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254 Cards in this Set
- Front
- Back
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the upper airway is defined as what
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the extra pulmonary air passage, consisting of the nasal and oral cavities, pharynx, larynx, trachea and principal bronchi
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the pharynx is divided into what
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nasopharynx and oropharynx separated by the soft palate
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the pharynx extends from where to where
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posterior nose to cricoid cartilage
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the oropharynx sensory innervation is via what
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3 cranial nerves
*vagus *facial *glossopharyngeal |
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what innevates the vagus nerve
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the superior laryngeal nerve
(internal branch) |
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what nerve innervates the base of the tongue and eppiglotis
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superior laryngeal nerve
(internal branch) |
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what nerve innervates the posterior tongue, vallecula, epiglottis, walls of pharynx and tonsils
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the 3 branches of the glossopharyngeal nerve
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where does the epiglottis attach
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below the root of the posterior tongue and projects into the laryngeal inlet
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what is the vallecula
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the depressions between the epiglottis and the root of the tongue on either side of the median fold
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the laryngeal skeleton consists of how many cartilages
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9
(3 paired and 3 unpaired) |
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what are the paired laryngeal skeleton cartilages
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*corniculates
*cuniform *arytenoid |
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what are the unpaired laryngeal skeleton cartilages
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*epiglottis
*thyroid *cricoid |
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the larynx is innervated by what bilaterally
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the vagus nerve
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what 2 branches come off of the vagus nerve and innervate the larynx
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*superior laryngeal nerve
*recurrent laryngeal nerve |
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what nerve that innervates the larynx has a greater chance of injury and why
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*recurrent laryngeal nerve
-b/c it is more superficial |
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the trachea begins where
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the level of the 6th vertebra
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the trachea has what kind of shape POSTERIORLY
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flat
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the trachea has what kind of shape ANTERIORLY
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horseshoe shaped cartilage rings
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what are predictors for determining a difficult airway
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*mallmpati classification
*3-3-2-1 rule *neck mobility |
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what is the definition of a difficult airway
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the existence of clinical factors that complicate either ventilation administered by face mask or intubation perfomed by experienced and skilled clinicans
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a mallampati classification is performed with the pt in what position
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sitting or standing
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how do you perfome a mallampati classification
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ask pt to open mouth as wide as possible and stick out their tongue WITHOUT phonation
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what is the principle of mallampati classification based on
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size of tongue and relevance to size of oropharynx
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what is a class I mallampati
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visualization of the soft palate, fauces, uvula and ant and post pillars
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what is a class II mallampati
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visualization of the soft palate, fauces and uvula
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what is a class III mallampati
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visualization of the soft palate and the base of the uvula
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what is a class IV mallampati
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soft palate is not visable at all, only HARD palate is visable
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inter-incisor distance should be what
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3 fingers
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thyromental distance should be what
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3 fingers
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what is thyromental distance
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distance from beginning of chin to beginning of neck
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floor of mandible to thryoid notch should be what distance
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2 fingers
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jaw anterior subluxation should be what
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1 finger
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what is the normal range of motion in the c-spine (atlanto-occipital ROM)
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35 degrees of flexion
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what should you note when having pt do c-spine/neck ROM
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*paresthesias
*restrictions *trauma *pain |
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how should c-spine ROM of motion be perfomed
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have pt place their chin on their chest and tilt head backwards as far as possible
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what is the definition of difficult ventilation
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the inability of a trained anesthetist to maintain the o2 sat >90% using a face mask for ventilation & 100% inspired o2 provided that the preventilation o2 sat level was within normal range
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what is the number one reason for difficulty ventilating a patient
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upper airway obstruction d/t the tongue resting against posterior pharynx
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what are the ways in which to establish a patent airway
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*chin lift and jaw thrust maneuver
*oropharyngeal airway *nasopharyngeal airway *LMA *ET intubation |
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what is the simpliest appliance for increasing delivered o2
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nasal cannula
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what oxygen delivering device is used frequently on pts receiving monitored anesthesia care or regional anesthesia
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nasal cannula
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what type of airway management may result in gastric distention
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mask ventilation
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with what type of airway management may laryngospasm occur
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mask ventilation
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what are the indications for using a LMA
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*free the anesthetists hands
*establishment of emergency airway *facilitate intubation |
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what are the contraindications to use of a LMA
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*full stomach
*hx of gastric reflux *low pulmonary compliance (pulm fibrosis, morbid obesity) |
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what do you do for preparation of a LMA
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*check cuff patency
*lubricate POSTERIOR surface only |
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what is the definition of difficult intubation
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the need for more than 3 intubation attempts or attempts at intubation that last > 10 min
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what are the indications for intubation
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*airway protection
*need to deliver pp ventilation *sx procedures involving head, neck, chest, and or in non-supine positions *almost all situations that involve NMB *procedures that may involve intracranial HTN |
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what are the contraindications for intubation
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*pts with intact gag reflex
*basilar skull fx (avoid nasal intubation, nasal airways, NG tubes) *operator limitations |
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how should you position the pt for intubation
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*elevate head to approx 10 cm
*sniff position |
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intubation attempts should never exceed how long
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30 sec
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what should ALWAYS be available with intubation
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SUCTION
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when should you oxygenate the pt with intubation and how
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pre and post intubation attempts with positive pressure with 100% o2
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tube placement should always be checked how
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*auscultation
*fogging of tube *chest excursion *******Co2 on capnography***** |
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how do you preoxygenate/denitrogenate
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*TVB-3 min @ 5 L o2
*DB-8 DB x 1 min @ 10 L 02 *DB-4 DB x 30 sec @10 L 02 |
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denitrogenation is 95% complete within what amt of time and at what liter flow if doing TVB in a circle system
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within 3 min at 5 L/min flow
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what is the main reason for failure to acheive adequate preoxygenation
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face mask leak
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what is the ideal state for the cords to be in after a paralytic has been given
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open and relaxed
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the BURP maneuver does what
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improves visulization of the airway
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how do you perform the BURP maneuver
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*posterior pressure on the larynx against cervical vertebra (backward)
*superior pressure on the larynx as far as possible (upward) *lateral pressure on the larynx to the right (right) |
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what are the steps for preparation for RSI
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*consider prophylactic use of bictra, robinal, reglan
*prepare pt that they might feel "pressure on neck" as they go to sleep *suction close at hand *preoxygenate to the max |
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what is the difference b/t a glidescope and a regular laryngoscope blade
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a glidescope has a more acute (60 degree) distal angulation
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what are some causes of failed intubation
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*poor positioning of the head
*tongue in the way *pivoting laryngoscope against upper teeth *rushing or too cautious *inadequate sedation *inappropriate equipment *unskilled anesthetist |
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when should the sellick maneuver be started
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BEFORE induction drug is pushed
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how is the cricoid pushed in the sellick maneuver
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posteriorly
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when should the "helper" release the sellick maneuver
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not until instructed
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when is nasal intubation indicated
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*oral sx
*long term intubation |
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what are the contraindications for NASAL intubation
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head injury that might include a skull fx
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how should you prepare the nose for a nasal intubation
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*lubricate nasal passage
*oxymetazoline or phenylephrine nose gtts to shrink nasal mucosa |
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with a left broncho-cath tip tube the small tip and blue cuff enter where
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left main stem
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with a left broncho-cath tip tube the second lumen terminates where
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in the trachea
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what secures the airway with a left brocho-cath tip tube
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tracheal cuff
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extubation in a light plane of anesthesia may cause what
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laryngospasm
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what are the things that should be done with extubation
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*assure NMB is adequately reversed
*preoxgenate pt with 100% o2 *thoroughly suction mouth & pharynx PRIOR to deflating cuff *apply a small amt of pp while pulling ET tube *always apply a face mask immediately & confirm movement of air |
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what are signs that the pt is NOT ready for extubation
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*eyes deviate from midline
*breath holding |
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what are indicatios that the pt can protect their airway
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coughing and bucking on the tube
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laryngospasm can usually be broken how
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with application of CONTINUOUS positive pressure
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is the normal way to break laryngospasm doesn't work what needs to be done
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*reanesthetize
-succinylcholine -propofol |
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who is more prone to laryngospams adults or children
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CHILDREN
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with extubation anything on cords will cause what to occur
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LARYNGOSPASM
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if you hear stridor after extubation that is a sign that what is occuring
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LARYNGOSPASM
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what are you trying to prevent by using the sellick maneuver
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passive regurgitation
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what do you NOT do with a RSI that is perfomed with a routine intubation
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positive pressure ventilation
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when should the sellick maneuver NOT be perfomed
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with active vomiting
(could rupture esophagus) |
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where is a "weak point" for leaks on mask
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on the side where fingers form a "c"
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what LMA can you suction gastric contents through and provide positive pressure ventilation through
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proseal
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what LMA can you intubate through
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Fastrach
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if the recurrent laryngeal nerve is damaged on both sides what may occur
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may have trouble breathing secondary to some motor involvement
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total body water is what percent of body weight
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~60%
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water content decreases rapidly when
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during the 1st 3-5 yrs of life
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water content is less in what population
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*females
*elderly |
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intracellular fluid is what percent of body weight
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40%
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extracellular fluid is what percent of body weight
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20%
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extracellular fluid is further divided into what categories
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*interstitial fluid
*plasma |
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what is interstitial fluid
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it is primarily in gel structure with proteoglycans
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what is plasma
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the fluid portion of the blood
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plasma is in equillibrium with what
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interstitial fluid
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what contains higher protein content intersitial fluid or plasma
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plama
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what fluid compartment intracellular or extracelluar contains most of total body sodium
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extracellular
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what is the value for extracellular sodium
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140
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the predominate INTRACELLUAR cation is what
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POTASSIUM
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what is the value for potassium intracellularly
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150 mEq/L
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what is the most osmotically active substance of the EXTRAcellular fluid
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ALBUMIN
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albumin is in a larger concentration in the interstitial fluid or plasma
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PLASMA
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the intercompartmental distribution of water is maintained by what
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hydrostatic, osmotic and oncotic forces
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what is hydrostatic pressure
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pressure exerted by the weight of a fluid, thus water moves from a compartment of high hydrostatic pressure to one of low hydrostatic pressure
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what is osmosis
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movement of water across a semi-permeable membrane from a compartment of low solute concentration to a compartment of high solute concentration
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what is osmotic pressure
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pressure on one side of the semipermeable membrane that is just sufficient to keep water from moving to a region of higher solute concentration
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osmotic pressure is determined by what
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the number of non-diffusable particles in a solution
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what is oncotic pressure
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the osmotic pressure exertged by plamsa proteins
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what is tonicity
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the effect a solution has on cell volume
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a hypotonic solution does what to cell volume
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increases it
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a hypertonic solution does what to cell volume
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deceases it
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what is diffusion
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random movement of molecules d/t their kinetic energy
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what is responsible for the majority of fluid and solute exchange b/t compartments
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diffusion
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the rate of diffusion of a substance across a membrane depends on what
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*the permeability of that substance
*the concentration diff across the membrane *the pressure diff across the membrane *the electrical potential across the membrane (for charged particles) |
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diffusion through cell membranes is by what mechanisms
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*directly through the lipid bilayer
*through protein channels *by reversibly binding to a carrier protein |
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what substances use diffusion by going directly through the lipid bilayer
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*o2
*Co2 *water *lipophillic molecules |
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what molecules use protein channels with diffusion
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*na
*K *Ca |
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what molecules use carrier proteins in diffusion
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*glucose
*amino acids |
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what type of molecules readily cross intracellular clefts in diffusion
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LOW molecular weight
(Na, Cl, K, glucose) |
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what type of molecules cross the intracellular clefts in diffusion poorly
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HIGH molecular weight
(plasma proteins) |
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what are the primary factors determining fluid exchange across the capillary membrane
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*cap hydrostatic pressure
*interstitial hydrostatic pressure *interstitial oncotic pressure *plasma oncotic pressure |
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as a result of the primary factors determining fluid exchange across the cap membrane fluid does what
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moves OUT of the cap at the ARTERIAL end and BACK at the VENOUS end
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normally all but what amt of fluid filtered is reabsorbed into the capillaries
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10%
(rest enters the interstitium & returned by lymphatic flow to intravascular compartement) |
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what is the primary EXTRAcellular cation
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SODIUM
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what electrolyte provides osmotic forces to maintain water balance in the interstitial space
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SODIUM
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what electrolyte regulates osmotic concentration and pressure
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SODIUM
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generally sodium and ______ disturbances occur simultaneously
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water
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sodium levels are regulated by what
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kidney
-primarily via action of aldosterone |
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what electrolyte levels indicate overall fluid balance
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SODIUM
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what is HYPERnatremia
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an increase in sodium concentration in the ECF
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how does HYPERnatremia occur
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with either pure water loss, hypotonic fluid loss or salt gain
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what is volume status with HYPERnatremia
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may be either hypovolemic, euvolemic or hypervolemic
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HYPERnatremia ALWAYS results in what tonicity
|
HYPERtonicity
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what are causes of HYPERnatremia
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*impaired thirst
*osmotic diuresis *excess water loss *iatrogenic (NG feeding w/ hypertonic solution) |
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what are the s/s HYPERnatremia
|
*lethargy or mental changes
*shock *peripheral edema *muscle tremor *muscle rigidity *coma *sz *intracranial hemmorage |
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what is the tx for HYPERnatremia
|
*aimed at correcting normal osmolality and volume status
*correct hypovolemia with 0.9% NS *correct HYPERnatremia with hypotonic fluids (D5W) |
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what can occur if HYPERnatremia is corrected too RAPIDLY
|
it can result in sz or cerebral edema
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what is HYPOnatremia
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body fluids are diluted by an excess of water relative to total solute
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majority of HYPOnatremic pts have what type of total body sodium
|
normal or increased qtys
(usually d/t impaired urinary diluting capacity) |
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what is the most common electrolyte disturbance in hospitalized pts
|
HYPOnatremia
|
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what electrolyte disturbance is associated with non-physiologic release of ADH with impairment of renal diluting capacity
|
HYPOnatremia
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factors that cause release of ADH include what
|
*pain
*sympathetic stimulation *nausea (the stresses of sx) |
|
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a hyponatremic states lends itself to what kind of fluid shift
|
osmotic shift of fluid out of the extracellular compartment and into the intracellular compartment
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the fluid shift that occurs with HYPOnatremia causes what
|
fluid depletion in the ECF compartment and hypovolemia
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a severe fluid shift with HYPOnatremia can cause what to occur
|
cerebral edema
|
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rapid tx of HYPOnatremia can result in what occuring
|
brain dehydration
(central pontine demyelination) |
|
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in anesthesia HYPOnatremia is a concern in what type of cases
|
*irrigation with large amts of fluids (TURP, endometrial ablation)
*pts receiving oxytoxin which has an intrinsic antidiuretic effect leading to increase in water reabsorption |
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what are the symptoms of acute HYPOnatremia
|
*confusion
*weakness *nausea *lethargy *sz |
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when do s/s of HYPOnatremia begin to appear
|
with a sodium level below 120 mEq
|
|
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what is the predominant INTRAcellular cation
|
POTASSIUM
|
|
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what amt of total body potassium is located INTRAcellularly
|
98%
|
|
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what electrolyte provides the osmotic forces to maintain water balance in intracellular fluid space
|
POTASSIUM
|
|
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potassium imbalances result in what
|
altered function of excitable membranes
(heart, CNS) |
|
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what electrolyte is the major determinant of the RESTING MEMBRANE POTENTIAL
|
POTASSIUM
|
|
|
what is required to prevent hyperkalemia
|
normal renal function
|
|
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what is HYPERkalemia
|
elevated potassium concentration in the ECF
|
|
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what are the causes of HYPERkalemia
|
*renal failure
*re-perfusion of large ischemic vascular bed *transfusion of blood *addisions dz *use of cardioplegia solutions *drugs |
|
|
what is the most common cause of HYPERkalemia
|
DRUGS
|
|
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what are drugs that INHIBIT potassium excretion
|
*NSAIDs (also ketolorac)
*ACE inhibitors *cyclosorin *K sparing diuretics |
|
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HYPERkalemia signs are associated with what
|
interference of normal nerve and muscle function
|
|
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HYPERkalemia does what to the resting membrane potential
|
makes it LESS negative
(cells become MORE excitable b/c it is easier to reach threshold) |
|
|
what are the myocardial symptoms seen with HYPERkalamia
|
*peaked T waves
*decreased P waves *widened QRS *v-tach *v-fib |
|
|
what is the tx for HYPERkalemia
|
*calcium (1 gm over 3 min)
*NaHCO3 *hypertonic dextrose with regular insulin (10 units) *furosemide *b-adrenergic agonists |
|
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what is HYPOkalemia
|
low potassium concentrations in the ECF
|
|
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what is the most common cause of HYPOkalemia
|
diuretic therapy
|
|
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what are causes of HYPOkalemia
|
*diarrhea
*gastric suctioning *starvation *insulin therapy *catecholamines |
|
|
HYPOkalemia does what to the resting membrane potential
|
makes it LESS negative
(cell become LESS excitable and it is more difficult to reach threshold) |
|
|
what are the ECG signs with HYPOkalemia
|
*flattened or depressed T wave
*prominent U wave *a-fib *PVC's |
|
|
what are the s/s of HYPOkalemia
|
*anorexia
*weakness *decreased muscle tone and weakness |
|
|
what is the treatment for HYPOkalemia
|
potassium replacment and tx of the underlying cause
|
|
|
what is the usual K replacement regimen for HYPOkalemia
|
10-20 mEq/hr
avoid > 0.5 mEq/kg/hr |
|
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what electrolyte is a vital ion in normal neuromuscular activity, cardiac rhythm & contractility, cell membrane fxn and coagulation
|
CALCIUM
|
|
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what electrolyte is the major determinant of the THRESHOLD POTENTIAL
|
CALCIUM
|
|
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what electrolyte is highly protein bound (40%)
|
CALCIUM
|
|
|
total plasma calcium levels vary with what
|
plamsa albumin levels
|
|
|
what form of calcium is the physiologically active form
|
ionized calcium
-50% of circulating Ca |
|
|
what can change levels of protein bound and ionized Ca
|
*acidemia
*alkalemia |
|
|
what is calcium regulated by
|
parathyroid hormone and vit D
|
|
|
what are symtoms of MODERATE HYPERcalcemia
|
*lethargy
*anorexia *nausea *polyuria |
|
|
what are symptoms of SEVERE HYPERcalcemia
|
*muscle weakness
*impaired memory *HTN *dysrhytmias *heart block *cardiac arrest *digitalis sensitivity |
|
|
what does HYPERcalcemia do to threshold potential
|
it shifts AWAY from the resting membrane potential
(cell become LESS excitable b/c it is more difficult for the RMP to depolarize to threshold) |
|
|
what is the most common cause of HYPOcalcemia in the OR
|
*hyperventilation
*admin of large amts of citrated blood |
|
|
what is the hallmark of HYPOcalcemia
|
increased neuronal membrane irritability and tetany
|
|
|
what are s/s of HYPOcalcamia
|
*numbness
*tingling *muscle spasm (+ Chvosteks & Trousseaus sign) *laryngospasm *bronchospasm *resp arrest |
|
|
with HYPOcalcemia decreased cardiac fxn manifest as what
|
*heart failure
*hypotension *dysrhythmias *insensitivity to digitalis *impaired b-adrenergic action |
|
|
how does HYPOcalcemia affect threshold potential
|
threshold potential shifts TOWARD RMP
(cells become MORE excitable b/c it is easier for the RMP to reach threshold) |
|
|
what electrolyte is necessary for enzymatic reactions
|
MAGNESIUM
|
|
|
what electrolyte has been called the endogenous calcium antgonist
|
MAGNESIUM
|
|
|
what electrolyte regulates slow calcium channels to help maintain normal vascular tone and prevent vasospams
|
MAGNESIUM
|
|
|
what electrolyte partially regulates parathyroid hormone secretion
|
MAGNESIUM
|
|
|
HYPERmagnesemia is caused by what
|
usually iatrogenic
*antacids *enemas *parental nutrition |
|
|
what are the s/s of HYPERmagnesemia
|
*coma
*hypoventilation *hypotension |
|
|
what is the anesthetic importance of HYPERmagnesemia
|
depolarizing and non-depolarizing blockade is potentiated
|
|
|
what are the clinical features of HYPOmagnesemia
|
*neuronal irritiabilty & tetany
*weakness *muscle spasm (+ Chvosteks & Trosseaus sign) *parasthesias |
|
|
what are the causes of HYPOmagnesemias
|
*prolonged gastric suctioning
*GI fistulas *intestional drains *drug therapy (aminoglycosides, cardiac glycosides, diuretics) |
|
|
osmolality is regulated by what
|
osmoreceptors in the hypothalmus
|
|
|
osmoreceptors in the hypothalamus control what
|
*ADH
*thirst mechanism |
|
|
what controls ADH secretion
|
specialized cells in supraoptic nuclei of the hypothalamus
|
|
|
ADH is released from where
|
the posterior pituitary
|
|
|
ADH increases water reabsorption where
|
renal collecting tubules
|
|
|
decreased ADH secretion causes what
|
diuresis
|
|
|
carotid baroreceptos and atrial stretch receptors can stimulate ADH secretion how
|
following a 5-10% decrease in blood volume
|
|
|
water requirement is proportional to what
|
metabolic rate
|
|
|
what is normal water requirement
|
~1ml of water/kcal
|
|
|
in a normal 24 hr period water intake should equal what
|
water output
|
|
|
daily water loss occurs how
|
via
*skin *urinary, GI, resp tracts |
|
|
what are INSENSIBLE water losses
|
water losses via the skin (except sweat) and resp tract
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what amt of water lost per day is INSENSIBLE
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1 L/day
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what amt of total water loss is from INSENSIBLE sources
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~ 25-30%
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INSENSIBLE water loss is increased with what
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*elevated temp
*ventilation with dry anesthetic gases |
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what are SENSIBLE water loses
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*GI
*urine *sweat |
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what is average urine output
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1ml/kg/hr
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GI water loss is how much per 24 hrs
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100-150 ml
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what is maintence fluids
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replacement of the insensible and sensible water losses
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pts have a pre-existing fluid deficit after fasting that is proportionate to what
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the duration of the fast
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in what situations may abnormal fluid losses be present prior to sx
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*pre-op bleeding
*vomiting *diarrhea *diuresis *fluid sequestration from trauma or infection (edema) |
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with fluid loss there may be increased INSENSIBLE loss d/t what
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*hyperventilation
*fever |
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a fully soaked 4x4 has approx how much blood
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10-15 ml
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a fully soaked lap sponge has approx how much blood
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80 ml
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what are causes of PERI-op fluid loss
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*blood loss
*evaporation from surgical wound *internal redistribution of fluids (third spacing) *dz caused fluid loss |
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mobilization of accumulated fluid from third spacing to the ECV and PV occurs when
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approx 3 post op day
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what are the purposes of fluid admin during anesthesia
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*replace INSENSIBLE fluid losses
*replace SENSIBLE fluid losses *maintain an adequate and effective blood volume *maintain CO and tissue perfusion |
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what is the primary objective of peri-op fluid management
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maintenance of adequate tissue perfusion for o2 delivery
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what is the formula for fluid replacement for pts weighing over 20kg
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pts weight in kg + 40 =
maint in ml/hr |
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for estimating 3rd space losses for MAJOR tissue trauma what is the replacement amt
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8ml/kg/hr
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for estimating 3rd space losses for MODERATE tissue trauma what is the replacement amt
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6ml/kg/hr
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for estimating 3rd space losses for MINIMAL tissue trauma what is the replacement amt
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4ml/kg/hr
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for blood replacement if using blood products it is replaced in what ratio
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1:1
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for blood replacement if using colliods it is replaced in what ratio
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1:1
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for blood replacement if using crystalliods it is replaced in what ratio
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3:1
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for blood loss you replace with either crystalloids or colliods until what point
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the danger of anemia outweighs the risk of transfusion
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with most pts a transfusion point corresponds to a Hgb of what
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7-10
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elderly and those with cardiac and/or pulmonary dz may have a Hgb of what as a transfusion point
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10
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what is the formula for determining max allowed blood loss
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MABL=
EBV(pts Hct - min allowedHct) -------------------------------------------- Hct |
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what is the average blood volume for an adult
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70 ml/kg
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what is the average blood volume for the elderly
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65 ml/kg
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crystalloids for replacement fluids are generally what type of fluids
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polyionic isotonic fluids
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what type of crystlloids closely mimic plasma electrolyte concentrations
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*LR
*Plamalyte 148 *Plasmalyte A |
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what are colliod solutions
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usually solution of starch or dextrans of various molecular wts
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what are colloids designed for
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to remain in the vascular space increasing osmotic pressure
(helps maintain intravascular fluid volume) |
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what type of problems are associated with colloids
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*allergic rxns
*impaired coagualation *renal damage |
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what blood product contains colloids, clotting factors including plts, and RBC for o2 carrying capacity
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whole blood
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why is stored whole blood not as useful as fresh blood
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d/t reduced o2 carrying capacity, plts are inactive and clotting factors may degrade
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what blood product is useful in treating anemia
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packed RBC
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what blood product reduces the risk of overload
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PRBC
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what should be done with PRBC
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reconstitute with equal volumes of 0.9% saline
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what does fresh plasma contain
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*colloids
*active plts *clotting factors |
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what blood product is useful in treating coagulation defects
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fresh plasma
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frozen plamsa can be stored for how long
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1 year
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frozen plasma is a source of what
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colloids (plasma proteins)
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what is the difference b/t LR and NaCl
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LR contains Ca and NaCl does NOT
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what is the FIRST sign of HYPOnatremia
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confusion
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what makes up the blood brain barrier
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tight intracellular clefts
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