Line isolation monitor
- alarms what does this mean?
- What do you do
- what if it alarms and faulty piece of equiptment were essential for life support (defibrillator
- LIM is designed to alarm when the potential flow of current from isolated power supply to the ground is at an unacceptable level (limits are between 2-5mA) placing pt at risk of macroshock
- LIM alarms after plugging in device-1) faulty piece of equiptment with short circuit exceeding 5mA. pt at risk for shock of second fault occurs. Avoid plugging in additional equiptment into ciruit until the situation can be resolved.
2) sum of leak current in OR exceeding >5mA, not a true fault. unplug a nonessential piece of equiptment, if alarm stops likely 2/2 leak. If alarm continues likely fault due to faulty piece of equiptment
An alarm goes off if an unacceptably amount of current to the ground is possible (i.e. the “isolated” system is no longer isolated, but rather is grounded, thus only one additional fault could result in a shock).
- Use another debrillator
- Use the debfillator bc cause of 2 faults rare
- use the definrillator battery source if possible
- unplug nonessential equipement-if it goes away likely due to sum of leak current
- avoid plugging in extra device to avoid fault
Issues w hypothermia
neuro: AMS, delayed awaking
Cardiac;: myocardial depression, vasoconstriction (increased epi/NE levels), shivering (increased O2 consumption,increased PVR
Heme: left shift of hgb-O2 dissociation curve, plt dysfunction, poor wound healing/infection
other: decreased drug metabolism
difference between macro and micro shock
macroshock-amount of current applied outside body necessary to cause injury 100mA
micro-amount of shock directly applied to heart necessary to cause VF (100microA)
Anesthesia machine component
- Gas inlet: cynlinders PISS or pipeline supply (DISS)
- Pressure regulator: reduce gas pressure from cylinders/ wall
- Fail-safe: downstream of N20 that proportionally decreases or completely discontinues N20 supply in response to a drop in O2 supply
- oxygen supply failure alarm: alarms is pressure drops below 30 PSIG
- Second stage regulator: reduces pressure ~14 PSIG before entering flowmeter
- Flow control valves/flow meters: allow adjustment of gas flow
7
How can hypoxic mixture be minimized with flowmeters
- O2 downstream (can still occur if crack in O2flow meter)
- flowmeteter proprotioning system: reduces chance of hypoxic mixture. links the 2 gases
- fail safe
- oxygen supply pressure alarm
- PISS/DISS/colors
- oxygen analzyer
- pulse ox and vigilance
Describe DES and varibale bypass vaporizer (why cant use variable bypass w des)
- varibale bypass-most bypass vaporing chamber, temperature compensated, agent specific
- Des: electricaly heated gas-vapor blender.
2 problems w standard vaporizer w des: High VP of 660 at 20C requires a large amount of heat (otherwise temp would drop) and extensive fresh gas flow through varibale bypass chmaber to dilute carrier gas (to allow for delivery of clinically useful concentrations)
-DES heated to 39C creating 2atm and blending pure des into fresh gas mixture
Providing an external heat source compensates for the significant heat loss associated with desflurane vaporization. And unlike stand variable bypass vaporizers that pass fresh gas through the vaporizing chamber, desflurane vaporizers add agent directly to the gas stream.
Circuits for sponatneous and controlled ventilation
components of circle system
3 rules to prevent rebreathing
spontaneous: pop off near pt A>D>C>B
Controlled : pop off far from pt: D>B>C>A
FGF :: btw absorber and inspiratory valve to min dilution
expiratory, insiratory valves: as close to pt as possible to minimize backflow in inspiratory limb
tubes,
Y piece connector,
APL: before absorber to conserve soda limb and min venting fresh gas
reservoir,
CO2 absober
unidirectonal valve close to pt
FGF can not enter between expiratory valve and pt
APL can not be located between inspiratory valve and pt
Conditions that predipose to compound A
- low flows/closed anesthesi circuit
- baralyme
- high conc sevo
- high absorbant temp
5, frsh absorbant
alarms for ventilator malfunction 4
- low pressure: should be set to 5 less than PIP
- volume
- expired Co2
- Inspired O2
causes increase and decreases ETCO2
- hypermetabolic state, MH, defective inspiratory/expiratory valvles, exhausted absorber, low MV
- hypothermia, anesthesia, increased vent/decreased perfusion (hypervent, PE, hypotesion), lose sampling tubing, airway leak (BP fistula, rutptured ETT, extubatiom), impaired exhalation (asthma, kitckec ETT)
Why is scavaging needed
max for halogenated agents alone
N20 alone
N20 and Halogenated agents together
halogenated alone
amount of gas used in anesthesia exceeds pt needs and would cause environmental contamination
halogenated alone: 2ppm, mix (0.5ppm)
N20: alone and together 25ppm,
8 steps to machine check
- check for emergeny ventilation equiptment: ambu suction
- check high pressure system: cylinders (1/2 full: 1000PSIG) and pipeline pressures (50-55 PSIG)
- check low pressure system: (vaporizers filled and caps tight, flowmeters cant deliver hypoxic mixture and tested through full range, negative pressure test (bulb to common gas outlet >10 sec)
- check scaavangeing: connection of APL to scavaneging system, NPRV: apl open and O2 flow low should collapse and gausge read 0, PPRV: APL open and and flush O2, bag should distent and read no more than 10 cm H20
- check breathign system: calibrate O2 monitor to RA and 100% oxyegn, inspect ciruit and CO2 absorber, Postive pressure leak test circuit (>30 10 seconds)
- check bmanual and automated breathign system: place bag on Y piece and set paremeters for pt, check this under manual and automated ventilation
- monitors
- machine final position: APL open, vaporizer off, flow off, manual vent selected
Bellow collpase and pt impossible to ventilate. Response
- bag collapsing most likely circuit disconnect. inspect for disconnection
- No diconnect. occlude Y piece and closeAPL and see if I can sustain PP in machine. If not, likely prob w machine, ambu bag hand ventilate looking for ETco2 , summetric chest rise
- If I can generate postive pressure, likely pt ETT: check for extubation, cuff leak, BPF leak
- bag remains collpased from negative pressure, could be nehative pressure release valve in scavaneging, see if bag collapsed. consider detaching scavanging suction
discharge criteria
- Stable vitals
- Absence of unexpected bleeding from surgical site
- Controlled NV
- Adequate pain control with oral analgesics
- Ability to walk w/o dizziness
- Discharge instructions verbal and written, prescriptions, patient acceptance of instructions, escout
POVN what to check
hypoglycemia
pain
oxygenation
fuids hemodynamics
RF PONV
What does fast look for
fluid in pericardium thorax and peritoneum
perisplenic hepatorenal, pericardium, retrovesical pouch
risk of propofol infusion syndrome
sx
population
4-5mg/kg/hr
children and critically ill (sepsis, steriods, pressors,
refractory bradycardia
met acidosis, rhabdo, lipdemia, hyperkalemia, hepatomegaly, liver failure renal failure, cardiomegaly
head to toe burn pts
Anesthesia:increase free fraction opioid benzos, 25-30% burns resistance to NDMB at 72 hr, increased binding to alpha 1 glycoprotein, increased fetal Ach R (resistant to NDM
Neuro: head injury
Cards: hypovolemic-leaky capillaries (Parkland)
pulm: inhalational injury–>VQ mismatch, CO posioning (cooximetry) edema
GI: curling ulcer, aspiration risk
Heme: infectionsepsis/ disrupted skin barrier
complications of TPN
Why can be difficult to wean
infection, clot, placement complications, fatty liver, cholestasis, low mag phosphate, K, high/low glucose/calcium, hypercarbia
hypercarbia in COPD, low Phosphate
sedation levels
what should be available
Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands.Example: Small amount of fentanyl or midazolam
Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Example: More midazolam or fentanyl
-airway intervention is, by definition, NOT required in a patient receiving moderate sedation.
Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired.
oxygen, ASA monitors, airway and emergency medical equiptment, personell trained in CPR
narcotic acuse
addiction
dependence
use of a physcoactive substance in a manner detrrimental to individual or society
addiction: uncontrolled/compulsive drug use despite harmful side effects
dependence: physiolocial state of adaptation characterized by emergence of withdrawl symptoms during abstinence
What is PPV
When fluid reponsive
what conitions need to be met
- Condition that needs to be met
- Be in normal sinus rhythm
Be intubated and be mechanically ventilated, making no spontaneous respiratory efforts
Be ventilated with at least 8mL/kg of tidal volume
Have no significant alternations to chest wall compliance, such as an open chest
- PPmaxx-PPmin/PPavg
- Usually responsive when PPV is >13% likely unresponsive if <9%, and 9-13% unreliable
