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Nurs568 test 3

Induction maintenance emergence and fluid and electrolite

Holding area routine Id surgeon, paperwork, analgesia, into to OR
In the OR Lock bed with 2 people, announce lock bed, move patient and document as such
After pt is in or table Sfety strap, ask pt to place arms on pad, bp cuff, pre oxyg, hook up monitors, keep airway at head of bed, talk to pt, induce, hold mask, lid reflex, tape eyes, mask vent
If unable to vent Change position, airway nasal or oral
After ventilation establish Give nmbd wait for effect then intubate, confirm placement
Oince intubated Turn on vent, lower O2 flow, turn on vaa, secure ett, tape eyes if not done so, insert goos stethoscope, airway, check final position
An anesthetic must consist of Unconscious, analgesia, amnesia, hemodynamics stability, control pt movement
Anesthesia 4 stages 1. Analgesia 2.excitment 3. Surgical plane 4. Anesthetic overdose
Stage 1 gudel Stage one analgesia, pt awake Able to communicate
Stage 2 gudel Stage 2 excitment, may experience delirium or become violent BP increase irregular, Resp increase, maybe bypassed by meds avoid noxious stimuli
Stage 3 guedel Surgical, Resp regular, constriction of pupil, no involuntary movement, loss of vocalization
4 planes Of stage 3 Plane 1 light anesthesia has lid reflex swallow reflex intact regular chest Resp movement. Plane 2: loss of blink, pupils fixed Resp regular. Plane 3: loss of chest movement and abd, shallow and assisted breathing. Plane 4: no chest movement deep surgical
Stage 1 Guedel and pupil Reactive Resp irregular, pulse irregular bp normal
Stage 2 guedel pupil Reactive pupils, irregular Resp faster, irregular fast hr high bp
Stage 3 Guedel Fixed pupils reg Resp, steady slow pulse, normal
Stage 4 Guedel Dialted pupils, short shallow breath, weak thready pulse, low BP
Induction dose sequence of general induction dose for avg adult Midazolam 1-2mg; fentynyl 50-100 mcg; lidocaine 100 mg; Propofol 150-200mg; succs 160mg; or Roccuronium 50mg followed by securing the tube
Time line for induction Formulation of anesthetic plan, premedicate, monitors, preoxygenation, give agents, stages of Guedel, intubate
Intubation Ventilation (stage3 plane 2) Can you ventilate? Give nmbd roccuronium 0.4-1.2mg/kg Onset 45s-3min duration 25-30min. Vec 0.08-0.1mg/kg onset 1-2min duration 45 min. Succs 1-2Mg/kg 45sec 3-5min
When to intubate? Wait for nmbd to kickin, 0/4TOF Adequate anesthesia to blunt BP response, cumulative effect of agents realized, hemodynamics maintained! BIS 60 or less
Positioning Head neck, tape eyes before masking, neutral position, oral airway pressure on mucosa, mask vent can cause pressure necrosis, arm
Arm positioning Ulnar nerve and brachial plexsus injury
Femoral positioning obturator and sciatic nerve injuries in the lower extremities
Maintenance aim nAnalgesia nUnconsciousness (anesthesia) nSkeletal muscle relaxation nControl of sympathetic response nBalance medications while maintaining hemodynamics, and vital functions.
When is maintenance decided? Preoperatively, Tiva vs vaa, narcotics? Nmbd yes or no
Fluid management during maintenance 4-2-1 rule; hourly maintance, blood loss, urin output
Ephedrine dose 5-10mg
Phenylephrine 100-200mcg
ESMOLOL dose 5-10 mg, 25-300mg/kg/hr
Labetolol dose 2.5-5mg
Glyccopyrolate dose 0.2mg
Atropine 0.4mg
Temp is fifth vital sign True
Emergence Final stage, planning before induction, taper to off of vaa, speed depend on anesthetic, maintain hemodynamics, reversal of nmbd
Reversal of nmbd Neostigmine 0.035-0.07mg/kg, glycopyrrolate 7mcg/kg, usually one ml of each ratio. Need at least one twitch on TOF
Adjunct to reversal of nmbd Toradal 30mg IV/IM, for pain Zofran 4mg IV for PONV
Midazolam range 0.07-0.15mg/kg
Propofol range 1.5-2.5 mg/kg
Sodium Pentothal range 1-1.5 mg/kg
Etomidate 0.3mg/kg
Ketamine 2 - 4 mg/kg
Extubation criteria Mac awake, adequate spont Resp, TV > 7-10ml/kg, sat >95%, negative inspiratory force of >20cm of water, follows commad ( head for5 sec, grasp)
RSI indication nFull stomach nPregnant nGERD nTrauma nDifficult airways nRSI with cricoid (Selleck’s maneuver) nYou’re on call nIt’s after five o’clock nYou’re going on vacation tomorrow
RSI procedure Drugs, inductions agent succs give simultaneously hold cricoid, no mask vent, intubate.
Arthur c Guyton
How fluid in human body 42L
Intra cellular 28L
Interstitial 11L
Plasma 3L
Intra cellular ion K and mg
Female volume need 65ml/kg
Male volume need 75ml/kg
Solute means? Particulate
Osmosis Net movement of water across semi permeable membrane toward higher concentration of molecules
Starling forces: Determine motion of fluid across membrane 1. Capillary pressure 2. ISF pressure 3. ISS colloid osmotic pressure 4. Plasma colloid osmotic pressure
Osmolarity Number of osmoles per liter can change with temp and pressure
Osmolality Number of osmoles per kg of solution
One mole equals 6.02x10^23
Tonicity Effect of solutions on cell: hypo hyper iso
Cretinate Shrink
Plasmalyte Has no calcium, no anti microbial ,
LR has Ca, k, lactate which becomes bicarbonate (hopefully)
Males are 60% and females are 50% what? Water
ADH Hypothalamus, ADH is aka avp argentine vasopressin
High ADH in respect to osmolality Decreased as solute is dilute
Cation Na, k, ca, mg
Normal hemodynamics affected by what? Anesthetic agent, positive pressure vent, vasodilator drug,
Pre sacral edema Bedridden 3rd spacing
Edema in ambulatory pt Pretibial
Increased urin output possible indication of what? Edema
Late sign of edema Tachy, pulm crackles, pink frothy
Third spacing during surgery From intra vascular to interstitial, replace with balanced salt solution, typically returned on 3rd day post op, may lead to volume over load with renal and cv compromise
What can asses fluid status? Serial hematocrit, ABG, bun cr ration ( 10:1 20:1) urin osmolality,
Hypovolemia vs dehydration Hypovol redistribution of body water leads to reduced Circulating volume. Dehydration insufficient water in present relative to sodium level.
Hypovolema cause Npo for 10 or more hours
Crystaloids Solution contain low molecular salt may contain glucose In system for 30 min
Colloids High molecular weight substances like proteins or large polymers, in system for 3 or hours
Crystaloid ratio 3:1
Colloid ration One to one
To figure out intra vascular volume you Weight in kg x 0.65
Water loss only Hypotonic
Electrolyte and water loss you give Isotonic
Too much nss Hyper chloremic acidosis plasma bicarbonate decrease, nss good for diluting packed red cells
D5w On sodium restriction, and hypotonic
Colloids given in the presence of Hypo albumin , nutritional def, or extensive burns
Albumin 5% and 25% are treated how? Heat treated for 10 hours at 60 deg Celsius
Prekallikrein is what? With histamine these plasma protein fractions may cause hypotension when giving albumin.
Lactate ringer Slightly hypotonic due to 100 ml of free water. If liver compromised then no bicarbonate end up with lactic acid build up.
4 2. 1 fluid maintance estimate First 10 kg is 4ml/kg/hr Second 10 kg is 2 ml/kg/hr For each kg above 20 add 1 ml/kg/hr
Calculating volume deficits Number from 4:2:1 times number of hours NPO gives you volume deficit Adults NPO at least 6 hours
Saturated 4x4 10 ml of blood
Saturated lap spong 100 to 150 ml of blood
When calculating blood loss take into consideration what Irrigation solution should be subtracted
Minor surgery fluid loss 2ml/kg/hr
Moderate surgery such as cholecystectomy 2-4ml/kg/hr
Extensive surgery fluid loss 4-8ml/kg/hr up to 12
Max allowable blood loss Estimated blood volume x ( starting hct - target hct)/starting hct
What influences water content in brain Sodium
Sodium most important influence over Water content of brain tissue
Hyponatremis seen with Turp, CHF, GI, renal disease, cirrhosis, glucocorticoid deficiency, siadh
Hyponatremia Demyelination, central pontine myelinolysis with less than 110 meq/L
Hyponatremia treatment Loop diuretic, 3% nacl ( may cause hypo k , acidosis, hypotension)
Sodium level of what is safe for anesthesia 130 or greater.
Atrial naturetic peptide followed by atrial distention Increase GFR Inhibit renin angiotensin, aldosterone and ADH Which intern increase dieresis vasodilation and increase osmolality
ADH more water control than Sodium control
ADH is correlated with_____activity Sympathetic nervous system
Hypernatremia Seizures, brain vessel hemorrhages with rapid decrease of brain volume, plasma greater than 158,
Cause of hypernatremia Diabete insipidous
Postpone surgery if sodium plasma is Greater than 150 need isotonic and water
Hypovolemic are sensitive to vasodialating negative inotropic agents such as Barbituates, histamine releaseing agents (morphine, Demerol, atracurium) sympathetic blockade from spinal,
Dietary intake of K 80 Meq/day, reabsorbed in proximal tubule of loop of Henley, majority filtered
pH change of 0.1 is equal to 0.6meq/L
Cardiac action potential and K Phase 1 and 3 K repo levies
EKG changes in hyper k Peak t wave, long pr, wide qrs, loss of p then sin wave
Calcium given for hyper k why? Membrane stabilization
Sucks increases what electrolyte and by how much? Plasma k and 0.5 to 1 meq/L
Cause of hyper k Beta blocker in renal impaired pts, blood transfusions older than 21 days. Increase k to 30meq
Hyper k treatment Cacl 10% 3-5ml calcium gluconate 5-10mls) beta agonist, bicarbonate, k above 6 should be treated
CaCl is how much more potent than calcium gluconate 3x
Calcium administration can cause Dig toxicity if on dig, bradycardia, hypotension,
Hyper k insulin 10 to 20 units with glucose 50g or 25-50ml
Hypo k from 4 to 3 represents 100 to 200 meq/L def
Hypo k reasons Alkalosis, insulin, beta agonist, hypothermia, rbc transfusion
K losses can lead to Renal tubular acidosis and ketoacidosis
EKG change of hypo k Depressed st and biphasic t wave with u wave.
Hypo k treatment Should not exceed 8meq per hour, po safest way to treat, IV 10 to 20 mew per hour
K of what is desired for dig pt? K of 4
K ceiling dose per day 240 meq/day IV
Transfusion A b and o bloods one unit of rbc will increase hg by 1g or 3%
How much of population has d antigen 80 percent rh positive
Type and screen vs cross match Type and screen 99.7% safe cross match only adds 0.001%
What is missing from packed rbc Ca, citrated cpda1 less coagibility
O neg is Universal donor
AB is Universal receiver
Whole blood breakdown Rbc 250ml hct 70% Platelet 70ml of plasma Plasma fresh or frozen Cryoprecipitate factor 8 fibrinogen Von bilirubin
Blood tubing has a filter of 170micron
Blood should be warmed up to 37 c
2 3DPG can cause Shift to left in oxy hgb curve
Massive blood transfusion is defined as One blood volume over 24 hours 50% of blood volume over 3 hours 10 units or more of whole blood
Complication of massive blood transfusion Citrate poisoning, metabolic alkalosis, from citrate and lactic acid conversion to bicarbonate in liver
Alkalosis means what to k levels? Hypo k, k goes back into cell
Blood A Rbc antigen A serum anti b comp with A and o
Blood b Rbc antigen b, serum anti a, comp with b and o
AB blood Rbc antigen AB, no serum antigen, comp with, a b ab and o
Blood o No rbc antigen, anti a and b serum, comp with O only
Two types of diabetes insipedous 1. Central DI decreased ADH secretion 2. Nephrogenic DI failure of renal tubules to respond to ADH
DI secondary to Renal disease, hyper or hypo k, Sickle cell Meds like lithium, ampotericin, mannitol,
Created by: Rooz