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