Principles I, Exam 2

Front 1

The CO2 waveform is helpful in 3 ways...

Back 1

1) determining that the patient is in fact being ventilated, 2) as an estimate of PaCO2, and 3) as an evaluation of dead space.

Front 2

The CO2 waveform itself is characterized by four phases:

Back 2

1) an inspiratory baseline, 2) an expiratory upstroke, 3) expiratory plateau, and 4) an inspiratory downstroke

Front 3

A sustained CO2 waveform (>30) confirms an ...

Back 3

Endotracheal tube is placed in the trachea

Front 4

A tube placed in the esophagus should be distinguishable from a tracheal intubation because any CO2 present in the stomach will quickly vanish within ... and the waveform will become essentially a flat line

Back 4

usually within three "tidal volumes"

Front 5

BIS number lower than 60 is though to represent a state at which the patient is...

Back 5

unable to respond to verbal commands

Front 6

A BIS number higher than 70 is believed to correspond to a higher likelihood of ...

Back 6

awareness

Front 7

A BIS number of 100 percent represents the ...

Back 7

awake state

Front 8

BIS numbers between ... and ... are, in general, considered to be optimal for a relatively healthy patient undergoing a routine general anesthetic and surgery.

Back 8

45 & 60

Front 9

Mild hypothermia can

Back 9

delay recovery from anesthesia

Front 10

Shivering can cause increase ... (3) and result in ...

Back 10

oxygen utilization, systemic blood pressure, and heart rate, and can result in myocardial ischemia in the elderly or physiologically weakened patients.

Front 11

Profound hypothermia may be directly related to ... It may also impair ...(2)

Back 11

myocardial dysrythmias; Coagulation times and wound healing

Front 12

Best core temperature monitors ...

Back 12

PA, tympanic membrane, bladder, esophagous

Front 13

4 types of Inhaled anesthetic monitoring

Back 13

monochromatic infrared spectrometry, polychromatic infrared spectrometer, mass spectrometry, raman scattering spectrometry

Front 14

Standard I for Basic Anesthetic Monitoring

Back 14

Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care.

Front 15

Standard II for Basic Anesthetic Monitoring

Back 15

During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually evaluated

Front 16

Oxygen Monitoring Objective:
Monitoring methods (3):

Back 16

to ensure adequate oxygen concentration in the inspired gas and blood during all anesthetics.
1)Inspried gas: oxygen analyzer with a low O2 conc. limit alarm
2)Blood oxygenation: pulse ox with variable-pitch pulse tone & alarm audible
3)adequate illumination and exposure of the patient to assess color

Front 17

Ventilation Monitoring Objective:
Monitoring methods (4)

Back 17

To ensure adequate ventialtion of the patient during all anesthetics.
1)chest excursion, resevoir bag observation, ausculation of breath sounds, EtCO2, TV
2) EtCO2 monitoring
3)Audible alarm for disconnection of breathing system
4)continual observation

Front 18

Circulation Monitoring Objective:
Monitoring methods (3)

Back 18

To ensure adequacy of the patient's circulatory function during all anesthetics.
1)EEC monitoring continuously until discharge from PACU
2)BP & HR every 5 minutes
3) and by at least one of the following: palpation of a pulse, auscultation of heart sounds, arterial BP, u/s of peripheral pulse or pulse ox

Front 19

Body Temperatue Monitoring Objective:
Monitoring method (1)

Back 19

To aid in maintenance of appropriate body temperature during all anesthetics.
1) monitored when clinically significant changes in body temp are intended, anticipated, or suspected

Front 20

Hypothermia is associated with

Back 20

delayed drug metabolism, increased blood glucose, vasoconstriction, impaired coagulation and impaired resistance to surgical infections.

Front 21

Hyperthermia can lead to

Back 21

tachycardia, vasodilation and neurological injury

Front 22

Capnography rapidly and reliably indicates...

Back 22

esophageal intubation- a common cause of anesthetic catastrophe-but does not detect bronchial intubation

Front 23

Factors Influencing the Oxyhemoglobin Diss. Curve
-Curve shift to the Right (4)

Back 23

1) Elevated CO2
2) Elevated temp.
3) Elevated levels of 2, 3-DPG
4) Decreased pH, acidosis (elevated H+ ions)

Front 24

Factors Influencing the Oxyhemoglobin Diss. Curve
-Curve shift to the Left (4)

Back 24

1) Decreased CO2
2) Decreased temp.
3) Decreased levels of 2, 3-DPG
4) Elevated pH, alkalosis (decreased H+ ions)

Front 25

Monitoring site: Bladder
Advantage/Disadvantage

Back 25

A: reflects core temperature, correlates accurately6 with other core sites;
D: Invasive-requires urinary cath. placement, Risk of UTI

Front 26

Monitoring site: Pulmonary artery
Advantage/Disadvantage

Back 26

A: reflects core temperature, correlates accurately with other core sites;
D: Invasive-requires PA catheter, not reliable during open chest procedures

Front 27

Monitoring site: Esophageal
Advantage/Disadvantage

Back 27

A: Considered by most authors to reflect core temperature, ease of insertion;
D: Slight potential for oral or esophageal trauma, bleeding, not useful in awake patients, inaccurate if placed too close to the stomach

Front 28

Monitoring site: Nasopharynx
Advantage/Disadvantage

Back 28

A: considered by most authors to reflect core temperature, ease of insertion;
D: potential for nasopharyngeal trauma, epistaxis, bleeding, less useful in awake patients, inaccurate if breathing through nares

Front 29

Monitoring site: Tympanic
Advantage/Disadvantage

Back 29

A: Considered by most authors to reflect core temperature, accurate if contact probe is used, ease of insertion, possible for awake patients;
D: Slight potential for tympanic membrane trauma, possible to push ear wax from canal to membrane, infrared device less accurate

Front 30

Monitoring site: Axillary
Advantage/Disadvantage

Back 30

A: safe, noninvasive, ease of placement, reasonable correlation with core in adducted arm when placed close to axillary artery;
D: Not a direct measurement of core temperature, influenced by IV fluids, easily dislodged

Front 31

Causes of Changes in the exhaled concentration of Carbon dioxide: Increases (6)

Back 31

hypoventilation, malignant hyperthermia, sepsis, rebreathing, administration of bicarbonate, insufflation of carbon dioxide during laparoscopy.

Front 32

Causes of Changes in the exhaled concentration of Carbon Dioxide: Decreases (6)

Back 32

hyperventilation, hypothermia, low cardiac output, pulmonary embolism, accidental disconnection or tracheal extubation, cardiac arrest

Front 33

The CDC is a branch of the ... and makes suggestions for ...

Back 33

The Center for Disease Control is a branch of the Department of Health and Human Services that makes suggestions for practice.

Front 34

OSHA and the EPA set the rules and regulations to protect ...

Back 34

Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) set the rules and regulations to protect healthcare workers.

Front 35

CDC- Responsible for ...

Back 35

developing safe guidelines to help prevent and control the spread of infectious disease

Front 36

OSHA- Responsible for ...

Back 36

maintaining minimum health and safety standards for employees

Front 37

AANA established a set of guidelines for the Nurse Anesthetist (2)

Back 37

1) Help promote infection control in anesthesia practice
2) Providence education to the nurse anesthetist in conjunction with CDC suggestions

Front 38

Two tier standard for isolation precautions

Back 38

Tier I: Standard Precautions
Tier 2: Transmission Based Precautions

Front 39

Tier I: Standard Precautions
Applies to but not limited:

Back 39

Blood and all body fluids, secretions, excretions, non-intact skin, mucous membranes
-Designed to care for all patients regardless of their diagnosis.

Front 40

Tier II: Transmission Precautions
Used in addition to Standard Precautions for patients known to be ...

Back 40

infected or colonized with epidemiologically important pathogens that can be transmitted by airborne, droplet or by contact: or by contamination of these routes

Front 41

Tier II Transmission Routes (3)

Back 41

Contact, Airborne, Droplet

Front 42

Contact Precautions: Prevention and Control includes but not limited to (3)

Back 42

-Gloves/gowns use when in contact with pt.
-Strict hand/washing/scrubbing/gloving b/w pts.
-Aseptic technique, cleaning, sterilatization

Front 43

Examples of pathogens spread by Contact Route:

Back 43

TB, Hepatitis, HIV/AIDS, VRE, MRSA, C-Diff, E-Coli, Scabies, Herpes, Shigella

Front 44

Airborne transmission occurs by dissemination of either ...

Back 44

airborne droplet nuclei of evaporated droplets that may remain suspended in the air/and dispersed for long periods of time and distance included on dust particles

Front 45

Airborne droplet nuclei are ...

Back 45

small-particle residue 5 micrometers or smaller in size

Front 46

Airborne droplet nuclei can be emitted during ...

Back 46

talking, whispering, sneezing, coughing, etc

Front 47

Examples of pathogens spread by Airborne Route:

Back 47

TB, Measles, avian influenza, chicken pox, varicella zoster, shingles

Front 48

Airborne Precaution Measures (6)

Back 48

-Standard Universal Precautions, eye protection
-Use properly fitted mask with high efficiency filtration (N95)
-Use disposable equipment when possible
-Negative Pressure OR room
-Use smoke evacuator to minimize aerosolized spores
-Keep pt. masked until intubation & on transport

Front 49

Negative Pressure Room: air ...

Back 49

Air comes in and doesn't go out

Front 50

Anesthesia Machine Control Measure for airborne transmission

Back 50

Bacterial filters to prevent contamination of the ventilator

Front 51

Droplet transmission propels short or long distances through the air?

Back 51

short

Front 52

Droplet transmission involves contact of (5)

Back 52

-conjunctivae or mucous membranes
-nose or mouth
-susceptible person with large particle droplets containing microorganisms generated from a person who has a clinical dz
-carrier of the micro-organism

Front 53

Large particle droplets are larger than

Back 53

5 micrometers in size

Front 54

Droplet transmission can be emitted during ...

Back 54

talking, sneezing, coughing and during common procedures in anesthesia such as suctioning; surgical procedure: Bronchoscopy

Front 55

Examples of Pathogens spread by droplet route ...

Back 55

Adenovirus pneumonia, H-influenza, seasonal human influenza, meningococcal dz, pertussis, rubella, strep-pneumonia

Front 56

Droplet Precaution measures

Back 56

standard precaution, eye protection, mask should be worn within 3ft of patient

Front 57

Hepatitis B vaccine is or isn't recommended for health care providers?

Back 57

is recommended

-Serological marker prevalence in anesthesia personnel is 15-50% compared to 3-5% of general population

Front 58

Hepatitis C, is there a vaccine available

Back 58

NO

-50-90% of these infections lead to chronic hepatitis which may result in death

Front 59

Risk from a single needle stick from an HIV infected patient has been estimated at

Back 59

0.4-0.5%

-organism infectivity, stage of the pt's dz, size of the inoculums, and immune status of the health care provider will determine the rate of transmission

Front 60

Operating Room Personnel, 3/4 of all sharps injuries are caused by

Back 60

suture needles
scalpel blades
IV catheters & hypodermics
retractors/skin hooks
electrosurgical needle tips
anesthesia (IV, A-line, neuro needles)

Front 61

Never place hands into the ... container

Back 61

Sharps

Front 62

Exposure to Bloodborne Pathogen Protocol (4)

Back 62

-Make announcement to OR staff in room
-Call/ notify supervisor for immediate relief
-Wash / milk the wound
-Follow hospital protocol for exposure

Front 63

Traffic Pattern in OR:
Unrestricted area ...

Back 63

Communication and control area “Front Desk”
Traffic not limited

Front 64

Traffic Pattern in OR:
Semi-Restricted area ...

Back 64

Support and storage areas
External corridor around the OR suites
Traffic limited to authorized personnel and pts
** Scrub suits required to include hair covering

Front 65

Traffic Pattern in OR:
Restricted area ...

Back 65

-OR Suites or where unwrapped instruments are sterilized
-Traffic limited to authorized personnel and patients
** Attire is same as for semi-restricted area with the addition of masks
** Patients are required to wear a hair covering

Front 66

Traffic Pattern in OR:
Prior planning equals

Back 66

reduced traffic in/out of room

Front 67

Keep doors to the OR ...

Back 67

CLOSED

-maintaining positive pressure keeps bacterial count down

Front 68

Traffic Pattern in OR:
ALWAYS enter from the ...
NEVER enter from the ...

Back 68

enter from substerile core area, never from hallway

Front 69

Keep ... field in view during movement

Back 69

sterile

Front 70

Surgical Site Infection (SSI):
Preventative steps (3)

Back 70

-Was antibiotic ordered and is it appropriate
-Timing (30 min-1 hour before cut time)
-Duration of administration (long surgery-do you need to repeat dose?)

Front 71

Infection Control for Anesthesia Equipement
5 steps:

Back 71

-Wipe down equipment daily and between each patient use: Monitors, leads, BP tubing, pumps, stethoscopes, flat surfaces, machine & carts
-Remove used gloves before opening carts & drawers
-Discard any items that are contaminated or potentially contaminated during case
-If something falls on the floor throw it out!
-Don’t put dirty equipment on top of clean

Front 72

Surgical Conscience:

Back 72

Internal voice / value system that motivates correct performance (observed or alone)

Front 73

Anesthesia machine care and cleaning:

Back 73

-At the end of each case discard portions of the system that are disposable
-Refer to manufacture’s guidelines for care and cleaning of other portions of the anesthesia machine

Front 74

Temperature Regulation is controlled by the ...

Back 74

Hypothalamus

Front 75

Anterior preoptic hypothalamic area has ... (3)

Back 75

-Heat sensing neurons: transmitted by unmyelinated C fibers
-Cold sensing: travel centrally via myelinated A delta fibers
-Ascending thermal: travel cephalad via the anterior spinothalmic tract

Front 76

Normothermia is a range or 'set point' that is ...
The body will activate control mechanisms in order to maintain this set point.

Back 76

36.4-37.0 Celsius or 98.0-98.6 F

Front 77

Fahrenheit (F) & Celsius (C) conversion

Back 77

F = 1.8(C) + 32
C = (F - 32)/ 1.8

Front 78

At temperatures above the set point heat loss will be greater or less than heat production?

Back 78

greater than

Front 79

At temperatures below the set point heat production will be greater or less than heat loss?

Back 79

less than

Front 80

Temperature regulation:
A .../... feedback system utilized to control temperature withing the normal range balancing heat loss and heat production mechanisms

Back 80

negative/positive

Front 81

Thermoregulatory Processing: 3 types

Back 81

Afferent Input, Central Control, Efferent Responses

Front 82

Afferent Input

Back 82

How the brain receives information that the body is exposed to a temperature change

Front 83

Centrol Control

Back 83

Hypothalamus

Front 84

Efferent Responses

Back 84

How the body responds to alterations in temperature

Front 85

Hypothermia:
definition & range...

Back 85

-Clinical state of subnormal body temperature in which the body is unable to generate enough heat for bodily functions.
-Body temperature <36C or 96.8F

Front 86

Stages of Hypothermia including range

Back 86

-Mild: vasoconstriction and shivering present not with GA.
32- 36 C (90 – 96.8 F)
-Moderate: depression of metabolism, maximal vasoconstriction, and cessation of shivering
27 – 32 C (80.6-89.6 F),
<30 C- cardiac dysrhythmias, <28 C- APNEA
-Severe: < 27 C ( 80.6F)

Front 87

Clinical Signs of Hypothermia:
Early & prolonged

Back 87

Early Signs:
shivering
decrease sweating
vasoconstriction
Prolong:
altered mental status
muscle weakness

Front 88

Defenses Against Cold (4)

Back 88

-Sympathetic stimulation & skin vasoconstriction
-Pilo-erection (goosebumps)
-Shivering: Heat production up to 300%, Increases oxygen consumption as much as 5 folds, Undesirable in patients w/ CAD & pulmonary insufficiency, Treat with meperidine 25mg IV (not given to L&D ladies)
-Sympathetic- mediated increase in basal metabolism rate, Epinephrine and norepinephrine affects, Declines by 1% per year after age 30, Increase in thyroxine

Front 89

Major Mechanisms of Heat Loss:
4 types ...

Back 89

Radiation, Evaporation, Convection, Conduction

Front 90

Radiation

Back 90

Radiation (60%): greatest source of heat loss
-loss of energy through radiant electromagnetic waves in the infrared spectrum and involves no direct contact
-due to exposed surface area, exp. warm body loses heat to any cold item in the OR

Front 91

Evaporation

Back 91

Evaporation (20%)
-loss of heat energy contained in water vapor
-loss of water to the environment
-depends on expose area and relative humidity of ambient air, exp: perspiration, open wounds

Front 92

Convection

Back 92

Convection (15%)
-heat loss through fluid (liquid or gas) currents in DIRECT CONTACT with the body's surface, exp: skin prep, IVF

Front 93

Conduction

Back 93

Conduction (5%)
-loss or gain of heat by transfer of thermal energy via DIRECT CONTACT
-transfer of heat from one surface to another, exp. warm body exposed to cold OR table/ instruments

Front 94

Patients at Risk for Hypothermia

Back 94

infants
elderly
burn patients
trauma
cardiac
ETOH (vasodilation: prevents/impairs vasoconstriction)
autonomic neuropathy (diabetic)
procedure type
procedure length
pre-op body temperature

Front 95

Risk for Hypothermia:
Infant & Children- have increase or decreased surface area (large head) per weight ratio therefore an increased or decreased O2 consumption, CO2 production, cardiac output, and alveolar ventilation.

Back 95

INCREASED surface area (large head) per weight ratio therefore an INCREASED O2 consumption, CO2 production, cardiac output, and alveolar ventilation.

Front 96

Risk for Hypothermia:
Infant & Children- Low or high body fat content, thin or thick skin, allows for great or less loss of heat to the environment. Hypothermia inhibits or promotes brown fat thermogenesis

Back 96

LOW body fat content, THIN skin, allows for GREATER loss of heat to the environment. Hypothermia INHIBITS brown fat thermogenesis

Front 97

Risk for Hypothermia:
Elderly- Basal and metabolic oxygen consumption decreases or increases with age. Inefficient thermoregulation. Loss of muscle mass results in decreased or increased heat production.

Back 97

Basal and metabolic oxygen consumption DECREASES with age. Inefficient thermoregulation. Loss of muscle mass results in DECREASED heat production.

Front 98

Risk for Hypothermia:
Elderly- Heat production decreases or increases, heat loss decreases or increases, and the hypothalamus temperature regulating centers may reset to a lower or higher level

Back 98

Heat production DECREASES, heat loss INCREASES, and the hypothalamus temperature regulating centers may reset to a LOWER level

Front 99

Patient who received spinal and epidural (regional) anesthesia secondary to: Vasodilation and redistribution of heat; and Blocked dermatomes are at great risk for hypo/hyperthermia?

Back 99

Hypothermia

Front 100

Neuroaxial Anesthesia:
Neuroaxial blocks inhibit numerous aspects of ...

Back 100

thermoregulation

Front 101

Neuroaxial Anesthesia:
Vasoconstriction and shivering thresholds are enhanced or reduced?

Back 101

reduced

Front 102

Neuroaxial Anesthesia:
Sensory input from the legs is blocked during neuroaxial anesthesia and the brain interprets this as indicating that the body is cold or warm

Back 102

warm

Front 103

Neuroaxial Anesthesia:
Concurrent administration of sedatives and anesthetic drugs further alters the regulation of ...

Back 103

temperature

Front 104

Anesthesia & Decrease in Temperature:
Phase I: ...
occurs within the ... or so and is due to movement of heat from ... to ... as a result of vasodilation.

Back 104

Phase I : REDISTRIBUTION
This occurs within the FIRST HOUR or so and is due to movement of heat from CORE to PERIPHERY as a result of vasodilation.

Front 105

Anesthesia & Decrease in Temperature:
Phase II: ...
During this phase, heat loss does or does not exceed heat production; most surgery does not extend beyond this phase. Losses are due to radiation, convection, conduction, evaporation, and respiratory losses.

Back 105

Phase II: LINEAR
During this phase, heat loss EXCEEDS heat production; most surgery does not extend beyond this phase. Losses are due to radiation, convection, conduction, evaporation, and respiratory losses.

Front 106

Anesthesia & Decrease in Temperature:
Phase III:
Once temperature falls below the thermoregulatory threshold, peripheral vasoconstriction increases or decreases to limit the heat loss from the core compartment.

Back 106

Phase III: PLATAEU
Once temperature falls below the thermoregulatory threshold, peripheral vasoconstriction INCREASES to limit the heat loss from the core compartment.

Front 107

Body temperature is not uniform there is a variation between the periphery and the core of approximately ...

Back 107

2-4 ° C.

Front 108

Initial change in core temperature is related to the transfer of heat from the core/periphery to the core/periphery. Normally this is protected by tonic thermoregulatory vasoconstriction.

Back 108

core to the periphery

-Redistribution Phase

Front 109

The initial phase of heat loss is approximately ... in duration

Back 109

one hour

-Redistribution Phase

Front 110

A secondary phase of heat loss occurs lasting approximately ... this is the result of heat loss exceeding heat production.

Back 110

2-4 hours

-Linear Phase

Front 111

In Linear Phase, a steady state may result in patients that are maintained in a relatively warm/cold fashion

Back 111

warm

-Linear Phase

Front 112

In Linear Phase, if continually exposed to low/high temperatures, the body will continue to loose heat to the periphery despite attempts to maintain the core temperature

Back 112

low

-Linear Phase

Front 113

Effects of Hypothermia
-Tissue solubility of volatile agents increases/decreases
-Prolonged or quick recovery from anesthesia

Back 113

-Tissue solubility of volatile agents
INCREASE in tissue solubility
-PROLONG recovery from anesthesia

Front 114

Effects of Hypothermia
-MAC (minimum alveolar concentration)
For every ... ° C in body temperature, MAC of
volatile agent decreases by ... %

Back 114

MAC- For every 1° C in body temperature, MAC of
volatile agent decrease by 5%

Front 115

Effects of Hypothermia
-Neuromuscular blocking drugs increase or decrease duration

Back 115

increase

Front 116

Effects of Hypothermia
-Coagulation,
blood loss is increased/decreased
prolongs/shortens PT/PTT
impairs ... function

Back 116

blood loss is INCREASED
PROLONGS PT/PTT
impairs PLATELET function

Front 117

Deleterious Effects of Hypothermia:
10 effects

Back 117

Cardiac arrhythmias and ischemia
Increased peripheral vascular resistance
Left shift of the oxy-hemoglobin disassociation curve
Reversible coagulopathies (platelet dysfunction)
Postoperative protein catabolism and stress
Altered mental status
Impaired renal function
Decreased drug metabolism
Poor wound healing
Increased incidence of infection

Front 118

Advantage Effects of Hypothermia
2 effects

Back 118

-Protection of the brain: after or during focal or global ischemia; For each 1 ° C decrease in temperature, cerebral oxygen consumption & cerebral blood flow decrease by 5% - 7%
-Protection spinal cord

Front 119

Therapeutic mild/mod/severe hypothermia is used in cardiac and neurosurgical procecures to protect against ... and ...

Back 119

mild hypothermia protects against ischemia and hypoxia

Front 120

Therapeutic Hypothermia decreases/increases the metabolic demand and oxygen requirement

Back 120

decreases

-also thought to decrease excitatory amino acids

Front 121

Hypothermia is thought to decrease/increase both basal and electrical metabolic requirements in the brain.

Back 121

decrease

Front 122

Ways to Prevent Hypothermia
9 ways

Back 122

-Pre-surgical warming of the patient.
-Maintenance of ambient room temperature.
-Administration of warmed fluids/blood.
-Padding of the bed/ blankets/use of a patient gown and head covering.
-Active application of forced air warming blanket.
-Reduce gas flow through anesthesia circuit.
-Warm irrigation and prep solutions .
-Use of fluid warming blanket or pad under the infant/child.
-Have surgeon cover the incision with sterile towel if case is delayed.

Front 123

Hyperthermia
Temperature > ...

Back 123

37.5 C

-uncommon in the OR

Front 124

Hyperthermia:
Hypermetabolic state with a rise in body temperature of ...° C per hour under GA

Back 124

2 ° C

Front 125

Hyperthermia:
10 Causes

Back 125

-Sepsis
-Fever
-Transfusion reaction
-Neuroleptic malignant syndrome
-**Malignant hyperthermia**
-Thyrotoxicosis (excess of thyroid hormone)
-Pheochromocytoma
-Catecholamine surges
-Production of bacteremia during surgery
-Vigorous warming techniques (Hipac surgery-heated chemo for reduction of tumor in peritoneal cavity)

Front 126

Manifestation of Hyperthermia
6 s/s

Back 126

-Increased oxygen consumption
-Increase minute ventilation
-Sweating
-Vasodilation
-Decreased intravascular volume & venous return
-Increase heart rate by 10 bpm per Centigrade

Front 127

Malignant Hyperthermia:
Hypermetabolic state that results from administration of ... or ... to an individual with a mutation in the ... receptor

Back 127

inhalation anesthetics or Succinylcholine
ryanodine 1 receptor

Front 128

Malignant Hyperthermia:
Uncontrolled release of ... from the sarcoplasmic reticulum results in intense muscle contracture

Back 128

Calcium

Front 129

Malignant Hyperthermia:
Increased/Decreased O2 consumption and CO2 production which results in lactic acidosis and hyperthermia

Back 129

Increased

Front 130

Tissue and cellular breakdown result in ... and ... which can result in ventricular fibrillation and death

Back 130

hyperkalemia and acidosis

Front 131

FYI: MH is a fulminant hypermetabolic crisis triggered by certain types of anesthetic agents, typically succinylcholine, sevoflurane, desflurane, isoflurane, and halothane. MH is characterized by an uncontrolled increase in skeletal muscle metabolism. Contrary to common belief, pyrexia, is not first indicator of an MH crisis. The earliest sign and symptom that will present is an increase in end-tidal carbon dioxide.

Back 131

FYI: Early signs include tachycardia, tachypnea, and rigidity of the masseter muscle called trismus. As an MH crisis progresses, other signs and symptoms are unstable BP, cyanosis, and/or mottling of the skin, diaphoresis, cardiac dysrhythmia, and a dramatic increase I the body temperature. The patient’s temperature may elevate as much as 1-2°C every 5 minutes. The surgical team may confirm that blood on the field is dark in color due to central venous saturation

Front 132

Treatment of MH:
7 steps

Back 132

-Stop the agent & Succinylcholine
-Hyperventilation w/100% O2
-Dantrolene 2.5mg/kg bolus; A total of 10mg/kg
ie 50kg, 60ml of H20, 20mg/vial; ~6-7 vials for pt
-Treat metabolic acidosis
-Treat hyperkalemia
-Institute cooling measures
-Support with inotropes
(Must reconstitute in sterile H20 not LR d/t calcium)

Front 133

Treatment of Hyperthermia in the OR
3 things

Back 133

-Cooling blankets
-Cool IV fluids
-Antipyretics

Front 134

Temperature Monitoring:
Tympanic Membrance is close to ...
Rare risk of ... and ...

Back 134

close to core via internal carotid artery
bleeding and perforation

Front 135

Temperature Monitoring:
Nasopharynx is close to ... and has risk of ...
Is contraindicated in ... trauma
Evidence of ... rhinorrhea

Back 135

-Close to Internal Carotid Artery
-Risk of bleeding nosebleed
-Contraindicated in head trauma
-Evidence of cerebrospinal fluid rhinorrhea

Front 136

Temperature Monitoring:
Esophagus is close to ...
Placed in lower ... of esophagus
Accurately reflects ...temp

Back 136

-Close to great vessels and heart
-Placed in lower 1/3 of esophagus
-Accurately reflects core temp
-Useful for auscultation

Front 137

Temperature Monitoring
FYI: Rectum, Bladder, Mouth, Axilla, skin, PA cath

Back 137

-Rectum: Variable
-Bladder: Foley catheter, Close to core, Affected by rate of urine flow
-Mouth: Affected by food, Hyperventilation
-Axilla: Placed over axillary artery, Approximately 1 ° C below core
-Skin: Variable accuracy, 3- 4 ° C lower
-Pulmonary catheter: Most accurate, Mixed venous core temperature

Front 138

An Important tool in preoperative volume status assessment is ... and factors include

Back 138

Patient History:
recent oral intake, persistent vomiting or diarrhea, gastric suction, significant blood loss or would drainage, iv fluid and blood admin., and recent HD

Front 139

S/S of HYPOvolemia

Back 139

dehydration of mucous membranes, thready peripheral pulses, increased resting heart rate and decreased blood pressure, orthostatic heart rate and blood pressure changes, and decreased urinary flow. HOWEVER, due to many meds given during anesthesia these signs can be unreliable.

Front 140

S/S of HYPOvolemia intraoperatively

Back 140

the fullness of a peripheral pulse, urinary flow rate, and indirect signs such as the response of BP to PP-ventilation and to the vasodilating or negative inotropic effects of anesthetics, are most often used.

Front 141

S/S of HYPERvolemia

Back 141

pitting edema and increased urinary flow are signs of excess extracellular water in pts with normal cardiac, hepatic, and renal function

Front 142

Late S/S of HYPERvolemia in settings such as CHF may include:

Back 142

tachycardia, elevated JVP, pulmonary crackles and rales, wheezing, cyanosis, and pink frothy pulmonary secretions

Front 143

Surrogates (indirect) of intravascular volume and adequacy of tissue perfusion:

Back 143

serial Hct, arterial blood pH, urinary specific gravity or osmolality, urinary NA or CL concentration, serum Na, and the BUN to serum CR ratio.

Front 144

Laboratory signs of dehydration may include

Back 144

rising Hct & Hgb, progressive metabolic acidosis (including lactic acidosis), urinary sp. Gravity > 1.010, urinary NA < 10 mEq/L, urinary osmolality > 450 mOsm/L, hypernatremia, and BUN-to-Cr ratio > 10:1

Front 145

Radiographic indicators of volume overload include

Back 145

increased pulmonary vascular and interstitial marking (Kerley ‘B’ lines) or diffuse alveolar infiltrates.

Front 146

... monitoring has been used in patients with normal cardiac and pulmonary function when volume status is difficult to assess by other means or when rapid or major alterations are expected

Back 146

CVP

Front 147

Static CVP readings do or do not provide an accurate or reliable indication of volume status?

Back 147

do NOT

Front 148

... monitoring has been used in settings where CVP do not correlate with the clinical assessment or when the pt has primary or secondary (LV or RV) dysfunction?

Back 148

Pulmonary artery pressure
-primary or secondary RV dysfunction

Front 149

PAOP readings < ... mm HG indicate HYPOvolemia in the presence of clinical signs.

Back 149

< 8
HOWEVER, values < 15 mm Hg may be associated with relative hypovolemia in patients with poor ventricular compliance

Front 150

PAOP > 18 mm Hg are elevated and generally imply LV or RV volume overload?

Back 150

LV

Front 151

Normal r/t b/w PAOP and LV end-diastolic volume is altered by ... dz particularly stenosis, severe AS, or a left atrial myxoma/thrombus, as well as increased thoracic and pulmonary airway pressures.

Back 151

MV

Front 152

All PAOP measurements should be obtained at end ...

Back 152

EXPIRATION

Front 153

... provide a much more accurate and less invasive estimate of cardiac filling & function

Back 153

Echos

Front 154

... solutions are aqueous solutions of ions (salts) with or without glucose

Back 154

Crystalloid solutions

Front 155

Crystalloids rapidly equilibrate with and distribute throughout the entire ... fluid space.

Back 155

extracellular

Front 156

Crystalloid solutions half-life is ...

Back 156

20-30 min

Front 157

... contain high-molecular-weight substances such as proteins or large glucose polymers.

Back 157

Colloid solutions

Front 158

Colloids help maintain plasma colloid oncotic pressure and remain ...

Back 158

intravascular

Front 159

Colloids half life is ...

Back 159

3-6 hrs

Front 160

Replacing an intravascular volume deficit with crystalloids generally requires ... to ... times the volume needed when using colloids.

Back 160

3 to 4 times

Front 161

Surgical patients may have an ... fluid deficit that exceeds the ... deficit.

Back 161

Surgical patients may have an EXTRAcellular fluid deficit that exceeds the INTRAvascular deficit.

Front 162

Severe intravascular fluid deficits can be more rapidly corrected using ... solutions

Back 162

Colloid solutions

Front 163

The rapid administration of large amounts of ... (>4-5L) is more frequently associated with tissue edema

Back 163

crystalloids

Front 164

... solution considered as the initial resuscitation fluid in pts with hemorrhagic and septic shock, burns, head injury (to maintain CPP), and those undergoing plasmapheresis and hepatic resection

Back 164

Crystalloid

Front 165

For losses primarily involving water, replacement is with ... solutions (maintenance-type solutions)

Back 165

hypotonic (crystalloid)
i.e., D5W:used for replacement of pure water deficits and as a maintenance fluid for pt on sodium restriction

Front 166

o Losses involving water and electrolytes, replacement is with ... electrolyte solutions (replacement-type solutions).

Back 166

isotonic
i.e., lactated Ringer's and normal saline

Front 167

Most intraoperative fluid losses are ...

Back 167

isotonic

Front 168

Lactated Ringer’s are a ... solution although slightly hypotonic, providing approximately 100mL of free water per liter and tending to lower serum sodium.

Back 168

isotonic

Front 169

Lactated Ringer's have the (least or most) effect on extracellular fluid composition and appears to be the most physiological solution when large volumes are necessary.

Back 169

Least

Front 170

... is the preferred solution for hypochloremic metabolic alkalosis and for diluting PRBCs prior to transfusion

Back 170

Normal Saline

Front 171

When given in large volumes NS produces a ... because of its high Na and Cl content: plasma bicarbonate concentration decreases as Cl concentration increases

Back 171

dilutional hyperchloremic acidosis

Front 172

... is used for replacement of pure water deficits and as a maintenance fluid for pts on Na restriction.

Back 172

D5W

Front 173

Hypertonic 3% saline is employed in therapy of severe symptomatic ...

Back 173

hyponatremia

Front 174

Hypertonic solutions must be administered ... to avoid inducting hemolysis.

Back 174

slowly

Front 175

Accepted indication for Colloid solution: fluid resuscitation in pts with severe ... fluid deficts (hemorrhagic shock) prior to the arrival of blood for transfusion

Back 175

severe intravascular fluid deficit

Front 176

Accepted indication for Colloid solution: fluid resuscitation in the presence of severe ... or conditions associtated with large ... lossess such as burns.

Back 176

hypoalbuminemia, protein

Front 177

Colloids can be used in conjunction with crystalloids when fluid replacement needs exceed ... prior to transfusion.

Back 177

3-4L

Front 178

Colloid solutions are prepared in NS and thus can also cause ...

Back 178

hyperchloremic metabolic acidosis

Front 179

Colloid solutions are derived from either ... and are supplied in isotonic electrolyte solutions

Back 179

plasma proteins or synthetic glucose polymers

Front 180

Blood-derived colloids include ... (5% & 25%) and ... (5%).

Back 180

albumin and plasma protein fraction

Front 181

Synthetic colloids include ... and ...

Back 181

dextrose starches and gelatins.
-Gelatins are associated with histamine-mediated allergic reactions and are not available in U.S.

Front 182

Dextran is available (70 & 40), although dextran 70 is a better volume expander than Dextran 40, the latter improves ... through the microcirculation, presumably by decreasing blood viscosity.

Back 182

blood flow

Front 183

Synthetic colloids have ... effects and are associated with ...

Back 183

Antiplatelet effects and associated with kidney failure.

Front 184

..., the starch molecules are derived from plants

Back 184

Hetastarch

Front 185

Hetastarch is highly effective as a ... expander and is less expensive than albumin. Moreover, it is a nonantigenic and anaphylactoid reactions are rare. Coagulation factors not significantly affected

Back 185

Plasma expander

Front 186

Normal Maintenance Requirements:
1-10 ... ml/kg/h
11-20 Add ... ml/kg/hr
21-n Add ... ml/kg/hr

Back 186

4-2-1 Rule
1-10 4ml/kg/h
11-20 Add 2 ml/kg/hr
21-n Add 1 ml/kg/hr

i.e., 25kg child = 40+20+5= 65 ml/hr

Front 187

Normal Maintenance Requirements:

in patients > 20kg, just add ... ml/kg/hr

Back 187

40

i.e., 25kg pt= 25 + 40 = 65 ml/hr

Front 188

In the absence of ..., fluid and electrolyte deficits can rapidly develop as a result of cont. urine formation, GI secretions, sweating, and insensible losses from the skin and lungs.

Back 188

oral intake

Front 189

Pts presenting for surgery after an overnight fast w/o any fluid intake will have a preexisting deficit proportionate to the ...

Back 189

duration of the fast

Front 190

Fluid deficit equation:

Back 190

Multiply the normal maintenance rate by the length of the fast.
i.e,. 70kg pt fasting for 8h = (40+20+50)ml/h x 8h = 880ml

Front 191

Most commonly used method for estimating blood loss in the OR is measurement of blood in the surgical ... and visual estimation of the blood on ... & ...

Back 191

suction container, surgical sponges & lap pads

Front 192

A fully soaked 4x4 sponge holds ... of blood

Back 192

10ml

Front 193

A fully soaked lap pad holds ... of blood

Back 193

100-150ml

Front 194

Serial H & H’s reflect the ratio of ... to ..., not necessarily blood loss, and rapid fluid shifts and iv replacement affect measurements

Back 194

blood cells to plasma

Front 195

Other fluid loss comes from ... and ... of body fluids

Back 195

evaporation and internal redistribution

Front 196

Evaporative losses are most significant with ... and are proportional to the surface area exposed and to the duration of the surgical procedure.

Back 196

large wounds

Front 197

Internal redistribution of fluids (third spacing) can cause massive fluid shifts and severe ... depletion.

Back 197

intravascular

Front 198

Traumatized, inflamed, or infected tissue can sequester large amounts of fluid in the ... space and can translocate fluid across serosal surfaces (ascites) or into bowel lumen

Back 198

interstitial

Front 199

Protein-free fluid shift across an intact vascular barrier into the interstitial space is exacerbated by ..., and pathological alteration of the vascular barrier allows protein-rich fluid shift.

Back 199

HYPERvolemia

Front 200

FYI: Intraoperative fluid replacement
Should include supplying basic fluid requirements and replacing residual preoperative deficits as well as intraoperative losses (blood loss, fluid redistribution & evaporation).

Back 200

FYI: Intraoperative fluid replacement
Should include supplying basic fluid requirements and replacing residual preoperative deficits as well as intraoperative losses (blood loss, fluid redistribution & evaporation).

Front 201

Selection of the type of iv solution depends on the ... and the expected ...

Back 201

Selection of the type of iv solution depends on the surgical procedure and the expected blood loss

Front 202

Minor procedures involving minimal blood loss, ... can be used. For all other procedures, ... or ... is generally used even for maintenance requirements.

Back 202

dilute maintenance solution
LR or Plyte

Front 203

Blood Loss: ideally replaced with ... or ... solutions to maintain intravascular volume (normovolemia) until the danger of ... outweighs the risks of transfusion, at which, blood loss is replaced with transfusions of ...

Back 203

crystalloid or colloid solutions, anemia, PRBCs

Front 204

Most administer LR or Plyte in ~...-... times the volume of blood lost or colloid in a ... : ... ratio

Back 204

LR or Plyts 3-4:1
Colloid 1:1

Front 205

Average blood volumes:
Neonates: Premie/FT
Infants
Adults: Men/women

Back 205

Neonates: Premie 95ml/kg FT 85 ml/kg
Infants: 80 ml/kg
Adults: Men 75 ml/kg Women 65 ml/kg

Front 206

The transfusion point can be determined preoperatively from the hct and by estimating blood volume. Pts with normal hct should generally be transfused only after losses > ... - ...% of their blood volume.

Back 206

> 10-20%

Front 207

The amount of blood loss necessary for the hct to fall to 30% can be calculated as follows:
• Estimate blood volume
• Estimate the red blood cell volume (RBCV) at the preop hct
• Estimate RBCV at hct of 30%, assuming normal blood volume is maintained
• Calculate the RBCV lost when the hct is 30%; RBCVlost = RBCVpreop-RBCV30%
• Allowable blood loss = RBCVlost x 3.

Back 207

• i.e,. 85kg, hct 35%. How much blood loss will decrease her hct to 30%
o 65ml/kg x 85 kg = 5525 ml
o RBCV 35% = 5525 x 35% = 1934
o RBCV 30% = 5525 x 30% = 1658
o Red cell loss at 30% = 1934-1658 = 276ml
o Allowable blood loss = 3 x 276 = 828ml
• Therefore, transfusion should be considered only when this pt’s blood loss exceeds 800ml.

Front 208

One unit of RBCs will increase Hgb ... g/dL and the Hct ... - ...% in adults

Back 208

One unit of RBCs will increase Hgb 1 g/dL and the Hct 2-3% in adults;

Front 209

A 10-mL/kg transfusion of RBCs will increase hemoglobin concentration by ... g/DL and the Hct by ...%

Back 209

A 10-mL/kg transfusion of RBCs will increase hemoglobin concentration by 3 g/DL and the Hct by 10%

Front 210

Procedures can be classified according to the degree of tissue trauma.
-Minimal (i.e., herniorrhaphy) ...-... ml/kg
-Moderate (i.e., cholecystectomy) ...-... ml/kg
-Severe (i.e., bowel resection) ...-... ml/kg

Back 210

-Minimal (i.e., herniorrhaphy) 0-2 ml/kg
-Moderate (i.e., cholecystectomy) 2-4 ml/kg
-Severe (i.e., bowel resection) 4-8 ml/kg

Front 211

o A, B, AB, O: each represent an ... (antigen) that modifies the cell surface

Back 211

enzyme

Front 212

Rh: represents presence or absence of the ... antigen

Back 212

D antigen
-Rh + have the D antigen
-Rh – do NOT have the antigen

Front 213

Individuals lacking D antigen usually develop antibodies against the D antigen only after an Rh... transfusion or w/ pregnancy, in the situation of an Rh... mother delivering an Rh... baby

Back 213

Rh+
Rh – mother delivering an Rh + baby

Front 214

The most severe transfusion rx’s are d/t ...

Back 214

ABO incompatibility

Front 215

ABO incompatibility: naturally acquired antibodies can react against the transfused (foreign) antigens, activate complement, and result in intravascular ...

Back 215

hemolysis

Front 216

... detects in the serum the presence of the antibodies that are most commonly associated with non-ABO hemolytic reactions

Back 216

Antibody screen

Front 217

A ... mimics the transfusion: donor RBCs are mixed with recipient serum.

Back 217

Crossmatch

Front 218

Crossmatch serves 3 functions ...

Back 218

confirms ABO and Rh typing, it detects antibodies to the other blood group systems, and it detects antibodies in low titers or those that do no agglutinate easily

Front 219

PRBC's should be warmed to ... C during infusion to prevent ... The additive effects of ... and the typically low levels of 2,3-DPG in stored blood can cause a marked ... shift of the Hgb-Ox diss. Curve and at promote tissue hypoxia

Back 219

-37 C , hypothermia
-The additive effects of hypothermia and the typically low levels of 2,3-DPG in stored blood can cause a marked left shift of the Hgb-Ox diss. Curve and at promote tissue hypoxia

Front 220

Fresh Frozen Plasma (FFP) contains all ..., including most clotting factors. Each unit of FFP generally increases the level of each clotting factor by ...-...% in adult

Back 220

plasma proteins
2-3%

Front 221

FFP transfusions are indicated in ... (4)

Back 221

Transfusions are indicated in the tx of isolated factor deficiencies, reversal of warfarin, correction of coagulopathy associated w/ liver disease, pts receiving massive blood transfusions who cont. to bleed

Front 222

Platelet transfusions are given to pts with ... or ... in the presence of bleeding

Back 222

thrombocytopenia or dysfunctional platelets

Front 223

Prophylactic plts given if plt count ...-...k d/t increased risk of spontaneous hemorrhage

Back 223

10-20k

Front 224

Plt counts < ...K are associated with increased blood loss during surgery.

Back 224

<50k

Front 225

Administration of plt increases the count by ...-...K . -ABO compatible plts are desirable but not necessary (increases plt survival)

Back 225

5-10K

Front 226

Granulocyte is prepared by leukapheresis and may be indicated in ... pts with bacterial infections not responding to antibiotics.

Back 226

neutropenic

Front 227

Hemolytic Reactions usually involve specific destruction of the transfused red cells by the (recipient’s or donor's) antibodies

Back 227

recipient's

Front 228

Acute Hemolytic Reactions occur ... usually due to ABO blood incompatibility. Most common cause is .... Often severe and occur with 10-15mL of blood

Back 228

intravascularly
misidentification

Front 229

In awake patients S/S of Hemolytic Reactions are ...

Back 229

chills, fever, nausea, and chest and flank pain

Front 230

In anesthetized patients S/S of Hemolytic Reactions are ...

Back 230

rise in temp, unexplained tachycardia, hypotension, hemoglobinuria, diffuse oozing in the surgical field

Front 231

In anesthetized patients having a hemolytic reaction what 3 things can develop rapidly?

Back 231

DIC, shock and kidney failure can develop rapidly

Front 232

What are the 5 steps to take if a hemolytic reaction occurs?

Back 232

-Stop transfusion immediately and notify blood bank
-The unit should be rechecked ag. The blood slip & pt’s ID
-Blood should be drawn to identify hgb in plasma, to repeat compatibility testing and to obtain coagulation studies and plt count
-Urinary cath should be inserted and the urine should be checked for hgb
-Osmotic diuresis should be initiated with mannitol and IVFs

Front 233

Delayed Hemolytic Reactions occur ... and are generally mild and caused by antibodies to ... of the Rh system to foreign alleles in other systems such as the Kell, Duffy, or Kidd antigens.

Back 233

extravascularly
non-D antigens
-By the time sign. Amts. Of these antibodies have formed (wks to months), the transfused RBCs have been cleared from the circulation. Reexposure to the same foreign antigen during a subsequent red cell transfusion triggers an antibody response s/s (delayed 2-21 days later) malaise, jaundice (hemolysis), and fever. Management: Primarily supportive

Front 234

Nonhemolytic Immune Reactions are due to sensitization of the recipient to the donor’s white cells, platelets, or plasma proteins; the risk of these reactions may be minimized by the use of ... blood products.

Back 234

leukoreduced

Front 235

Nonhemolytic Immune Reactions
Febrile reactions ...
Tx ...

Back 235

increase in temp without evidence of hemolysis.
Tx: should receive leukoreduced transfusions only

Front 236

Nonhemolytic Immune Reactions
Urticarial reactions ...
Tx ...

Back 236

erythema, hives, and itching without fever.
Tx: antihistamine drugs and steroids

Front 237

Nonhemolytic Immune Reactions
Anaphylactic reactions ...
Tx ...

Back 237

typically in IgA-deficient pts.
Tx: epi, fluids, corticosteroids, and antihistamines.

Front 238

Nonhemolytic Immune Reactions
Transfusion-related acute injury (TRALI) ...
Tx ...

Back 238

acute hypoxia and noncardiac pulmonary edema w/in 6h of blood transfusion.
Tx: ARDS tx but it may resolve within a few days of supportive therapy

Front 239

Nonhemolytic Immune Reactions
Graft-Verse-Host Disease ...
Tx ...

Back 239

seen in immunocompromised pts. Cellular blood products contain lymphocytes capable of mounting an immune response against the compromised (recipient) host.
Tx: leukocyte filters

Front 240

Nonhemolytic Immune Reactions
Post-Transfusion Purpura ...
Tx ...

Back 240

profound thrombocytopenia. Plt count drops 5-10 days following transfusion.
Tx: IV IgG and plasmapheresis

Front 241

Nonhemolytic Immune Reactions
Transfusion-related Immunomodulation ...

Back 241

allogeneic transfusion of blood products may diminish immunoresponsiveness and promote inflammation.

Front 242

Infection Complications of blood transfusions
Viral Infections ...

Back 242

Hepatitis, AIDS, CMV - Immunocompromised and immunosuppressed pts (premies, transplant recipients and cancer pts) are particularly susceptible to severe transfusion-related CMV infections.

Front 243

Infection Complications of blood transfusions
Parasitic Infections ...

Back 243

malaria, toxoplasmosis and Chagas’…very rare

Front 244

Infection Complications of blood transfusions
Bacterial Infections ...

Back 244

2nd leading cause of transfusion-associated mortality.
-Blood products should be administered <4hrs.

Front 245

Massive Blood Tranfusion is tranfusing ... to ... times the pt's blood volume. For most adults ~...-...units

Back 245

1 to 2 times
10-20 units

Front 246

Massive Blood Transfusion complications:
Coagulopathy ...

Back 246

dilutional thrombocytopenia

Front 247

Massive Blood Transfusion complications:
Citrate Toxicity ...

Back 247

calcium binding by the citrate preservative can rise. Clinically important hypocalcemia, causing cardiac depression

Front 248

Massive Blood Transfusion complications:
Hypothermia ...

Back 248

Warm all blood products and IVFs. Ventricular arrhythmias progressing to fibrillation often occure at empt close to 30C

Front 249

Massive Blood Transfusion complications:
Acid-Base Balance ...

Back 249

Although stored blood is acidic d/t to the citric acid anticoagulant and accumulation of red cell metabolites, metabolic acidosis d/t transfusion is uncommon b/c citric acid and lactic acid are rapidly metabolized to bicarb by the normal liver. In mass transfusion, acid-base status is dependent upon tissue perfusion, rate of blood transfusion and citrate metabolism. Once normal tissue perfusion is restored, any metabolic acidosis typically resolves, and metabolic alkalosis commonly occurs as citrate and lactate contained in transfusion and resus. fluids are converted to bicarb by the liver

Front 250

Massive Blood Transfusion complications:
Serum Potassium Concentration ...

Back 250

The extracelleur concentration of K in stored blood steadily increases with time. Hyperkalemia can devop when transfusion rates exceed 100 ml/min. Hypokalemia is commonly encountered postoperatively, particularly in association with metabolic alkalosis.

Front 251

Autologous transfusion ...

Back 251

donate their own blood for surgery

Front 252

Blood Salvage & reinfusion ...
Contraindications ...

Back 252

The shed blood is aspirated into a reservoir and mixed with heparin, the red cells are concentrated and washed to remove debris and anticoagulant and then reinfused. Contraindications: septic contamination of the wound and perhaps malignancy.

Front 253

Normovolemic Hemodilution ...

Back 253

if the concentration of red cells is decreased, total red cell loss is reduced when large amounts of blood are shed; moreover, CO remains normal b/c intravascular volume is maintained. 1-2 units of blood are removed just prior to surgery and replaced with crystalloid/colloids. The blood is stored (up to 6 hrs) to preserve plts function and then given back to pt after blood loss.

Front 254

Donor-Directed Transfusions

Back 254

request donated blood rom family members or friends known to be ABO compatable.

Front 255

TBW: total adult (men and women) body water 50-60%= approximately ... L

Back 255

48L
-dependent on sex, age and weight

Front 256

TBW is distributed into the into extracellular (ECF) and intracellular (ICF)
Intracellular 2/3 of TBW = ...L
Extracellular 1/3 of TBW = ...L

Back 256

Intracellular 2/3 of TBW= 32 L
Extracellular 1/3 of TBW= 16L

Front 257

Extracellular Fluid includes ... fluid & ... fluid, each composed of ...L & ...L respectively.

Back 257

Intravascular fluid 1/4 of ECF= 4L
Interstitial fluid 3/4 of ECF= 12L

Front 258

Extracellular composition (3)

Back 258

Sodium (+), Chloride(-) and Bicarbonate(-)

Front 259

Intracellular composition (4)

Back 259

Potassium(+), Magnesium(+), Phosphate and Proteins (-)

Front 260

Fluid movement between the intravascular and interstitial spaces occurs across capillary walls by either filtration or diffusion and is determined by ...

Back 260

Starling Forces

Front 261

Starling Forces is the ...

Back 261

oncotic and hydrostatic pressures involved in the movement of fluids across the capillary membrane.

Front 262

Capillary ... pressure - the pressure that will force fluid out from the capillary (pushing pressure)

Back 262

hydrostatic

Front 263

Capillary ...pressure the osmotic pressure that will force the fluids to enter the capillary from the interstitial space (pulling force)

Back 263

oncotic

Front 264

Hydrostatic pressure is the ... pressure

Back 264

pushing

Front 265

Oncotic pressure is the ... force

Back 265

pulling

Front 266

Evaluation of fluid volume
give examples ...

Back 266

Patient’s history
Systemic BP (supine & standing)
Heart Rate
Urine output
Hematocrit
BUN
Electrolytes
ABG
CVP
NPO status/ length of time
persistent vomiting/ diarrhea
inpatient gastric secretion
hemodialysis
bowel prep
significant blood loss
wound drainage

Front 267

Pre-op patients can become volume depleted & experience alterations of electrolyte balance due to several processes ... (5)

Back 267

burns
vomiting
diarrhea
fever
gastric secretions
-All could lead to hypovolemia before surgery

Front 268

During Intra-op the effects of surgery & anesthesia combine to challenge fluid and electrolyte homeostasis. Surgery losses include but not limited to ... (3)

Back 268

-evaporative loss
-viscera exposure
-manipulation of tissue leading to 3rd spacing (3rd space redistribution of fluid from the intravascular space to the interstitial space)

Front 269

... can result from absolute loss of fluid from the body or a relative loss of bodily fluids in which water is ... within the body, leading to a reduced circulating volume.

Back 269

-HYPOvolemia
-redistributed

Front 270

Because most causes of hypovolemia are caused by the loss of ...; replacement with ... crystalloids (same composition similar to ... is appropriate

Back 270

ECF
isotonic
ECF

Front 271

Hypovolemia Physical exam
Pre-op s/s ...

Back 271

-abnormal skin turgor
-dehydration of mucous membrane
-thready peripheral pulses
-increase resting HR
-decrease BP (positional)
-decrease u/o

Front 272

Hypovolemia Physical exam
Intra-op s/s ...

Back 272

-decrease BP may be extra secondary to positive pressure ventilation,
-vasodilating and/or negative inotropic effects of anesthetic

Front 273

Hypervolemia is an excess of fluid volume in an ... concentration

Back 273

isotonic

Front 274

Hypervolemia is not usually encountered in surgical patients but can be seen if diseases such as ..., ..., or ... are present.

Back 274

CHF, renal failure, or cirrhosis of the liver

Front 275

Iatrogenic causes of fluid overload includes administration of ... & excessive IV administration of ... fluids

Back 275

steroids
isotonic

Front 276

Excessive consumption of ... in the diet or in medication can lead to retention of water and hypervolemia

Back 276

sodium

Front 277

Hypervolemia Treatment ... (3)

Back 277

sodium restriction, diuretics, hemodialysis (renal failure)

Front 278

Hypervolemia Physical exam
Pre-Op ... (3)

Back 278

-pitting edema seen more with bedridden patient
-pretibial edema seen more with ambulatory patient
-increase u/o

Front 279

Hypervolemia Physical exam
Late signs ... (6)

Back 279

-increase HR
-increase jugular pulse pressure
-pulmonary crackles & rales
-wheezing
-cyanosis
-pink frothy secretions

Front 280

Intravascular volume Measurement
Laboratory Evaluation ... (5)

Back 280

-Hemoglobin/Hematocrit
-Arterial blood pH
-Urine specific gravity & osmolality
-Serum and urine Na+
-BUN to creatinine ratio

Front 281

Intravascular volume Measurement
Hemodynamic Measurements:
a Low CVP: < ... mmHg
a High CVP: > ... mmHg

Back 281

<5
>12

Front 282

Low CVP: <5 mmHg may be normal unless associated with other signs of ...

Back 282

hypovolemia

Front 283

CVP greater than 12 mmHg is considered elevated and may imply hypervolemia in the absence of ... ventricular dysfunction, increased ... pressure, or restrictive ... disease

Back 283

-right ventricular dysfunction
-intrathoracic pressure
-pericardial disease

Front 284

PAOP <8mmHg may indicate ... and PAOP >15mmHG may indicate ...

Back 284

HYPOvolemia
HYPERvolemia

Front 285

... fluids:
-Provision of maintenance fluids
-Replacement of fluids loss as a result of surgery and anesthesia
-Correction of electrolyte disturbances

Back 285

Parenteral Fluids

Front 286

Parental Fluid Therapy includes
... & ... or a combination of both

Back 286

crystalloids (iso/hypo/hypertonic)
colloids

Front 287

Crystalloids are fluids with a (low/high) volume of distribution

Back 287

High

Front 288

Components of crystalloids are ...

Back 288

water, electrolytes and/or dextrose.

Front 289

Crystalloids cross ... easily and may dilute plasma proteins, resulting in a reduction of the plasma ... pressure

Back 289

-plasma membranes
-oncotic

Front 290

LR/NS distribute within the ... spaces

Back 290

extracellular

Front 291

D5W provides ... & distributes to both the intracellular and extracellular

Back 291

free water

Front 292

LR and NS are the two ... crystalloids generally used to correct the hypovolemia resulting from surgery and anesthesia.

Back 292

isotonic

Front 293

... is the preferred isotonic solution

Back 293

LR

Front 294

Crystalloid solutions intravascular half-life is ...-... minutes

Back 294

20-30 min

Front 295

Hypotonic crystalloid solution shifts fluid out of ... into ...
-It ... cells
-examples ...

Back 295

out of vessels into cells.
-Hydrates cells
-0.25% NS, 0.45% NS, D5W

Front 296

Hypotonic crystalloid solution nursing considerations ... (3)

Back 296

May worsen hypotension
Can increase edema
May cause hyponatremia
D5W may also irritate veins

Front 297

D5W spares protein, provides calories and free water, treats ..., is a diluent for IV drugs

Back 297

hyperkalemia

Front 298

Isotonic crystalloid solution has no ... It's action is ... and ...
-examples ...

Back 298

No fluid shift
Vascular expansion and electrolyte replacement
-0.9% NS
Lactated Ringer's (LR)

Front 299

Isotonic crystalloid solution nursing considerations ... (6)

Back 299

-May cause fluid overload
-Generalized edema
-Dilutes Hemoglobin
-May cause hyperchloremic acidosis
-May cause electrolyte imbalance
-Proinflammataory in large doses

Front 300

Isotonic solutions may cause ... acidosis

Back 300

hyperchloremic acidosis

Front 301

Hypertonic crystalloid solutions shift fluid back into ... Is is a ... and replaces ...
-examples ...

Back 301

-circulation
-vascular expansion
-replaces electrolytes
-D50.45%NS
-D50.9%NS
-Hypertonic saline (HS) 3% or 5%

Front 302

Hypertonic crystalloid nursing considerations ... (5)

Back 302

-irritating to veins
-may cause fluid overload
-may cause hypernatremia
-may cause hyperchloremia
-HS slows inflammation and increases capillary permeability

Front 303

Hypertonic saline (HS) slows/speeds up inflammation and decreases/increases capillary permeability

Back 303

slows
increases

Front 304

Colloid Solutions contain osmotically active substances of (low/high) molecular weight that (do/do not) easily cross the capillary membrane, therefore they draw fluid into the ... space and expand ... volume

Back 304

-high molecular weight
-do not cross easily
-intravascular space
-circulating volume

Front 305

Colloid solutions intravenous half life is between ... & ... hours

Back 305

3-6 hours

Front 306

Many anesthetists use colloids in conjunction with crystalloids when fluid replacement needs exceed ...-... liters

Back 306

3-4L

Front 307

Colloids particles are much larger than the electrolyte components in crystalloid solution, so they will provide (less/more) free water & stay primarily in the ... space.

Back 307

less free water
intravascular space

Front 308

Colloids contain large molecules such as proteins and/or starches to increase ... pressure in the intravascular space

Back 308

oncotic

Front 309

Colloid:
Blood derived example ...

Back 309

albumin

Front 310

Colloid:
Synthetic derived examples (3)

Back 310

Dextran, Hetastarch, Mannitol

(Dextran prevents clots during surgery but now there is a correlation w/ leaking so it's not used often)
(Mannitol is used with eye cases & cranies)

Front 311

Albumin (plasma protien) keeps fluid in/out vessels. It maintains volume and is used to replace ... and treat ... and erythroblastosis fetalis

Back 311

fluid IN vessels
-protein and treat shock

Front 312

Albumin comes in ..% and ...%

Back 312

5% and 25%

Front 313

Albumin nursing considerations ... (2)

Back 313

-May cause anaphylaxis (watch for hives, fever, chills, headache)
-May cause fluid overload and pulmonary edema

Front 314

Dextran (polysaccharide) shifts fluid into ... It causes vascular ... and prolongs hemodynamic response when given with HS.

Back 314

into vessels
vascular expansion

Front 315

Dextran (40 kDa or 70 kDa) nursing considerations ... (3)

Back 315

-May cause fluid overload and hypersensitivity
-Increased risk of bleeding
-Contraindicated in bleeding disorders, CHF and renal failure

Front 316

Hetastarch (HES) (synthetic starch in 6% or 10%) shifts fluid into ... It causes vascular ...

Back 316

into vessels
vascular expansion

Front 317

Hetastarch nursing considerations ... (3)

Back 317

-May cause hypersensitivity and fluid overload
-Increased risk of bleeding
-Contraindicated in bleeding disorders, CHF, and renal failure

Front 318

Mannitol (alcohol sugar) (5% or 25%) causes ... It also reduces ... edema and eliminates toxins.

Back 318

oliguric diuresis and reduces cerebral edema

Front 319

Mannitol nursing considerations ... (4)

Back 319

-May cause fluid overload.
-May cause electrolyte imbalances
-Cellular dehydration
-Extravassation can cause tissue necrosis

Front 320

Estimation of intra-op fluid requirements is based on an understanding of your patient’s fluid needs as well as the dynamic of fluid compartments
3 types of fluid therapy ...

Back 320

-Fluid therapy is administered to compensate for pre-op fluid deficit
-Maintenance fluids are administered to compensate for evaporative losses & to provide solute for excretion of waste
-Replacement fluids are administered to compensate for surgical fluid losses (3rd spacing and blood loss)

Front 321

Fluid Losses
-GI ...-... ml/day
-Insensible losses ...-... ml/day
-urinary losses ...-... ml/day

Back 321

-GI 100-200 ml/day
-Insensible losses 500-1000 ml/day
-urinary losses 1000 ml/day

Front 322

Fluid loss increases with ... (6)

Back 322

Fever
Wound drainage
GI losses
Perspiration
Blood loss
Drugs

Front 323

Intra-Op Fluid Loss types (4)

Back 323

Surgical
Suction Canister
Surgical sponges
Evaporation (3rd space)

Front 324

4x4 sponges holds approximately ... mL of blood
lap sponges holds approximately ...-... mL of blood
Raytec up to ... ml

Back 324

10ml
100-150ml
25ml

Front 325

Maintenance Fluid Calculation is the ... rule

Back 325

4-2-1

Front 326

Maintenance fluid calculation
>21 kg just add ... = hourly maintenance

Back 326

40

Front 327

Example: Calculate maintenance fluid for a 82 kg male.
1 – 10 kg 4ml/kg/hr x 10 kg = ... ml/hr
11 – 20 kg 2ml/kg/hr x 10 kg = ... ml/hr
21 – 82 kg 1ml/kg/hr x 62 kg = ... ml/hr

Hourly fluid requirement of: ... ml

Back 327

40, 20, 62 = 122 ml
or
Patient > 21 kg rule: 82 + 40 = 122 ml

Front 328

Replace Fluid Deficit Calculation:
Maintenance Fluid multiply by number of hours ....
1st hr. replace ... half, second and third hrs. replace ... of the other ½ half

Back 328

NPO
½
¼

Front 329

Example: 82 kg Male Patient NPO X 7 hours.
His maintenance fluid was ... ml x 7 hrs.= 854 ml
Replace deficit:
½ of (...ml) in the first hour = 427 ml.
¼ of (...ml) in the second hour = 214 ml.
¼ of (...ml) in the third hour = 214 ml.

Back 329

122 ml
854ml
427ml
427ml

Front 330

Third space losses of body fluids refers to the transfer of fluids from the ... space to the ... space or other non-intravascular spaces

Back 330

extracellular space to the interstitial space

Front 331

In third space loss, the volume of fluid that is transferred corresponds to the degree of manipulation of ... intra-op

Back 331

tissues

Front 332

The replacement of third space losses of fluids intra-op is therefore (in/dependent) on the type of surgical procedure the patient is undergoing

Back 332

dependent

Front 333

3rd space fluid losses becomes mobilized on about the ... day post-op and may manifest as an (increase/decrease) in the intravascular fluid volume.

Back 333

3rd
increase

Front 334

3rd Space fluid loss depends on ... (3) of procedure

Back 334

Type, length and extent of procedure

Front 335

3rd space Fluid Loss (ml/kg/hr)
Generic ...
Minimal ...
Moderate ...
Severe ...

Back 335

Generic 2 ml/kg/hr
Minimal 3 – 4 ml/kg/hr
Moderate 5– 6 ml/kg/hr
Severe 7 – 8 ml/kg/hr

Front 336

Current time = 1300 hrs
82 kg 55 yrs. old male
NPO since midnight
Surgery began at 7 am
Case = bladder repair (5 ml/kg/hr)
No blood loss
How much fluid should he have on board at 1300?

Back 336

4047ml

Front 337

Volume Replacement from Blood Loss
Crystalloid Ratio ...
Colloid Ratio ...

Back 337

Crystalloid (3:1 Ratio)
-3 ml of isotonic fluid per 1 mL blood loss
Colloid (1:1 Ratio)
-1 mL of colloid per 1 mL blood loss

Front 338

Goals of Fluid Management (6)

Back 338

Optimizing blood oxygenation
Circulating volume
Perfusion pressure
Electrolyte balance
Normoglycemia
Intra-op fluid Replacement Goal

Front 339

Intra-op fluid replacement Goals: (4)

Back 339

replace pre-op/ intra-op deficits
blood loss
fluid redistribution
evaporation

Front 340

Calculate This!
Current time = 1100
70kg 38 yrs. old female
NPO since midnight
Surgery began at 0800
Case: total abdominal hysterectomy (8 ml/kg/hr)
150 mL blood loss
How much fluid should she have on board at 1100?

Back 340

3340 ml

Front 341

A, B, AB, O : Each represents an enzyme (antigen) that modifies the ...

Back 341

cell surface

Front 342

AB blood: universal ...
O blood: universal ...

Back 342

AB blood: universal recipients
0 blood: universal donors

Front 343

Rh: represent presence/absence of ... antigens in RBC membranes

Back 343

D
80-85% have D antigen= Rh +
15-20% don’t have D antigen= Rh -

Front 344

The primary indication for the transfusion of blood is to increase the ... of the blood.

Back 344

oxygen-carrying capacity

Front 345

Blood has the advantages of ... volume expansion.

Back 345

intravascular

Front 346

... refers to the transfusion of the specific part of blood that the patient needs as opposed to the routine transfusion of Whole Blood

Back 346

Blood component therapy

Front 347

More than ...% of all RBC units are administered in the operating room.

Back 347

60%

Front 348

Average blood volume for adult is approximately ...- ... liter; women may be slightly lower.

Back 348

4.7-5L

Front 349

From ... Blood we can get RBC, Granulocytes, Platelets, FFP, Cryoprecipitate, Factor VIII, Factor IX, Alpha 1 Proteinase Inhibitor, Anti-Inhibitor Coagulation Complex, Albumin, Plasma Protein Fraction, Immune Globulin, Rh Immune Globulin, Anti-thrombin I

Back 349

Whole Blood

Front 350

RBCs
-From 450 mL (donor)
-... needed during administration to trap any clots or debris
-Blood for intra-op transfusion should be warmed to ... degrees centigrade during infusion

Back 350

Filter
37 degrees

Front 351

A single unit of PRBCs will increase adult hemoglobin concentrations about ...g/dL & Hct ...-...%

Back 351

1g/dL & Hct 2-3%

Front 352

RBC Shelf life ..., ... or ... days (1-6 degrees C)

Back 352

21, 35, or 42 days

Front 353

RBC indication for use:

Back 353

increase O2 carrying capacitiy

Front 354

... concentration is the basis on which the decision to transfuse is made

Back 354

Hemoglobin

Front 355

Blood transfusion is almost always justified when the hemoglobin valve is less than ...g/dL and some state it is rarely justified when the hemoglobin valve is greater than ...g/dL. Oxygen transport is said to be maximized when the hemoglobin level is ...g/dL.

Back 355

6g/dL
10g/dL
10g/dL

Front 356

Standard for transfusing blood
ASA – Hemoglobin ... g/dL
NIH – Hemoglobin ... g/dL

Back 356

ASA- 6
NIH- 7

Front 357

**Most important transfusion predictor pre-op is ... **

Back 357

hgb/hct

Front 358

What factor (#) helps determine the Hgb if you have the Hct and vice versa?

Back 358

3
i.e., Hgb 6, what is Hct
6 x 3 = 18

Front 359

Platelets are collected from (single/multiple) donor(s).
Plts are store ... days with gentle agitation

Back 359

multiple
5
-highest transfusion rx d/t multiple donors, may pretreat w/ benedryl or steroids

Front 360

Platelets indication for use (3)

Back 360

-Thrombocytopenia
-Abnormal functioning in the presence of bleeding
-Plt. Count < 50,000 pre-op or intra-op

Front 361

Giving platelets increases the count by ...-...

Back 361

5,000-10,000

Front 362

Fresh frozen plasma comes from whole blood and includes all ...

Back 362

clotting factors

Front 363

FFP is frozen within ...hrs of collection (-18C), has a volume of 200-250ml and is used within ... hrs of thawing

Back 363

8hrs, 24hrs

Front 364

FFP increases clotting factor levels by ...-...%

Back 364

2-3%

Front 365

FFP indication for use (2)

Back 365

coagulation factor deficiencies
volume expander?

Front 366

Albumin is from whole blood, can be stored for 5 years and has a plasma half life of ... hours

Back 366

6 hours

Front 367

Albumin indication for use (2)

Back 367

generally used for oncotic activity with hypovolemia or hypoproteinemia

Front 368

Cryoprecipitate is from thawed FFP (it precipitates), it is immediately refrozen and must be used within ... hours of thawing.

Back 368

4 hours

Front 369

Cryoprecipitate indication for use (1)

contains which clotting factors ...

Back 369

treating hemophilia A
-Contains factors: I, VIII, XIII, Fibronectin, von Willebrand’s factor.
-Contains ~100u of factor VIII + 250mg fibrinogen

Front 370

Autologous Blood is ...

Back 370

Collection, storage and re-infusion of the patient’s own blood.

Front 371

Autologous Blood is safest but not 100% safe.
Donate ... unit per week
Stored for 42 days

Back 371

one

Front 372

Intra-op Blood Collection- Autologous Blood (cell saver) is ...

Back 372

Blood suctioned from operative field, processed and returned to patient.

Front 373

Cell Saver minimized ... usage.
Sterile collection techinque must be maintained and cell save must be used within ... hours of collection

Back 373

Minimizes “banked blood” usage
6 hours of collection

Front 374

Cell Saver contraindication:

Back 374

contamination – tumor cells, bacteria, etc

Front 375

Potential Risks of Transfusion
examples ...

Back 375

Transfusion Reaction
Infection Transmission
Immunosuppression
TRALI
Graft-vs-Host Disease
Anaphylactic Reaction
Hypothermia
Metabolic issues
Circulatory overload
Hypocalemia

Front 376

Crystalloids advantages (3) & disadvantages (3)

Back 376

Advantages- Inexpensive, Increased Urine output,
Replaces ISF
Disadvantages- Transient hemodynamic effect, Peripheral edema, Pulmonary edema

Front 377

Colloids advantages (3) & disadvantages (3)

Back 377

Advantages- Smaller Volume used, Prolonged increase intravascular volume, Less Peripheral edema
Disadvantages- Expensive, Decreased GFR, Coagulopathy

Front 378

Estimated Blood Volume
Premie
Newborn
Child
Adult Female/Male

Back 378

Premie 95 ml/kg
Newborn 85 ml/kg
Child 75 – 80 ml/kg
Adult
Female 65ml / kg
Male 70ml/kg

Front 379

EBV Example: 70 kg adult male
70 kg X 70 ml = ... ml estimate blood volume (EBV)

Back 379

4900ml

Front 380

Calculating Hct Related to Intra-operative Blood Loss
[EBV x (starting hct – target hct 30)] / starting hct

example: male: 70kg, hct = starting hct 42, target hct 27
How much blood will your patient lose by the time their hct reaches 30?

Back 380

1750 ml

Front 381

Calculate This!
70 kg healthy male Hct 42%
Using humidifier on anesthesia circuit
Surgery began at 7am
Time now 10am
NPO since midnight
450 EBL
ORIF distal tibia
Hemodynamically stable
Assume we are only using crystalloid.
What’s the patients volume deficit at 10am?
Volume deficit currently?
What blood loss would put the patient at a HCT of 27%?

Back 381

770ml (NPO status)
2871ml
1750

Front 382

The fundamental requirement of the patient is ..., and sufficient ... delivery is a paramount goal of fluid management

Back 382

oxygen
oxygen

Front 383

Patients pre-procedure volume status may vary greatly.
Correct fluid management influences patient outcome.

Back 383

Patients pre-procedure volume status may vary greatly.
Correct fluid management influences patient outcome.

Front 384

The Anesthesia preoperative assessment is a medical evaluation of the patient’s (current/past) condition, integrated with the anesthesia provider’s unique knowledge of the potential clinical and operative events that may occur.

Back 384

current condition

Front 385

The Joint Commission for the Accreditation of Healthcare Organizations requires that all patients receive a ... anesthetic evaluation.

Back 385

preoperative

Front 386

Purpose of Preoperative visit (6)

Back 386

Learn as much about patient’s medical history as possible
Determine the need for additional pre-op testing
Plan anesthetic and obtain patient’s agreement (consent)
Answer questions and alleviate fears
Establish trusting relationship
Order appropriate pre-op medications

Front 387

Goals of Pre-op visit (7)

Back 387

Standardize Pre-op Care
Improve Patient Outcome
Increase Patient Safety
Reduce Medical Costs
Educate Patient
Improve Patient Satisfaction
Enhance Operating Room Efficiency

Front 388

FYI: Aspects of a Pre-op evaluation

Back 388

History / Medical Record Review
Current / Past Drug Therapy
Physical Examination
Interpretation of Laboratory Data
Risk of Anesthesia
Anesthetic Options
Postoperative Pain Management Options
Assign an ASA Classification
Obtain Informed Consent
Patient Specific Instructions
Additional Work Up

Front 389

History evaluation components ... (5)

Back 389

Previous Anesthetics / Medical Record
Thorough Review of History & Physical
Organ System Function
-CNS, CV, Lungs, Liver, Kidneys, Skeletal / Muscular, Endocrine, Coagulation, Reproduction, Dentition
Allergies
Family History of Anesthetic Complications

Front 390

Drug Therapy: know ... and ... drug therapy and give instructions related to drug therapy- continue/discontinue, half dose

Back 390

current and past drug therapy

Front 391

Physical Examination should include ... (6)

Back 391

Written H & P, transfer H & P
Focus on past and current status of:
-CNS, CV, Lungs and Upper Airway
Potential positioning issues
Regional Anesthetic
Line placement
Airway management issues-prolonged intubation

Front 392

Standard Labs/work-up ...

Back 392

H&H
Chemistries
Coagulation
Urinalysis
ECG
CXR
PFTs
Echo
Stress test
-Additional Labs driven by:
Anesthetic Technique, Surgical Intervention, Patient Condition, etc

Front 393

Risk of Anesthesia
1 death per ... Anesthetics

Back 393

1 death per 250,000 Anesthetics

Front 394

Risk of Anesthesia
1 permanent nerve paralysis per ... epidural placements

Back 394

1 permanent nerve paralysis per 150,000 epidural placements

Front 395

Risk of Awareness while under anesthesia
1 in ...

Back 395

1 in 1,000

Front 396

Postdural Puncture headache ...%

Back 396

1%

Front 397

FYI: Anesthetic options

Back 397

Co-existing Diseases
Site of Surgery
Body Positioning
Elective or Emergent
Age of Patient
Patient Cooperation
Patient Preference
General Anesthesia
Regional
Spinal – Epidural
Peripheral Nerve Block
Local
Sedation
MAC

Front 398

Postoperative Pain Management
Treatment delivered by ... (6 examples)

Back 398

Oral
IM
IV (PCA, Continuous, Intermittent
Neuraxial
-Epidural, Intrathecal
PNB
Transdermal

Front 399

ASA Physical Status Classification
Class 1 is

Back 399

1 - Normal and healthy
no organic, physiologic, biochemical, or psychiatric disturbances

Front 400

ASA Physical Status Classification
Class 2 is

Back 400

2 – Mild-to-moderate systemic disease
Heart disease that SLIGHTLY limits physical activity, HTN, DM, Chronic bronchitis, anemia, morbid obesity, extreme ages

Front 401

ASA Physical Status Classification
Class 3 is

Back 401

Severe systemic disease / Functional limitations
Heart or pulmonary disease that limits activity, poorly controlled co-morbidities, angina, h/o MI

Front 402

ASA Physical Status Classification
Class 4 is

Back 402

4 - Severe systemic disease / Constant threat to life
CHF, persistent angina, pulmonary, renal, hepatic dysfunction

Front 403

ASA Physical Status Classification
Class 5 is

Back 403

5 - Not expected to survive
moribund, resuscitative, minimal chance of survival

Front 404

ASA Physical Status Classification
Class 6 is

Back 404

6 - Organ Donor

Front 405

ASA Physical Status Classification
Class E is

Back 405

E = Emergency
can be attached to any ASA category

Front 406

Informed consent: Obtained by discussing the potential ... and ... of a proposed treatment or procedure and any available alternatives, and then ascertaining that the patient (or patient’s agent) understands and agrees to what is being proposed.

Back 406

risks and benefits

Front 407

Establish a ... relationship with patient

Back 407

personal

Front 408

Patient Instructions ... (3)

Back 408

NPO
Current Medications
Preoperative Medications

Front 409

The cornerstones of an effective preoperative eval are the ... and ..., which should include a complete account of all medications taken by the pt in the recent past, all pertinent drug and contact allergies, and responses and reactions to previous anesthetics

Back 409

history and physical examination

Front 410

the anesthesiologist should not be expected to provide the risk-vs-benefit discussion for the proposed procedure; this is the responsibility and purview of the responsible ...

Back 410

surgeon or proceduralist

Front 411

By convention physicians uses the ... classification to identify relative risk prior to conscious sedation and surgical anesthesia

Back 411

ANA

Front 412

In general, the indications for cardiovascular investigations are the same in surgical patients as in any other patient. How many factors warrant further investigation?

Back 412

at least 3

Front 413

Adequacy of long-term blood glucose control can be easily and rapidly assessed by measurement of ...

Back 413

hemoglobin A1c

Front 414

In pt's deemed at high risk for thrombosis (i.e., those with certain mechanical heart valve implants or with afib and a prior thromboembolic stroke), ... should be replaced by intravenous heparin or more commonly, by intramuscular heparinoids to minimize risk

Back 414

warfarin

Front 415

Current guidlines recommend postponing all but mandatory emergency suregery until at least ... month after any coronary intervention and suggest that treatment options other than a drug-eluting stent (which requires prolonged dual antiplatelet therapy) be used in pt's expected to undergo a surgical procedure withing 12 months after intervention

Back 415

1 month

Front 416

There are no good outcomes data to support restricting fluid intake (of any kind or any amount) more than ... hours before indcution of general anesthesia in healthy patients undergoing elective precedures

Back 416

2 hours

Front 417

There is evidence that nondiabetic pt's should be encouraged to drink glucose-containing fluids up to ... hours before induciton of anesthesia.

Back 417

2 hours

Front 418

To be valuable, pre-op testing must discriminate:
an ... risk exits when the results are abnormal (and unknown); a r... risk exits when the abnormality is absent or detected (and perhaps corrected)

Back 418

increased, reduced

Front 419

The utility of a test depends on its ... and ...

Back 419

Sensitivity and specificity

Front 420

Sensitive tests have a (low/high) rate of false-(positive/negative) results and rarely fail to identify an abnormality when one is present

Back 420

low, false-negative

Front 421

Spefici tests have a ... rate of false-(positive/negative) results and rarely identify an abnormality when one is not present

Back 421

low, false-positive

Front 422

FYI: Premedication should be given purposefully, not as a mindless routine

Back 422

FYI: Premedication should be given purposefully, not as a mindless routine

Front 423

Incomplete, inaccurate, or illegible records unnecessarily complicate defending a physician against otherwise unjustified allegation of ...

Back 423

malpractice