave form 3. Correct ETCO2 4. Type of monitor |
|
|
Name some of the various inhalation monitors and some of there characteristics.
|
1. Smart monitors
- identify the gas automatically - less smart require input labeling of appropriate gas 2. Agent Monitor continuous measurement of inhalation agent select agent gives read out for Inspiratory & Expiratory 3. Mass Spectometry - continuous measurement of inhalation agent for all gases (O2, CO2, N2O, N, Inhalation agents) - obtain sample via side port (to interface with central unit) - samples (via side port) are ionized by electron beam (spinning wheel) -concentration determined (molecules) - can sample up to 32 Locations (not at once; throughout OR’s) - lag time (r/t multiple OR’s), but can do a STAT if needed *break down: O2 (21%) & N2O (79%) and pre-oxygenation is done to de-nitrogenize |
|
|
What is a spirometer? What does it measure?
|
A manual or electric meter located on the expiratory limb of the circuit (ex. PEEP)
- Gives TV to calculate MV *MV (TV x RR) |
|
|
What is a BIS?
|
A practical EEG that measures the direct effects of anesthetics on the brain
- Enables you to deliver a more precise anesthetic - Improves patient care - Has a 15-30 second lag time Its a brain monitor. |
|
|
What are the index ranges for the BIS monitoring?
|
Index Range
80-100 Awake Responds to normal voice 60-80 Moderate Sedation Responds to loud commands or mild prodding 40-60 General Anesthesia Low probability of explicit recall 20-40 Deep Anesthesia Deep Hypnotic 0-20 Flat Line Burst Suppression |
|
|
What do you monitor neuromuscular junctions?
|
Nerve Stimulator
- Adductor polices muscle of thumb (toward the palm) is innervated solely by ulnar nerve and is the preferred site r/t find out peripherally that all twitches are back |
|
|
Where can you place the nerve stimulators?
|
Top
Temporal Two Zygomatic Zebras Buccal Bit Mandibular My Bottom Cholear C... |
|
|
What characteristics does a phase 1 block have when using a nerve stimulator?
|
1. Decrease twitch height
2. Absence of fade w/ tetanus 3. Decrease of all twitches in TOF 4. post tetanic potentiation absent 5. Fasiculations present |
|
|
What characteristics does a phase 2 block have when using a nerve stimulator?
|
1. Decrease twitch height
2. Fade with tetanus present 3. Fade with TOF 4. Post tetanic potentiation present 5. Absence of fasiculations |
|
|
How do you augment and antagonize a phase 1 block?
|
*Antagonized by NDMR
* Augmented by Cholinesterase inhibitors, cirrhosis, pregnancy, infants, atypical enzyme |
|
|
How do you augment and antagonize a phase 2 block?
|
* Antagonized by Cholinesterase inhibitors
* Augmented by NDMR |
|
|
Name the % of the TOF Blocks.
|
0/4 - 95% blocked
1/4 - 90% blocked 2/4 - 80% blocked 3/4 - 75% blocked 4/4 - 70-75% blocked |
|
|
Recovery from NDMR- What are the percentages in relation to recovery?
|
1. TOF 4/4: still <75% blocked
2. TV: still 80% blocked 3. VC >12cc/kg: still 75-80% blocked (vital capacity) 4. Tetanic 100 Hz: still 50% blocked 5. Negative Inspiratory Force (NIF) -20 to -50: still 50% blocked (remove reservoir bag, hold over opening, then check the pressure gauge; not done often r/t can cause negative pressure pulmonary edema) 6. Head lift 5 sec: still 33% blocked |
|
|
What does a EEG monitor do?
|
Monitors cerebral function to detect ischemia (during a CEA or cardiopulmonary bypass)
|
|
|
What is a EEG influenced by?
|
influenced by inhalation agents, IV drugs, temperature, and blood pressure;
|
|
|
What suggest injury on a EEG?
|
A change in pattern lasting up to 10 mins suggests injury.
|
|
|
What are EVOKED POTENTIALS?
|
The electrophysiologic responses of the Nervous System to SENSORY stimulation (Somatic, auditory & visual) that evaluates intactness of neuronal pathways during anesthesia
|
|
|
What is the definition of latency in Evoked Potentials?
|
Time between the stimulus and detection
|
|
|
What is the definition of amplitude in Evoked Potentials?
|
The intensity of response
|
|
|
What are somatasensory evoked potentials and what surgeries are they used for?
|
Somatosensory Evoked Potentials (Ascending pathways)
- SEP is produced by the application of small electrical currents that stimulate a peripheral nerve, such as the median nerve at the wrist or posterior tibial nerve at the ankle. This EP reflects the intactness or interruption of the neural pathway from the peripheral nerve through the spinal cord to the brain * SEP good for placement of Harrington rods, AAA, spinal cord tumors, cerebral/thoracic aneurysm, cervical laminectomy and carotids - Latency (time): Increase >10% from baseline indicates ischemia - Amplitude (intensity): Decrease >50% indicative of ischemia |
|
|
How long can the spinal cord tolerate ischemia?
|
* The spinal cord can tolerate ischemia for up to 20 minutes
|
|
|
What are Visual Evoked potentials and what surgery are they used on?
|
Visual Evoked Potentials (Ascending pathways)
- Flashing Lights (Goggles) measures the integrity of the optic nerve pathway * VEP good for Pituitary Tumor resection |
|
|
What are Auditory Evoked potentials and what surgery are they used on?
|
Auditory Evoked Potentials (Ascending pathways)
- Checking 8th cranial nerve via clicks/tones w/ a transducer * AEP good for Acoustic Neuromas |
|
|
What are Motor Evoked potentials and what surgery are they used on?
|
Motor Evoked Potentials (Descending pathways)
MEP can be produced by direct (Epidural) or indirect (Transoseous) stimulation of the brain or spinal cord. Stimulation of the motor cortex elicits peripheral nerve signals. MUST use N2O & Diprivan drip * Do not use Inhalation agents OR Muscle Relaxants with MEP |
|
|
What are the different effects of inhalation agents, hypothermia, and hypotension on Evoked Potentials? What is the treatment?
|
Inhalation agents > 0.5 MAC and N2O will adversely affect EP
*need TIVA, start Propofol at 200mcg/kg Hypothermia increases latency and decreases amplitude *1º C will increase latency by 1m second Hypotension Mean Arterial Pressure < 40mmHg decreases amplitude - Treatment - Increase BP, correct anemia, correct hypovolemia, increase O2 tension, ask surgeon to decrease retractor Rod pressure (remove/reposition) |
