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Nursing Exam II

For CQI, does every patient generate a CQI form?
SRNA's responsibility for CQI
Importance of CQI in Anesthesia?
Critical incidents
Sentinel Event
Root Cause Analysis
Non-punitive Environment
Why focus on safety?
100,000 Lives Campaign
What is SEAT?
When does the most human error occur?
Error reduction through CQI
What are other ways errors
Monitoring on floow
has decreased arrest
Serious Clinical event?
Joint Comission Sentinel Events
What are some methods to prevent events?
What are the clinical events that are serious?
What are high risks for awareness?
Crash trauma, bypass open heart surgery, and OB crash spinals
What are the most common causes of allergies?
Oral and Dental injuries are...
the most common complaint from surgery
Lasik surgery
What is induction?
The initiation of anesthesia, from intact reflexes from being unconscious
What do you need prior to any induction?
What is the importance of checking the machine?
Why do we preoxygenate?
Why has less FRC?
What is the suggested time of preoxygenation?
What is Propofol?
What is the dose of Propofol?
What are the disadvantages of Propofol?
1) Lowers BP because of negative inotropic effect,
2) Causes the largest decrease in SVR,
3) Burns on injection,
4) Expires in 6hrs,
7) Lactic acidosis risk
Why do kids need preservative free Propofol?
could be harmful to them?
What are the respiratory effects of Propofol?
What is sodium pentothal?
What are disadvantages of sodium penothal?
3) Post op drowsiness with hangover effect
4) It will precipitate other drugs.
What is Etomidate?
What does Etomidate cause?
What are advantages to Etomidate?
1) hemodynamic stability because it doesn't have drop in inotropoic effect
What are the disadvantages of Etomidate?
1) produces myoclonus
2) pain on injection
3) adrenal suppression for 6hrs post op
4) Increases PONV
5) decreases seizure threshold
What is Ketamine?
What are the advantages Ketamine?
2) Positive inotrope
4) Potent bronchodliaotr will dilate airway for asthmatics
5) maintains airway and respiratory reflexes
6) good to use with older people
What are the disadvantages of Ketamine?
1) produces a dissociative state
3) Increases salivation and respirator secretions.
4) Associated with emergence delirium, nightmare, and hallucinations
What is Versed?
What are the advantages to Versed?
When do you us an inhalation induction?
1) Slower onset than any IV agent
2) Dose dependent decrease in BP
3) Does causes airway irritability and Sevo is less irritating
What are anesthetic indications for cardiac patients?
What are anesthetic indications for neurosurgical patients?
What are the anesthetic indications for pediatric patients?
What are anesthetic considerations for geriatric patients?
What is the preparation for an LMA case?
What are the steps of induction?
1) Run IV wide open
2) give calculated dose of induction agent at steady rate
3) Recheck IV, make sure drug has infused
4) watch patient and observe for long deep breaths
5) assess LOC
7) If using LMA, insert once asleep
Why do you need the patient deep at incision?
How do you gauge the level of anesthesia?
The amount of tidal volume patient takes when breathing
What are the first steps of induction in regards to prepration?
1) make sure machine is checked
2) Adjust height of OR table
3) preoxygenate 3-5 minutes
1) give dose of induction agent
2) assess LOC, check lash reflex, and tape eyes
Wake them back up
What are the onsets of the different muscle relaxants?
2) Check onset of muscle relaxant with PNS
3) Preform laryngoscopy and insert ETT
4) Remove carefully
5) Inflate cuff
6) Check intubation
8) secure ETT
How do you check intubation?
What is the most reliable site for nerve stimulation?
Ulnar, with positive red lead closest to heart
Who is responsible to check breath sounds for the tube?
The person who intubated
When do you remove the stylet?
What are special indications for a RSI?
-When patient has a full stomach
-Bowel Obstruction
-Known hiatal hernia with reflux
What is the point of RSI?
To minimize change of regurgitation and aspiration.
What is required during an RSI?
What happens if you have a NGT?
What are the steps for an RSI?
2) Give full dose of induction agent
3) Have assistant hold pressure as soon as drugs are injected
4) follow with FULL dose of succ
5) Do not ventilate
6) wait for succ to work then intubate
How do you apply cricoid pressure?
When do you release cricoid presure?
once the ETT placement is confirmed with ETCO2 and breath sounds
When can you place an OGT?
After the ETT is secured.
What is maintenance?
What is the most important intraoperative maintenance?
Preoperative planning
What are the goals of intraop maintenance?
What are important factors of maintenance?
What factors determine types of monitors?
What senses are used during intraop?
observation for the rise and fall of chest, nail beds,
lips are blue,
bounding pulses,
look at surgical field and also at canister, mucous membrane,
skeletal muscle tone
What are we listening for?
Sense of touch for intraop?
Non invasive monitors during intraop
What are considerations for the evoked potentials?
What can affect SPO2 reading?
methylene blue, carbon monoxide, and blood pressure on same arm
EKG during intraop
Lead II monitors arrythmias
Lead V monitos ischemia
Get strip before induction
Do a 5 lead on pts with heart history
NIBP cuff
When would you see NO CO2 on your ETCO2?
Kink, PE, cardiac arrest
When would you see low CO2 on ETCO2?
decreased TV, prolonged hyperventilation
When would you see increased ETCO2?
hypoventilation, MH,
What are considerations for temp?
Why is controlling body temp such a big deal?
Do anesthetics inhibit central thermoregulation?
Yes, because they interfere with hypothalamic functions.
What happens when a patient is cold?
Left shift when pt is hypothermic!!
High SVR
Platelet dysfunction when cold
Stress response and catabolism
Impaired renal function
Decreased drug metabolites
Poor wound healing
Increased incidence of infection
Why do patients with spinal anesthesia lose heat?
vasodilation and altered perception of temp in the blocked dermatones
What is the purpose of BIS?
Why use salter?
Why use a peripheral nerve stimulator?
Where are nerve stimulator placed?
Adductor pollicis for ulnar and the orbicularis oculi for facial nerve.
The orbicularis oculi recovers from neuromuscular blockade before the adductor pollicis.
What could also happen with the orbicularis oculi?
What is special about a precordial stethoscope?
When do you place an aline?
based on a patients history, surgical procedure, expected blood loss
Urinary catheters
What is the risk of a catheter?
Positioning for patients
Any procedure over 1hr make sure they have padding.
Table turning considerations
What is the only continuous record of the intraop course?
What is the basic core information that must be documented?
What fluid is required intro-operatively to replace?
An essential condition of the anesthetized state is....
How can we measure unconsciousness?
What is the distinguishing factor for unconsciousness?
What is the order of loss of response?
2) Formation of implicit and explicit memories
3) Purposeful movement
4) Ventilation (loss of RR and apnea)
5) sudomotor (tearing and sweating)
6) Hemodynamics
What are the components of anesthesia?
amnesia, analgesia, LOC, muscle relaxation
Volatile anesthetics do what?
hypnosis, but have minimal analgesic effect
Opiates get rid of your hemodynamic response to noxious stimuli
before movement
Hypnotics ablate movement response to noxious stimuli before...
hemodynamic response
What increases or decreases BIS number?
increase with ketamiine and opioids lower BIS
What is associated with a BIS of less than 60?
How do you assure amnesia?
Assuring analgesia with regional cases
What are considerations for sedation cases?
1) keep track of local anesthetics
2) B3, Li5, R4
3) ask surgeon to give more local
What are considerations before the end of case?
for plastics do a deep extubation
When giving medication...
What is included in the break report?
What are some intraop complications?
1) accidents during maintenance phase due to a lack of vigilance
2) human error causes most anesthesia related deaths
3) most adverse complications are respiratory
What are the common intra-op complications?
Have a plan for every complication
1) use ambu bag if electricity goes out
2) have a plan for every complication possible
3) take care of the immediate problem
4) always label syringes
What are factors complications associated with human errors?
1) inadequate preparation
2) inadequate machine checkout
3) preop eval
4) haste in preparation
5) Inadequate experience and training
6) Environmental limitations
7) Poor communication with surgeon
8) physical and emotional factors fatigue and personal problems
Complications in the OR
1) unrecognized breathing circuit disconnection
2) mistaken drug administration
3) airway mismanagement
4) anesthesia machine misuse
5) fluid mismanagement
6) IV line disconnection
Why is O2 beneficial?
small increases can increase paO2, decrease PONV, and decrease infection
Low Flow system O2
What does the FiO2 depend on?
1) reservoir for O2
2) the oxygen flow rate
3) the patient's ventilation pattern
4) O2 device must fit properly
A low flow system...
You would use a low flow system if...
Nasal Cannula
Simple mask
-Not as comfortable as NC and may not be as tolerated
Partial re-breathing
-Valves are off and air is entrained
Non rebreathing mask
-Includes unidirectional valve and reservoir bag
-Increased flows can cause GI bloating and skin breakdown
Face tent
-flow rate 4-8L/min 30-55%
-Utilized in the eye room, post nasal plastic surgery
T piece/ Trach mask
High Flow
Why is giving high O2 to COPD patients a problem?
Absorption Atelectasis
Oxygen toxicity
Broncho Pulmonary dysplasia
Causes eye injury and lung injury with high amounts of O2.
ROP retinaopathy of prematurity
High V/Q
Air is entering but there is low perfusion.
Low V/Q
common intraop and post op, secondary to atelectasis. Usually have hypoxemia, hypercarbia, and low pH
Dead Space
The volume within the system that does not actually participate in gas change
Tidal Volume
Amount of volume given per breath. 6-8 ml/kg ideal body weight.
Minute Ventilation
The volume of gas exchange per minute. Tidal volume x respiratory rate = mV
Laminar flow
streamlines molecular flow in which there is little friction between the gas molecules themselves. Organized flow
Turbulent flow
gas molecules molecules in a random, chaotic, rapid pattern, interfering with each other and creating more resistance
Peak Flow
the velocity with which gas is delivered to the patient, measured in L/min
Peak pressure
the highest pressure reached during a ventilator breath, monitor constantly
I:E ratio
The amount of time spent during inspiration vs expiration 1:2 is typical.
Volume control
set volume delivered, insp pressure set 10-15 higher, will alarm if the set volume cannot be given before inspiratory is reached. If it tries to give it but cannot, then it will alarm.
Controlled ventilation
RR, TV, and I:E is set, used in brain dead patients and commonly used in anesthestized patients who are paralyzed. used for patients who cannot take their own breath
What if you see the bellows quivering on controlled ventilation?
It means the patient is trying to take their own breath and that they may need more muscle relaxant
Assist control
TV, RR, I:E. Pt will initiate breath, but the machine will give the breath at the programmed settings
The pt can initiate their own breaths and the ventilator will not help them, but when the ventilator is set to take a breath, the pt will get that mandatory setting thus leading to stacking of breath.
Detects when they are taking a breath and then adjusts the breath to the settings on the machine...lets the patient initiate their own volume and breath...but does not stack breaths and times the next breath with the ventilator
Pressure controlled
Pressure is set and volume can vary. No set tidal volume. The inspiratory phase is fast so it can open up the alveoli to allow O2 exchange to take place. This setting limits shearing and prevents atelectasis
Variations of pressure control
Smaller TV and higher RR, works to overcome the critical opening pressure in the alveoli
Pressure control volume guarantee
protects against trauma, delivers consistent TV at the lowest pressure possible. The machine delivers a pressure control breath auto set to whatever pressure is necessary to deliver the tidal volume.
SIMV pressure support
Delivers mandatory tidal volume and respiration rate, however synchronizes with patient effort when detected, no stacking of breaths and pts own breath is supported
for spontaneously breathing patients, doesn't have TV or rate but gives patient support with each breath. Prevents CRNA from having to bag.
How much is autopeep given by the machine. Therapeutic PEEP is 5-30. Do not give to COPD.
What are downfalls of PEEP?
1) decreased venous return
2) Barotrauma with PEEP greater than 10, mean airway pressure greater than 30, and PIP greater than 50
3) Increased intrathoracic pressure
4) Alterations in kidney function b/c venous return is impaired
Inspiratory pressure for spontaneously breathing patients. Indications are the same as those for PEEP, commonly used for those with sleep apnea and neonates.
What are areas of dead space?
Nose, bronchous, and nasopharynx
Physiologic deadspace
anatomical + alveoli or areas not participating
1/3 of our normal tidal volume
is usually physiologic deadspace
What causes hypercapnia
Conditions that affect rate of breathing, high deadspace, low minute volume, failure of the resp center
How much higher is the PaCO2 than ETCO2?
3-5. COPD will have a more drastic difference, accentuated by the admixture of deadspace air.
What are the only ways to increase oxygenation?
Increase O2 or Cardiac output
Amount of air entering to alveoli relative to what is being delivered to the tissues
V/Q 0.8
Difference is due to the fact that some units are underventilated for the amount of blood perfusing them (some units have not enough air and they have a lot of blood)
due to the V/Q imbalance or diffusion impairment not a true oxygen gradient between alveolus and pumlonary capillary bed.
What is the O2 pressure?
PaO2 x 0.003. This is the free oxygen molecules those not bound to hemoglobin, they are free in plasma
What is the O2 saturation?
Hbg x 1.34 x SaO2. On the hemoglobin molecules, there are Fe+++, prophyrin binding site. When all these sites are occupied by oxygen molecules, it is said to be saturated.
What is O2 content?
CaO2 = (Hgb x 1.34 x SaO2) + (0.003 x PaO2)
What is the normal oxygen content value?
16-22 O2/dl
what does a PaO2 of 60 correlate with?
SpO2 of 90%
What is hypoxia?
Impaired o2 delivery to the tissues, include cardiac output and tissue uptake. The problem getting O2 to the tissues
What is hypoxemia?
A decrease in PaO2, SaO2, or hemoglobin. Content delivery is the problem.
The oxygen content is the determinant of patient severity
If the O2 content is low, they are considered hypoxemic. Physical assessment of this is not always reliable.
How many grams of deoxygenated blood does it take to become cyanotic?
5 grams
Carbon Monoxide
in amounts greater than 10%, a person will start to experience symptoms and the curve will shift to the left
will give an accurate reading up to 85%
Where can we most rapidly compensate?
What is the significance of HCO3?
HCO3 has a lower pKa but is more available. Bicarb is in RBC and is also in the plasma. Not a higher capacity buffer, but more available.
What happens in regards to CO2, HCO3, and Cl during buffering?
CO2 enters cell, forms carbonic acid, the H binds with the hbg and the HCO3 goes outside of cell, the Cl comes back in to maintain neutrality
What happens in the lungs?
Cl comes out of the cell, HCO3 goes in, it makes carbonic acid with the H from the cell, then CO2 leaves to go into lungs.
What is the ratio of HCO2 to CO2?
Did the change in HCO3 result from a change in CO2 tension?
Determin this before the change in HCO3 caused by a metabolic state
What are causes of respiratory acidosis?
neuromuscular dysfunction, COPD, pickwickian disorder, CNS depression
What does body do when there is acidosis?
systemic depression: decreased myocardial contracitlity, decreased CO, blood vessels dilate thus less responsive to vasoactive drugs, ventricular irritability attenuates the effects of bronchodilating drugs.
With chronic respiratory acidosis, how long does it take the kidneys to compensate?
12hrs, peaks 3-5 days. Renal correction is slower. Each 10mmHG increase in PaCO2 means 4mEq increase in HCO3
How do you treat respiratory acidosis?
Increase mV, treat with bicarb if pH is less thatn 7.1 or HCO3 is less than 15, with chronic respiratory acidosis the goal is to return the patient to baseline
How does the body compensate for respiratory alkalosis?
Renal excretion of HCO3
What happens in the body when there is resp alkalosis?
Hyperventilation lowers PacO2 resulting in lower HCO3, nonbicarb buggers respond by releasing H+, mild hypokalemia occurs, acute changes in PaCO2 will make cerebral blood flow decrease by half.
What causes respiratory alkalosis?
physiologic response to hypoxemia, emotional disturbance, CNS disorders, excessive mechanical ventilation
What are hazards to respiratory alkalosis?
decreased cerebral blood flow, hypokalemia, arrhythmias, constriction of bronchiolar smooth muscle, shifts the O2 curve to the left
What causes metabolic alkalosis?
aggressive diuretics or steroid therapy, cushing disease, NG suctioning, N/V/D, overaggressive bicarb administration, metabolism of citrate to HCO3, ingestion of antacids.
What is the primary stimulus for metabolic alkalosis?
decreased arterial volume. This stimulates the release of renin and aldosterone, which act on renal tubes to increase NaCl resorbtion and promotes H+ ion secreation.
What can alkalemia cause?
a decrease in brochonial tone and can lead to atelectasis
What fluid should metabolic alkalosis patients receive?
the extent of ventilatory response should be proportional to the severity of metabolic acidosis
Lactic acidosis produces a greater degree of hyperventialtion and hypocarbia than ketoacidosis because lactic acidosis is produced by the brain. IF pt has lactic acidodic state, then the pt will be more prone for hyperventilation
When does compensatory hypperventilation occur?
with metabolic acidosis
What causes metabolic acidosis?
hypoperfusion, conditions that will affect where bicarb has gone, like increase anion gap means that higher lactate because bicarb is being used up to buffer the anion because it is being used as a buffer
After bicarb is given, how long should you wait to recheck?
5 minutes
If there is no anion gap?
you are losing bicarb to something that is going is not being used to buffer because it is leaving the body itself
What causes an increased ion gap?
lactic acidosis, ketoacidosis, renal failure, toxin ingestion, ethylene glycol, methanol, salicylate
Normal anion gap
renal tubular acidosis, early renal failure, diarrhea,, drainage of pancreatic juice. normal is 12 +/- 4
What can acidosis do?
potentiate the depressant effects of sedatives and anesthetic agents
Why can patients be more at risk for sedation and depression when acidodic?
because the opioids become nonionized and can penetrate the brain more.
Why is the circulatory depressant effect of anesthetic gases and IV meds be exaggerated in acidosis?
because they are depressants and make us have unopposed decreases in sympathetic tone by agents.
What can acidosis cause?
it can antagonize reversal
What can alkalosis cause?
respiratory alkaloids may prolong the duration of opioid induced respiratory depression
What is a negative effect of alkalosis?
when accompanied with hypokalemia, alkalosis can precipitate severe atrial and ventricular arrhythmia and it may also potentate NDMB
Why is heart rate a bad indicator of organ perfusion?
because of organ perfusion,
Citrate, phosphate, dextrose, adenine
Citrate- anticoagulant binds to calcium
Phosphate- buffer
Dextrose- energy source for RBCs
Adenine- precursor to ATP synthesis
How long can blood be stored?
35 days with citrate
Type and screen
Blood has been typed and then has been typed for
Factor VII
rescue drug when standard therapy has failed. though to enhance thrombin generation on already activated platelets
Why is the hespan limit 15-20ml/kg?
Because there is an increased risk for bleeding beyond that
What is special about hextend?
it can help cougalation up to 20ml/kg...then you can't clot effectively
Complex carb with different molecular weight and molar substitution than hespan. Max dose 50ml/kg/day. Can be given to cardiac patients. Give with large abdominal cases with fluid shifts because you can give more of it.
Dextrans limit?
20 ml/kg/24hr
What is hapten?
Substance capable of combining with immunoglobuins not producing a reaction, give with dextran
When would you use dextran 40?
use during carotid case to make viscosity of blood lower....reduces cell aggregation.
What are storage lesions?
cellular debris, microaggregates, decreased in pH, increase in plasma potassium, decrease in plasma Ca, decrease in factors V and VIII, decrease in 2,3, DPG, increase in lactate and CO2, increased hemoglobin
What are the metabolic abnormalities?
metabolic acidosis and hyperkalemia
Why is there metabolic acidosis r/t storage lesions?
perseratives, continued metabolic function of RBC's, mostly related to PCO2 levels of 150-220, but does not always lead to metabolic acidosis
How does hyperkalemia develop?
quickly administered blood, storage temps 1-6 deg will slow down the pump. This is very rare
What happens when there is a decreased in 2,3 DPG?
there is an increased of affinity of hemoglobin and there is less O2 available for tissues.
Citrate intoxication
causes metabolic alkalosis because the citrate metabolizes to bicarb.
Why does hypocalcemia happen?
Citrate causes calcium binding
What are the signs and symptoms of citrate intoxication?
hypotension, narrow pulse pressure, increased intraventricular EDP, increased CVP
Treat hypocalcemia...
rate of blood transfusion is over 50ml/min, if the patient has hypothermia or liver disease, neonates
Why do patients get hypothermia?
because blood is stored at low temp and it can cause cardiac irritability and post op shivering bc it can increase O2 consumption
Post op shivering...
can cause MI
Complications of Blood Therapy?
impairs coagulation, impairs metabolism of citrate, lactate, and drugs, increases, increases blood viscosity, impairs RBC deformability, increases intracellular K, cause leftward shift of O@ curve.
What is the most effective mechanism to warm someone?
ambient air
there are increased protein C levels which is a cascade of coagulation abnormalities, when you give large amounts of blood
What are the most important causes of coagulopathy?
1) volume of blood given dilutional coagulopathy because that part of blood doesn't have coag factors
2) duration of hypotension and hypoperfusion.
Dilution of coagulation factors due to transfusion of large amounts of stored blood....
1) dilutional thrombocytopenia
2) low factors of 5 and 7
3) DIC like syndrome
S/Sx of dilutional coagulopathy
1) oozing into surgical field
2) hematuria
3) gum bleeding
4) petechial bleeding
5) ecchymosis
What is dilutional thrombocytopenia?
1) cause of hemorrhagic diathesis in patient with multiple blood transfusions
2) Few viable platelets in blood stored > 24 hrs
3) Plt count less than 50,000-75,000
What happens when there are low factor 5 and 8 levels?
1) these decrease in stored blood
2) unlikely to be the primary cause of bleeding during massive transfusions
3) may intensify bleeding from other causes
DIC like syndrome?
Deranged clotting system leading to disseminated fibrin deposition, unclottable blood, severely altered microcirculation leading to ischemic necrosis esp kidney.
For low factor 5 and 8 give what?
What product has the highest incidence of viral infection B or C?
CRYO. These viruses are associated with viral hepatitis
What is TRI?
Transfusion related immuonodulation suppresses cell-mediated immunity. More plasma in product the higher risk and leukoreduction decreases TRI
#1 cause of transfusion related fatalities, within 6hrs, highest risk is FFP, characterized by dyspnea and hypoxemia non cardiogenic
What are s/sx of TRALI?
Fever, dyspnea, fluid in endotracheal tube, severe hypoxia
During general anesthesia how would GA present?
persistant decrease in blood oxygenation
How do you monitor for TRALI?
pulmonary edema in absence of L atrial HTN or circulatory overload and also the pulmonary fluid has high protein.
Treatments of TRALI?
Stop, support VS, determine protein concentration, obtain CBC and CXR, notify blood bank.