Quiz 3 Basics Of Anesthesia

Front 1

HOW DO YOU MONITOR ADEQUATE CIRCULATION?

Back 1

EKG continuous.
BP, and HR Q 5 min
ALSO---> palpation of a pulse, auscultation of heart sounds, a-line, ultrasound peripheral pulse monitoring or pulse ox, and adequate visualization of the patient.

Front 2

WHAT MUST YOU HAVE IF DOING A GENERAL ANESTHETIC?

Back 2

O2 analyzer with low level limit alarms on.

Front 3

WHAT DOES AN O2 ANALYZER MONITOR?

Back 3

It measures the % of O2 being delivered to the patient. Low limit is usually 30%. (usually given with nitrous)

Front 4

WHAT MUST YOU HAVE IF THE PATIENT IS INTUBATED?

Back 4

ETCO2, disconnect alarm, and stethoscope.

Front 5

WHAT DOES PULSE OX MONITOR?

Back 5

Monitors % of Hgb saturated with O2. Audible pulse flow should be audible, and low limit alarms should be set.

Front 6

WHAT ARE THE TWO LIGHT EMITTING DIODES AND WHAT DO THEY MEASURE?

Back 6

Infrared light --> (960nm) OxyHgb
Red light --> (660nm) DeoxyHgb

Front 7

WHAT DOES BEER-LAMBERTS LAW AND PRINCIPLES OF SPECTROPHOTOMETRY STATE?

Back 7

Relates the <> of a solute to the intensity of light transmitted through a solution.

Front 8

WHAT ARE THE FACTORS THAT ALTER READINGS OF A PULSE OX?

Back 8

-Decreased pulsatile blood flow (hypothermia, hypotension, hypovolemia) - bright lighting, shivering, venous congestion, nail polish, methylene blue, MethHgb, carboxyHgb, motion/electrical interference, mal position.

Front 9

WHAT IS CARBOXYHGB AND HOW DOES IT MANIFEST?

Back 9

COHb, exists in smokers and urban polluted areas. May occur in very high <>'s in smoke inhalation.
COHb has an absorption spectrum similar to Oxyhgb (960nm) so most pulse ox's will overread the SpO2 in smoke inhalation patients---> falsely high readings.
CO TOXICITY --> cherry red appearance late sign!!!!

Front 10

WHAT IS METHEMOGLOBIN AND HOW IS IT MANIFESTED?

Back 10

metHg, It is normal <1% in humans blood.
Oxidation product of hemoglobin Fe3+ (ferric) that forms a reversible complex with O2 and impairs unloading of O2 to tissues.
(Fe 2+) ferrous is the normal iron in Hgb
Can be congenital or acquired.
acquired--> nitrobenzene, benzocaine, prilocaine, and dapsone.
(Prilocaine) metabolite of o-toluidine, which oxidizes Hgb to metHgb.

Front 11

METHEMOBLOBIN AND ABSORPTION?

Back 11

has the same absorption at both the red and infrared wavelengths, this creates a 1:1 ratio.

Front 12

WHAT DOES THE RATIO 1:1 WITH METHEMOGLOBIN MEAN?

Back 12

Sats will read 85%
So metHgb causes a falsely low saturation when SpO2 is greater than 85%, and a falsely high SpO2 sat when the actual sats are lower than 85%.

Front 13

WHAT ARE THE SIGNS AND SYMPTOMS OF METHGB?

Back 13

Brownish grey cyanosis, tachypnea, metabolic acidosis.

Front 14

WHAT ARE THE S/S RELATED TO IN METHGB?

Back 14

1) tissue hypoxia
--LOC may occur in 50-60% of cases
Healthy patients can tolerate but ***patients with severe anemia, or heart failure cannot tolerate the reduced oxygen carrying capacity.

Front 15

WHAT IS THE TREATMENT FOR METHGB?

Back 15

Spontaneous reversal can occur in about 2-3 hours following last dose of the offending drug.
Methylene blue 1mg/kg for immediate treatment.

Front 16

WHAT HAPPENS WHEN YOU TREAT METHGB?

Back 16

Fe3+ turns back to Fe2+
Ferric goes back to ferrous.

Front 17

MAP IS WHAT?

Back 17

an indicator of end organ perfusion NOT a measure of end organ perfusion.

Front 18

WHAT SHOULD CUFF SIZE BE?

Back 18

20% > than diameter of limb and cover 2/3 of upper arm or thigh

Front 19

WHAT DO UNDERSIZED AND OVERSIZED CUFFS READ?

Back 19

UNDERSIZED falsely high readings
OVERSIZED falsely low readings

Front 20

WHAT IS TRUE ABOUT PULSE PRESSURE?

Back 20

The more peripheral (away from the heart) the wider the pulse pressure.

Front 21

WHAT IS PULSE PRESSURE?

Back 21

It is the difference between systolic and diastolic blood pressure.

Front 22

WHAT WILL HAPPEN IF THE BLOOD PRESSURE READING FROM EITHER THE A LINE OR CUFF IS ABOVE THE LEVEL OF THE HEART?

Back 22

+/- 0.7 mmHg for each cm off the horizontal plane of the heart.
If arm is above the level of the heart you will get a low reading.
If below the level of the heart you will get a high reading.

Front 23

WHAT IS THE DEFLATION RATE OF THE CUFF?

Back 23

2-3 mmHg per heartbeat or 3-5 mmHg per sec

Front 24

WHAT ARE KAROTKOFF SOUNDS?

Back 24

volatile blood flow which causes vibrations against the arterial walls.

Front 25

WHAT DO AUTOMATIC BP CUFFS MEASURE?

Back 25

They measure oscillations,

Front 26

WHAT IS MAP?

Back 26

Mean arterial pressure.
Formula 2 x diastolic + systolic/ 3
MAP is the point at which there are maximal oscillations.

Front 27

WHAT IS THE ALLENS TEST?

Back 27

Determines the adequacy of ulnar collateral flow and the integrity of the radial artery.
Hold pressure on radial artery for 5-6 seconds have patient make fists, let go and observe for return of pink color to the hand.
If the hand does not quickly turn back pink it is considered a (+) allens test and do not put a radial a line in that hand.

Front 28

WHAT HAPPENS WITH A READING THAT IS MORE PERIPHERAL FROM THE HEART?

Back 28

the wider the pulse pressure and the higher the systole, and the lower the diastolic.

Front 29

WHAT DO YOU NEED TO INSERT AN A-LINE?

Back 29

1) 18-22 gauge catheter
2) armboard
3) alcohol or betadine
4) lidocaine syringe 25g
5) tape
6) dressing
7) sterile gloves
8) transducer setup
9) face shield

Front 30

WHAT ARE THE STEPS FOR THE TECHNIQUE OF INSERTING AN A-LINE?

Back 30

Apply armboard, hyperextend the thumb
Palpate the radial artery
Clean the site
skin wheel with TB syringe of 1-2% lidocaine
Sterile gloves
Insert angio at 45 degree angle until you get flashback, flatten the angle and advance, guide wire if available thread over wire, occlude attach tubing, suture.

Front 31

WHAT INFORMATION DOES A-LINE MONITORING GIVE YOU?

Back 31

-slope of upstroke- myocardial contractility
- resp variations- large variations may be indicative of hypovolemia
- slope of downstroke- SVR (slurred delayed downstroke indicative of increased afterload
- Dicrotic notch- AV closure

Front 32

WHAT IS GOOD ABOUT LEAD II?

Back 32

Easiest to see the p wave, better diagnosis of arrhythmias, and will show inferior ischemia.

Front 33

WHAT DO LEADS II, III, AND aVF SEE?

Back 33

disease in the inferior side of the heart. RCA

Front 34

WHAT DO LEADS V1-V6 SEE?

Back 34

left anterior descending and circumflex artery distribution

Front 35

LEADS V1, V2, V3

Back 35

anteroseptal wall

Front 36

LEADS V3, V4, V5

Back 36

anteroapical wall

Front 37

LEADS V4, V5, V6

Back 37

anterolateral wall

Front 38

LEADS V1, AND aVL?

Back 38

posterior wall of the heart (reciprocal)

Front 39

DIAGNOSTIC MODE OF MONITOR FOR EKG?

Back 39

least amount of filtering, best for assessing acute changes or pt's risk for ischemia

Front 40

MONITOR MODE FOR EKG?

Back 40

more filtering therefore less diagnostic

Front 41

FILTER MODE FOR EKG?

Back 41

most filtering so changes can be missed

Front 42

WHAT DOES CVP MEASURE REFER TO?

Back 42

hydrostatic pressure generated by the blood within either the right atrium, or the great veins of the thorax at a point adjacent to the right atrium

Front 43

WHAT DOES CVP ESTIMATE?

Back 43

estimated by analyzing two factors, preload and the ability of the right ventricle to pump blood through the pulmonary circulation

Front 44

WHAT CAN YOU TELL FROM THE CVP NUMBER?

Back 44

vasodilation, myocardial ischemia, hypvolemia, hemmorhage, fluid infusion, alterations in local tissue metabolism, changes is sympathetic stimulation

Front 45

WHAT ELSE DOES CVP REFLECT?

Back 45

RVEDP which is preload for the right ventricle
*** if the patient is healthy, may also reflect LVEDP
*** if patient has pulm HTN, or ventricular failure a PAP may be warranted

Front 46

WHAT ARE THE NORMAL VALUES FOR CVP? AND WHAT DO THEY REFLECT

Back 46

1-15 mmHg
depends on patients volume status,
presence of PPV
cardiac function and chamber compliance

Front 47

WHAT ARE THE CONTRAINDICATIONS OF INSERTING A CVP?

Back 47

infected Tricuspid valve vegetations, renal cell tumor extension into right atrium, ipsilateral CEA, anticoagulation, SVC syndrome (obstruction of the SVC), infection at the site of insertion, newly inserted pacing wires, presence of carotid disease, CONTRA LATERAL DIAPHRAGMATIC DYSFUNCTION, thyromegaly or prior neck surgery

Front 48

WHAT ARE THE CVP WAVEFORMS?

Back 48

three peaks a, c, and v waves
two descents x, y

Front 49

WHAT IS THE A WAVE?

Back 49

R atrial contraction, occurs just after the p wave
(absent in a-fib, may be exaggerated in junctional rhythms)

Front 50

WHAT IS THE C WAVE?

Back 50

occurs due to isovolumic ventricular contraction, forcing the tricuspid valve to bulge upward into the right atrium

Front 51

WHAT IS THE V WAVE?

Back 51

reflects venous return against closed tricuspid valve
(LARGE v waves with tricuspid regurgitation

Front 52

CVP INSERTION TECHNIQUE

Back 52

1) Put on monitors 2) Remove pillow and rotate the head to the left 3) Use the bony landmarks of medial end of clavical and mastoid process 4) Place pt in trendelenburg (to distend IJ and reduce risk of air emboli) 5) Full glove and gown sterile prep 6) Recheck landmarks, palpate carotid and immediately lateral 7) If pt awake skin wheel 1% Xylocaine (withdraw on syringe before injecting) 8) using finder needle go b/t sternal head and clavicular head of sternocleidomastoid and insert finder needle aiming toward ipsilateral nipple as you aspirate 9) Once vein has been located leave the finder needle in place 10) Remove finder remember direction 11) Insert 18g 1 3/4 in catheter over needle unit into IJ (constant aspiration is required to see flashback) 12) when flashback is seen advance 1 mm then advance catheter- once iv placement established place finger or syringe over cap to prevent air - withdraw catheter until free blood flow - check for lack of pulsatile flow - compare IJ and arterial blood - pass flexible wire through the catheter (watch ECG monitor for arrythmias) - make small slit with scapel and advance dilator over the wire - advance catheter - check for blood return and flush all ports

Front 53

WHAT IS THE MOST COMMONE REASON TO USE A SWAN? OTHER REASONS?

Back 53

Shock (most common) - poor LV function - detect MI or IABP - complicated valve lesions - severe pulm disease - Bleomycin toxicity - complicated surgical proc - massive trauma - hepatic transplantation

Front 54

TECHNIQUE OF INSERTION OF SWANS

Back 54

Seldinger tech (same as CVP) - sheat over swan (flushed and checked) - insert until you get ~20cm - Inflate balloon and advance until you see RV waveform ~ 30-35cm - Cont to advance to PA ~40-45cm - at ~50cm balloon will wedge into PA - deflate balloon and it will float back into the PA *****know these numbers

Front 55

WHAT ARE THE CONTRAINDICATIONS OF INSERTING SWANS

Back 55

LBBB - tricuspid or pulmonary valve stenosis - right atrial or right ventricular masses - tetralogy of falot - all others same as with CVP

Front 56

WHAT IS THE TEE USED FOR?

Back 56

diagnose myocardial ischemia - valve problems - wall motion abnormalities - air emboli - confirm the adequacy of valve reconstruction - determine the cause of intraop complications or hemodynamic disorders

Front 57

WHAT DOES THE EEG MONITOR?

Back 57

- monitors cerebral function and ischemia - used in carotid and neurosurgery - measures electrical activity of the neurons in the cerebral cortex - detects risk of ischemia due to hypoperfusion

Front 58

ALPHA WAVEFORM ON EEG?

Back 58

eyes closed but awake

Front 59

BETA ON THE EEG?

Back 59

normal, awake waveform

Front 60

DELTA ON EEG?

Back 60

sleep state (deep sleep)

Front 61

THETA ON EEG?

Back 61

sleep state

Front 62

WHAT ARE YOU CONCERNED WITH ON THE EEG?

Back 62

-decreased blood flow to the brain - loss of amplitude - increase in slow wave activity - loss of fast activity

Front 63

WHAT ARE THE WAVEFORMS AFFECTED BY?

Back 63

temp - bp - pH - (electrolyte/CO2 abnormalities) - anesthetics

Front 64

WHAT DO ANESTHETICS DO ON THE EEG ?

Back 64

cause a combo of slow frequencies and superimposed fast activity
**as depth of anesthesia gets deeper the EEG becomes slower

Front 65

WHAT DOES BIS MONITORING DO?

Back 65

Calculates a single number that correlates with depth of anesthesia and hypnosis

Front 66

WHAT DO THE NUMBERS IN BIS MONITORING MEAN?

Back 66

85-100 - awake, memory intact
65-84 - sedation
40-64 - general anesthesia, deep hypnosis
< 40 - cortical suppression

Front 67

WHAT ARE EVOKED POTENTIALS AND WHAT DO THEY DO?

Back 67

evaluate integrity of neural pathways by monitoring response to stimulus - electrical potentials are generated in response to stimulation of a peripheral or cranial nerve - potentials are recorded as they travel from the periphery to the brain -

Front 68

WHAT DOES A DAMAGED PATHWAY SHOW?

Back 68

decrease in amplitude of waveform and prolonged latency
AMPLITUDE - intensity of response
LATENCY - length of time from stimulation to time it reaches the brain

Front 69

WHAT ARE SSEP'S?

Back 69

somatosensory evoked potentials (dorsal)
- stimulate peripheral nerve
- record evoked potential over spinal cord or brain
- used in TAA'S, A/P spinal fusions, harrington rods, complex back surgeries
(SSEP'S are sensing (afferent) effector (efferent) motor coming down from the brain)

Front 70

WHAT ARE BAEP'S OR BAER'S?

Back 70

brainstem auditory ep's
reflect impulses along auditory pathways
MOST RESISTANT TO EFFECTS OF ANESTHESIA
Posterior fossa crani's, acoustic neuromas, CN VIII

Front 71

WHAT ARE VEP'S?

Back 71

Visual EP's
measure cerebral response to flashing light
surgery near optic nerve, pituitary tumor resections

Front 72

WHAT ARE MEP'S?

Back 72

Motor evoked potentials.
(ventral)
Detect motor function of the spinal cord.
MOST SENSITIVE TO EFFECTS OF ANESTHESIA
TAA'S and spinal surgeries

Front 73

WHAT DOES CAPNOGRAPHY MEASURE?

Back 73

ETCO2, gold standard of ET placement and verification
- Continuous monitoring of alveolar ventilation
(PaCO2 <> on avg are 4-6 mmHg > than ETCO2 due to V/Q mismatching (alveolar dead space, alveoli that are ventilated but not perfused)

Front 74

WHAT DOES CAPNOGRAPHY HELP YOU EVALUATE?

Back 74

-evaluates co2, pulm and metabolic status of the patient,

Front 75

WHAT IS CAPNOMETRY?

Back 75

the measure of CO2

Front 76

WHAT IS A CAPNOGRAM?

Back 76

plotting of CO2 over time

Front 77

WHAT IS A CAPNOMETER?

Back 77

instrument used to measure CO2

Front 78

IF NO CO2 DETECTED?

Back 78

ASSUME FAILURE TO VENTILATE--> then check equipment failure, apnea, disconnect, accidental extubation, esophageal intubation, no perfusion state

Front 79

WHAT WILL HAPPEN IN A NO PERFUSION STATE?

Back 79

your CO2 will be low

Front 80

HOW DO YOU ANALYZE A CO2 WAVEFORM?

Back 80

HEIGHT - higher (increasing CO2)
FREQUENCY - more frequent increasing RR
RHYTHM -
BASELINE - should return each time to zero

Front 81

WHAT DO YOU DO IF THE CO2 WAVEFORM DOES NOT RETURN TO ZERO?

Back 81

Recalibrate, could be rebreathing CO2, or retaining CO2.
Check the soda lime, change it and check the expiratory valve

Front 82

WHAT ARE THE FOUR PHASES OF ETCO2 MONITOR MEAN?

Back 82

4 PHASES
I - inspiration (no CO2, breathing in O2)
II - expiratory upstroke (beginning to exhale)
III - expiratory plateau, (static period, no air movement)
IV - inspiratory downstroke, (fresh gas entrained, CO2 washed away)

Front 83

WHAT IS GOING ON IF YOU HAVE A LEANED OVER CO2 WAVEFORM?

Back 83

the patient is having trouble exhaling
- COPD, kink, foreign body obstruction, emphysema

Front 84

STAIR STEPPING FORM ON CO2 WAVEFORM?

Back 84

cardiac oscillations (normal)

Front 85

V FORM IN THE MIDDLE OF THE CO2 WAVE?

Back 85

curare cleft ( patient is attempting to breathe)

Front 86

WHAT'S PROB HAPPENING WITH A GRADUAL DOWNSTROKE?

Back 86

inspiratory problem probably kink in tube

Front 87

WHAT DOES ESOPHAGEAL INTUBATION LOOK LIKE?

Back 87

waveform small and gradually decreased to zero

Front 88

WHAT MAY A LOW ETCO2 WITH A GOOD ALVEOLAR PLATEAU SHOW?

Back 88

hyperventilation or an increase in dead space ventilation
***comparison of PetCO2 with PaCO2 is necessary to distinguish these two conditions
**you can also slow their breathing and see what happens

Front 89

ELEVATED ETCO2 WAVEFORM WITH GOOD ALVEOLAR PLATEAU?

Back 89

may be hypoventilation or increased CO2 delivery to the lungs
**could be not fast enough or deep enough breathing, MH, hyperthermia, could also be the belly inflated with CO2

Front 90

CURARE CLEFT?

Back 90

looks like a M
occurs during spontaneous breathing, the cleft is in the last plateau, and is caused by a lack of synchronous action between the intercostal muscles and the diaphragm, most commonly caused by inadequate muscle relaxant reversal.
**the depth of the cleft is proportional to the degree of muscle paralysis
**the notch is also seen in patients with cervical transverse lesions, flail chest, hiccups, and pneumothorax when a patient tries to breathe during mechanical ventilation.

Front 91

SPONTANEOUS RESPIRATIONS DURING MECHANICAL VENTILATION?

Back 91

causes include maladjusted ventilator (hypoventilation), inadequate muscle paralysis, severe hypoxia, or the patient waking up

Front 92

CARDIAC OSCILLATIONS?

Back 92

believed to represent the effects of the contractions and relaxations of the heart and intrathoracic great vessels of the lungs, forcing air in and out.
***many things contribute - presence of negative intrathoracic pressure, a low RR, dimunition in the VC: heart size ratio, low inspiratory : expiratory ratio, low tidal volumes, and muscular relaxation
**rule rather than the exception in pediatric patients

Front 93

OBSTRUCTIVE ETCO2 WAVEFORM?

Back 93

slanting and prolongation of the expiratory upstroke, indicative of tube obstruction, or obstruction in patient's airway, (chronic obstructive lung disease, bronchospasm, asthma, or upper airway obstruction)

Front 94

PROBLEM WITH ETCO2 BASELINE?

Back 94

incompetent expiratory valve, (normal waveform just not going to baseline)
**could also be exhauseted absorbent in the circle system, insufficient gas flow in mapleson system, problems with the inner tube of the Bain system, deliberate addition of CO2 to the fresh gas,
**might also be a spontaneously breathing patient under the drapes that is not intubated

Front 95

INCOMPETENT INSPIRATORY UNIDIRECTIONAL VALVE?

Back 95

prolonged CO2 plateau and an inspiratory downstroke that is less steep
***may be seen with suction on a chest tube

Front 96

REINSTATING SPONTANEOUS BREATHING?

Back 96

In the beginning first breath is typically of small volume,

Front 97

WHAT COULD CAUSE A SUDDEN DECREASE IN ETCO2 READING FROM NORMAL TO ZERO?

Back 97

PE, esophageal intubation, ventilator disconnection or defect in ventilator, defect in CO2 analyzer, kinked ET tube

Front 98

SUDDEN DECREASE OF ETCO2 BUT NOT TO 0?

Back 98

leak in ventilator system, partial disconnect, partial airway secretions, (secretions)

Front 99

EXPONENTIAL DECREASE IN ETCO2?

Back 99

PE, cardiac arrest, hypotension (sudden), severe hyperventilation

Front 100

CHANGE IN CO2 BASELINE?

Back 100

CO2 absorber saturation (anesthesia), calibration error, water droplet in analyzer, mechanical failure (ventilator),

Front 101

SUDDEN INCREASE IN ETCO2?

Back 101

Accessing an area of lung previously obstructed, release of tourniquet, sudden increase in bp

Front 102

GRADUAL LOWERING OF ETCO2?

Back 102

hypovolemia, decreasing CO, decreasing body temp, hypothermia, drop in metabolism

Front 103

GRADUAL INCREASE IN ETCO2?

Back 103

rising body temp, hypoventialtion, CO2 absorption, partial airway obstruction (foreign body) reactive airway disease.

Front 104

WHAT DO SPIROMETERS MEASURE?

Back 104

RR, MV, AND TV (manual or electric)

Front 105

INFRARED ANALYSIS?

Back 105

Absorption of energy yields measurement, (gas drawn out of circuit, exposed to infrared energy, --> CO2, ISO

Front 106

MASS SPECTROMETRY OF ETCO2?

Back 106

sample ionized in electron beam, fragments form and are weighed, <> of agents are determined.