Week 2

Question 1

Week 2: Autonomic Nervous System

Anesthesia & the ANS
- Anesthesiology is the practice of _______(1) medicine.
- Drugs that produce anesthesia may also have potent _______(2) side effects.
- The greater part of our training and practice is spent acquiring skills in utilizing or averting the _______(3) (ANS) side effects of anesthetic drugs under a variety of pathophysiologic conditions.
- The success of any anesthetic depends upon how well _______(4) is maintained.
- What happens during DL?
- Produces a lot of _______(5) on the system

Answer 1

Answers:
1. autonomic
2. autonomic
3. autonomic nervous system
4. homeostasis
5. strain

Question 2

Chassaignac Tubercle
- The most prominent _______(1) in the neck
- The anterior tubercle of the transverse process of the _______(2), against which the carotid artery may be compressed by the finger (i.e., carotid massage).
- Extremely sensitive to stimulation during laryngoscopy.
- How can we avoid a sympathetic response during intubation?
- _______(3)
- Laryngoscopy and endotracheal intubation is the most stimulating procedure leading to acute hemodynamic responses (HDR) lasting for at least 10 min.[1,2] Stretching of pharyngeal and laryngeal mucosal tissue causes sympathoadrenal response resulting in HDR such as an increase in heart rate (HR), blood pressure (BP), and even ischemic ST-segment changes caused by the release of _______(4).

Study the Features Typical For Cervical Vertebrae (ChatGPT is unable to recognize this image)

Answer 2

Answers:
1. tubercle
2. 6th cervical vertebra
3. Give induction Drugs
4. catecholamines

Question 3

Anesthesia & the ANS
- The ANS includes that part of the central and peripheral nervous system concerned with _______(1) regulation of cardiac muscle, smooth muscle, and glandular and visceral functions.
- ANS activity refers to _______(2) reflexes that function below the conscious level. The ANS is also responsive to changes in somatic motor and sensory activities of the body.
- The main effect of vagal cardiac stimulation to the heart is _______(3). Vagal stimulation decreases the _______(4).
- The main effect of vagal cardiac stimulation to the heart is _______(3). Vagal stimulation decreases the rate of sinoatrial node discharge and decreases excitability of the AV junctional fibers, slowing impulse conduction to the ventricles.
- A strong vagal discharge can completely arrest sinoatrial node firing and block impulse conduction to the _______(5).

Answer 3

Answers:

1. involuntary
2. visceral
3. chronotropic
4. rate of sinoatrial node discharge
5. ventricles

Question 4

Anesthesia & the ANS

• Afferent fibers from visceral structures are the first link in the _______(1) arcs of the ANS, and may relay visceral pain or changes in vessel stretch.
• Most ANS _______(2) fibers are accompanied by sensory fibers that are now commonly recognized as components of the ANS.
• However, the afferent components of the ANS cannot be as distinctively divided as can the _______(3) nerves. ANS visceral sensory nerves are anatomically indistinguishable from ______(4) sensory nerves.
• The clinical importance of visceral afferent fibers is closely implicated in the management of _______(5) states.

Answer 4

Answers:

1. reflex
2. efferent
3. efferent
4. somatic
5. chronic pain

Question 5

Functional Anatomy:

• The ANS is organized into _______(1) divisions based on anatomy, physiology, and pharmacology.
• Langley divided this nervous system into two parts in 1921. He retained the term sympathetic (sympathetic nervous system [SNS]) introduced by Willis in 1665 for the first part, and introduced the term “parasympathetic” (parasympathetic nervous system [PNS]) for the second.
• The term ANS was adopted as a comprehensive name for both
• The physiologic evidence of visceral reflexes as a result of ______(a) events is abundantly clear. The ANS is therefore not as distinct an entity as the term _______(2) suggests.
• Neither somatic nor ANS activity occurs in _______(3). The ANS organizes visceral support for somatic behavior and adjusts body states in anticipation of emotional behavior or responses to the stress of _______(4)
  
  • Depth of _______(5) can help curb some of this response compared to when the patient is awake
• In brief, it organizes fight or flight responses
• Table 14-1 lists the complementary effects of SNS (_________(6), sympathetic) and PNS (_________(7), parasympathetic) activity of organ systems.
• For an example, please see the partial list on the next slide

Answer 5

Answers:

1. two
   a. somatic
2. distinct
3. isolation
4. disease
5. anesthesia
6. adrenergic
7. cholinergic

Question 6

Table 14-1 Homeostatic Balance Between Adrenergic and Cholinergic Effects 12

Organ System | Adrenergic | Cholinergic

Heart
Sinoatrial node | _______(1) | _______(2)

Atrioventricular node | Increased conduction | Decreased conduction

His-Purkinje | Increased automaticity and conduction velocity | Minimal

Myocardium | Increased _______(3), conduction velocity, automaticity | Minimal decrease in _______(3)

Coronary vessels | Constriction (α1) and dilation (β1) | Dilation and constriction

Answer 6

Answers:

1. Tachycardia
2. Bradycardia
3. contractility

Question 7

Review on your own…

• Central Autonomic Organization (Barash 334)
  Peripheral Autonomic Nervous System Organization (Barash 335)
• _______(1) Nervous System (Barash 336)
  _________(2) Nervous System (Barash 337)
  Autonomic Innervation (Barash 338)
  Peripheral Circulation (Barash 338)
  Lungs (Barash 338)

ANS Transmission
- Transmission of excitation across the terminal junctional sites (_________(3)) of the peripheral _______(4) occurs through the mediation of released chemicals
- Transmitters interact with receptors on the end organ to evoke a biologic response.

Answer 7

Answers:

1. Sympathetic
2. Parasympathetic
3. synaptic clefts
4. ANS

Question 8

Receptors

• An _______(1) is a substance that interacts with a receptor to evoke a biological response.
• ACh, NE, EPI, DA, and ATP are the major agonists of the ANS
• An _______(2) is a substance that interferes with the evocation of a response at a receptor site by an agonist
• Receptors are therefore _______(3) sites that lead to a response by the _______(4) cell when activated by an agonist.
• Receptors are protein macromolecules and are located in the _______(5).
• Several _______(6) receptors have been demonstrated in a single cell.
• The enormity of this network becomes apparent when one considers that ~25,000 single cells can be innervated by a single _______(7).

Answer 8

Answers:

1. agonist
2. antagonist
3. target
4. effector
5. plasma membrane
6. thousand
7. neuron

Question 9

Autonomic Nervous System Reflexes and Interactions

Please review these sections on your own:
- _______(1) (page 349)
- _______(2) Heart (page 349)
- Interaction of ANS Receptors (page 350)
- Interaction with other regulatory systems to include the _______(3) (RAAS) (Page 350)
- Clinical Autonomic Nervous System Pharmacology (Pages 351 – 356)

Autonomic Syndromes & Autonomic Regulation
- Horner Syndrome
- Diabetic Neuropathy
- Orthostatic Hypotension
- Monoamine oxidase inhibitors (MAOIs)
- Tricyclic antidepressants
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Great information to review however, I will not include this information on the _______(4) exam

Answer 9

Answers:

1. Baroreceptors
2. Denervated
3. renin-angiotensin aldosterone system
4. CVT

Question 10

CV Pharmacology

Hemodynamic Goals

• _______(1)
• _______(2)
  
  • Prevention of Myocardial Ischemia
• _______(3)
• _______(4) & Rhythm

Answer 10

Answers:

1. Preload
2. Afterload
3. Contractility
4. Rate

Question 11

CV Anatomy and Physiology

• Calcium plays a critical role in the regulation of peripheral vessel diameter.
  
  • _______(1) intracellular Ca(^{2+}) causes _______(2) (and inotropy? Basically a good thing for BP)
  • _______(3) intracellular Ca(^{2+}) leads to _______(4)
• G-protein cAMP and Nitric oxide cGMP —> _______(4)
• Phospholipase C —> _______(5) (PLP C FOR CONSTRICT)
• Increased cAMP and protein kinase A (PKA) increases intracellular ______(a)—> _______(6)? —> _______(4) bc PKA is associated with _______(4) —> source: look at the diagram below
• PKA affects excitation-contraction coupling by
  
  • Inhibition of voltage-gated Ca(^{2+}) channels in the sarcolemma
  • Inhibition of Ca(^{2+}) release from the SR
  • Reduced sensitivity of the myofilaments to Ca(^{2+})
  • Facilitation of Ca(^{2+}) reuptake into the sarcoplasmic reticulum via the SERCA2 pump
  • _______(7) below states _______(4) as a end result of PKA

Study the Schematic illustration of β-adrenoreceptor agonist mechanism of action (ChatGPT is unable to recognize this image)

Answer 11

Answers:

1. Increased
2. vasoconstriction
3. Reduced
4. vasodilation
5. Vasoconstriction
6. vasodilation?
7. Picture

Question 12

Selection of the Anesthetic
- No _______(1) anesthetic for patients with CAD.
- Choice should depend on the extent of pre-existing myocardial ______(a) and the ______(b) of the drugs.
- Most patients with mid or even moderate dysfunction may _______(c) from some degree of _______(2).

Cardiovascular drugs
- Used to adjust all components of cardiac output and organ perfusion
- Preload (end-diastolic volume) —> _______(3) to tension
- Afterload (vascular tone)
- Inotropy (contractility)
- Chronotropy (heart rate)
- Cardiac output
- Myocardial O2 supply and demand

Answer 12

Answers:
1. ideal
a. dysfunction
b. properties
c. benefit
2. myocardial depression
3. related

Question 13

Preload
- Determines how well the pump is _______(1).
- Directly related to tension developed in the ventricle.
- Filling pressure of the ventricles at the end of the diastole.
- _______(2) is the product of systemic venous return.

• _______(3) is the product of pulmonary circulation entering the left side of the heart.
• Frank-Starling Principle: Increased myocardial fiber length (preload) improves _______(4) up to a point of ultimate decompensation.
• Preload can be measured by CVP (RVEDP) and LAP or _______(5) by PCWP (LVEDP).
  
  • SATA qs?

Answer 13

Answers:

1. primed
2. Right ventricular end-diastolic volume
3. Left ventricular end-diastolic volume
4. contractility
5. indirectly

Question 14

Afterload
- Impedance to _______(1) _______(2)
- Can be altered with drugs that _______(3) or ______(a) vascular beds - mostly via arterial vessels
- Arterial vasodilators decrease resistance to ventricular contraction but can also _______(4) _______(5)
- Clinical indicator for right ventricular afterload is _______(6) _______ or (7)

(MPAP – PCWP x 80) / CO = (50-120 dynes/sec/cm-5)

• Left ventricular afterload is measured as systemic _______(8) _______(9) (SVR).

(MAP - RAP X 80) / CO = (800-1200 dynes/sec/cm-5)

NO FORMULAS ON THE TEST PER TOLSON PER ANDREW-SON
WILL NOT ASK FOR FORMULAS ON THIS EXAM PER MASTA TOLSEN

Contractility
- _______(10) of ventricular contraction and is defined as the _______(11) state of the heart.
- _______(12) agents affect the contraction of the heart muscle.
- Factors that influence ______(b)
- Appropriate amounts of _______(13), sodium and calcium
- Sympathetic nervous system via beta 1 receptors stimulation (increased contractility, HR, ventricular automaticity, and myocardial oxygen consumption
- Increased levels of _______(14) _______ or (15)
- Preload and afterload

Answer 14

Answers:

1. left
2. ventricular outflow
3. dilate
   a. constrict
4. decrease
5. preload
6. pulmonary vascular resistance
7. PVR
8. vascular resistance
9. SVR
10. Force
11. inotropic
12. Inotropic
    b. contractility
13. potassium
14. cyclic adenosine monophosphate
15. cAMP

Question 15

Cardiac output
- Volume of blood that the heart ejects each _______(1).
- CO = SV x HR
- SV = EDV-ESV
- Normal = 4 - 8 L/min
- Cardiac index (CI) adjusts the CO value for an individual _______(2) _______(3).
- CI = CO divided by BSA (2.5 - 4.0 L/min)
- 3 primary factors that determine CO (SVxHR)
- _______(4)
- _______(5)
- _______(6)

Answer 15

Answers:

1. minute
2. body
3. size
4. Preload
5. Afterload
6. Contractility

Question 16

Myocardial Oxygen Supply & Demand
- Myocardial oxygen supply is determined by oxygen content of _______(1) blood and _______(2) perfusion.
- Coronary perfusion is influenced by heart rate
- (Slower heart rate increases diastolic time thus allowing for increased coronary perfusion)
- Source: Filled during _______(3) via the _______(4)

• Diastolic pressure determines coronary perfusion pressure.
  
  • CPP = ADP – LVEDP
• Coronary blood flow is regulated by coronary _______(5) _______(6).
• Myocardial oxygen demand is influenced by _______(7), _______(8), _______(9), and ______(a).
• Myocardial oxygen demand is increased by an increase in preload (increase in ventricular diameter) and an increase in _______(9).
• Myocardial oxygen demand is decreased by a decrease in ______(b) and _______(10).

Answer 16

Answers:

1. arterial
2. coronary
3. Diastole
4. Coronary Ostia
5. vascular
6. tone
7. preload
8. afterload
9. inotropy
   a. heart rate
   b. afterload
10. HR

Question 17

Adrenergic Receptors
- _______(1) is the neurotransmitter responsible for most adrenergic activity of the sympathetic nervous system.
- Norepinephrine is released by _______(2) sympathetic fibers at end ______(a).
- _______(3) synapses near spinal cord, parasympathetic synapses near end organ
- Action of ______(b) is terminated by _______(4) into the _______(5) nerve ending.
- Divided into alpha and beta receptors.

Alpha 1 Receptors
- Located in smooth muscle throughout the body.
- The most important cardiovascular effect of alpha-1 stimulation is _______(6).
- Increase in peripheral vascular resistance.
- Increase in arterial blood pressure.

Answer 17

Answers:

1. Norepinephrine
2. postganglionic
   a. organ tissues
3. Sympathetic
   b. norepinephrine
4. reuptake
5. postganglionic
6. vasoconstriction

Question 18

Alpha 2 Receptors
- Located ______(a) on the _______(1) nerve terminals.
- Stimulation of Alpha 2 receptors creates a ______(b) feedback loop that ______(c) further norepinephrine (NE) release. Decreases _______(2). → _______(3) = alpha 2 agonist = hypotension
- ______(d) (blockage) of Alpha 2 receptors causes an enhanced release of NE from nerve endings.
- Note the added complexity and detail in Barash re: _______(4) Alpha 2

Beta 1 Receptors
- Most important Beta 1 receptors are located on _______(5) membranes in the heart
- Stimulation activates _______(6), which converts ______(e)
- Increases heart rate, conduction, and contractility
- “Positive inotrope”
- Positive: Chronotropy, dromotropy (affects the conduction speed in the _______(7) node), inotropy

Beta 2 Receptors
- Located on _______(8) receptors in ______(f).
- Stimulation _______(9) smooth muscle, resulting in bronchodilation, _______(10), and relaxation of the uterus, bladder, and gut.

Answer 18

Answers:

a. CHIEFLY
1. presynaptic
b. negative
c. inhibits
2. vasoconstriction
3. precedex
d. Antagonism
4. postsynaptic
5. post-synaptic
6. adenylyl cyclase
e. ATP to cAMP
7. AV
8. post-synaptic
f. smooth muscle and gland cells
9. relaxes
10. vasodilation

Question 19

Familiar Drugs and Classifications

• Alpha nonspecific agonist
  
  • (a)
  • (b)
• Alpha 1 agonist specific
  
  • (c)
  • (d)
• Alpha 2 agonist selective
  
  • (e)
  • (f)
• Alpha nonspecific antagonist
  
  • (g)
  • (h) → P.O. med
• Alpha 1 antagonist selective
  
  • (i)
  • (j)
  • (k)
• Alpha 2 antagonist selective
  
  • (l)

Answer 19

Answers

a. Epinephrine
b. Norepinephrine
c. Phenylephrine
d. Methoxamine (Vasoxyl)
e. Clonidine
f. Dexmedetomidine (Precedex)
g. Phentolamine (Regitine)
h. Phenoxybenzamine
i. Prazosin (Minipress)
j. Doxazosin (Cardura)
k. Terazosin (Hytrin)
l. Yohimbine

Question 20

Catecholamines

• Stimulate adrenergic receptors
• Endogenous catecholamines include _______(1), _______(2), and _______(3)
• Non-endogenous (or synthetic sympathomimetic) catecholamines include _______(4) and _______(5).

A1: N>E>D>I
A2: E>N>D>I
B1: I>E>N>D
B2: I>E>N>D
B3: I>N>E>D

Epinephrine
- Stimulates Alpha 1 + 2, and Beta 1 + 2 receptors
- Alpha 1 stimulation increases coronary and cerebral perfusion pressures and systolic BP. → _______(6) to save ur life so sends blood to heart and brain mainly
- However, stimulation of alpha 1 receptors in the skin, mucosa, and hepatorenal vasculature causes vasoconstriction and _______(7) flow.
- Beta_1 stimulation causes an increase in contractility & heart rate, which leads to increased CO and MVO2 (demand).
- Beta_2 stimulation causes vasodilation in _______(8) and _______(9) smooth muscle; may _______(10) diastolic pressure.
- Volatile anesthetics ______(a) dysrhythmic effects.
- Principal pharmacologic treatment for anaphylaxis and ventricular fibrillation
- Complications include cerebral hemorrhage, coronary ischemia, and ventricular arrhythmias.
- WILL NOT ASK FOR DOSAGES

• LOW DOSE EPI: CO INCREASE, SVR DECREASE
• Valley pg 184 Q6

Answer 20

Answers:
1. dopamine
2. norepinephrine
3. epinephrine
4. isoproterenol
5. dobutamine
6. flows
7. decreases
8. skeletal muscles
9. bronchial
10. decrease
a. potentiate

Question 21

Norepinephrine

• Endogenous neurotransmitter for alpha and beta receptors
• Direct Alpha 1 stimulation resulting in vasoconstriction, which _______(1) systemic vascular resistance (both arterial and venous vessels) and may cause a reflex _______(2).
• Beta 1 agonist stimulation _______(3) myocardial contractility.
• _______(4) effects are minimal or absent
• Increased afterload and reflex bradycardia may prevent an increase in _______(5).
• Increased myocardial oxygen demands _______(6) usefulness in cases of refractory shock.
• _______(7) renal blood flow
• Available in 4 or 8 or 16 mg in 250ml infusion
• Initiate at 2 – 4 mcg/min; titrate up to 20 mcg/min (non-weight based?) to effect
• Cardiac surgery 0.01-0.05 mcg/kg/min

Answer 21

Answers:
1. increases
2. bradycardia
3. increases
4. Beta 2
5. cardiac output
6. limits
7. Decreases

Question 22

Dopamine

• Effect is _______(1).
• Nonselective direct and indirect adrenergic agonist effects
  
  • Indirect leads to the release of _______(2)
• Directly stimulates _______(3), ______(a) and ______(b) receptors
• Unique because it stimulates dopamine (________(4)) receptors and increases ______(c) blood flow and, thus, _______(5)
• Available as an infusion 800 mg/250ml
• Renal vasodilation predominate at < 2 mcg/kg/min
  
  • Low dose
• Beta 1 stimulation at 2 – 10 mcg/kg/min resulting in increased myocardial contractility, HR and CO
  
  • Medium dose
• Alpha 1 stimulation at 10 – 20 mcg/kg/min resulting in increased PVR due to vasoconstriction.
  
  • High dose
• Doses > 20 mcg/kg/min and higher result in the release of norepinephrine, because dopamine is an ______(d) product in the enzymatic pathway leading to the production of norepinephrine; thus acts _______(6) by releasing norepinephrine.
  
  • “Much higher doses”
• High doses can inhibit _______(7) and cause _______(8)
• Rapid metabolism
• Extravasation can cause intense vasoconstriction – consider using ______(9) (nonselective alpha blocker) to prevent tissue extravasation injury.

Answer 22

Answers:

1. dose-dependent
2. norepinephrine
3. dopamine
   a. beta
   b. alpha
4. dopaminergic
   c. renal
5. diuresis
   d. intermediate
6. indirectly
7. insulin
8. hyperglycemia
9. Phentolamine

Question 23

Clinical Case Study

1. What hemodynamic changes would you anticipate from the infusion of dopamine at 2 mcg/kg/min?
   
   • _______(1)
2. What hemodynamic changes would you expect from a higher dose of dopamine at 10 mcg/kg/min?
   
   • _______(2) due to B1 Stimulation
3. How do the hemodynamic effects of dopamine differ from those of dobutamine?
   
   • _______(3) will not have any Alpha activity, so it will not impact PVR
4. How does milrinone differ from dobutamine?
5. Are there any benefits of combining drugs such as dopamine and dobutamine with Milrinone? Hell yeah. It _______(4).

Answer 23

Answers:
1. Renal Vasodilation
2. increased myocardial contractility, HR, and CO
3. Dobutamine
4. do

Question 24

Dobutamine

• Synthetic catecholamine with structural characteristics of ______(a) and _______(1).
• Acts on Beta 1 receptors (mostly selective beta 1 _______(2)).
• Increases cardiac contractility (inotropic effects) – Most inotropic properties as compared to epinephrine and ______(b).
• Dose-related increase in heart rate; increases myocardial oxygen demand.
• Increases cerebral blood flow (CBF).
• _______(3) cause indirect release of norepinephrine.
• Decreases systemic vascular resistance (has some beta 2 agonist) — just like Epi.
• Dosage 2 – 20 mcg/kg/min.

Answer 24

Answers:

a. dopamine
1. isoproterenol
2. agonist
b. norepinephrine
3. Does not

Question 25

Isoproterenol - Synthetic catecholamine (________ (1) beta agonist) with potent Beta 1 and Beta 2 effects - Most important Clinical Use: _________(2) in Complete heart block by increase flow through ______(a) Node - Increased Heart Rate, myocardial contractility, systolic blood pressure - No alpha effects - Excessive tachycardia and decreased diastolic pressure (b.c. _________ (3) stimulation) may decrease coronary flow - High incidence of cardiac dysrhythmias (_________(4) HR and decreased CBF) - Infusion: 2mg/250ml @ 1 – 20 mcg/min - Commonly used in electrophysiology ablations-Why? - Isoproterenol is used in electrophysiology ablations to induce or sustain arrhythmias, allowing for accurate mapping and effective treatment of the abnormal heart rhythms. It also helps in assessing the success of the ablation by challenging the heart to ensure the arrhythmia cannot be re-induced post-procedure.

Answer 25

Answers: 1. pure 2. Chemical Pacemaker a. AV 3. Beta 2 4. increased

Question 26

Beta Agonists - Relax bronchioles and uterine smooth muscles - Used to treat _______(1) - In OB: used to stop uterine ______(a) — _______(2) - Examples include Albuterol, Terbutaline and Ritodrine Sympathomimetics - Synthetic drugs that are used as vasopressors to reverse _______(3) - Classified as - direct-acting; mimic the _______(4) of ______(b) - indirect-acting; _______(5) the release of ______(c)

Answer 26

Answers: 1. bronchospasm a. contraction 2. terbutaline 3. hypotension 4. effects b. norepinephrine 5. evoke c. endogenous norepinephrine

Question 27

Ephedrine - Non-________(1) (bc does not have double hydroxyl group on benzene ring); ________(2) and______(a) -acting sympathomimetic - Cardiovascular effects are similar to those of epinephrine, although ephedrine is less potent with a longer ________(3) of action. - Increases blood pressure by ________(4) the release of ______(b). → indirect - Increases cardiac contractility and heart rate secondary to ________(5) receptor stimulation. → direct - Bronchodilator → beta 2 stimulation - Does not decrease ________(6) blood flow like the direct-acting Alpha 1 agonists - Dosage: 2.5 - 10 mg bolus - Subsequent doses are increased secondary to ________(7) of norepinephrine → tachyphylaxis - Available 50mg in 1 ml - Dilute with 9 ml NS to create 5 mg/ml in a 10 ml syringe - ________(8) Epinephrine: Less action but longer action - Valley pg 185 Q18-19

Answer 27

Answers: 1. catecholamine 2. direct a. indirect 3. duration 4. stimulating b. norepinephrine 5. Beta 1 6. uterine 7. depletion 8. Weak

Question 28

Phenylephrine - Non-catecholamine, direct acting (mimics the effects of norepinephrine) _______(1) _______(2) - Primary effect is peripheral vasoconstriction, which increases systemic vascular resistance and BP - No beta effects - Reflex ______(a) → _______(3) _______(4) - ______(b) renal blood flow - _______(5) cerebral blood flow - Available as 10 mg in 1ml - 10 mg mixed in 250 ml = 40 mcg/ml - Infusion rate: 0.25 – 1 mcg/kg/min - Valley pg 185 Q16-17

Answer 28

Answers: 1. Alpha 1 2. agonist a. bradycardia 3. baroreceptor 4. reflex b. Decreases 5. Increases

Question 29

A 37-year-old woman presents with worsening headaches, non-exertional diaphoresis, tremor and pallor. On physical examination, her blood pressure is 210/145 mm Hg with a heart rate of 120 beats per minute. Her 24-hour urine metanephrine concentration is 500 mcg. What is the most likely diagnosis in this patient? A CT scan identified a right adrenal mass. How would you pharmacologically prepare this patient for surgery? What are the intraoperative considerations in this patient? How would you manage post-operative hypotension in this patient?

Answer 29

Answer: 1. Dx: Pheochromocytoma a. Catecholamine secreting Tumor of the Chromaffin Tissue b. Diagnosis: Triad of Headaches, Palpitations, Diaphoresis c. Metanephrines: Metabolic byproduct of catecholamines 2. Phenoxybenzamine Started 2 weeks prior to surgery a. Alpha Adrenergic blockade immediately after diagnosis (Decreases BP, MI, Cerebral hemorrhage, Dysrhythmia) b. Beta blockers may be added AFTER Alpha blocker for Tachycardia 3. Prevention of HTN in provocative portions of the Procedure (ie DL) a. Sedative Medications: b. Medications: Phentolamine Used intraoperatively (Quicker acting) Sodium Nitroprusside c. Alpha blockade PRIOR to Beta Blockade is Crucial d. Communicate with Surgeon- Wear off of endogenous catecholamines happens FAST and can swing BP 4. Post-operative: a. First Line: Fluid volume b. Next: Phenylephrine c. Subsequent: Norepinephrine or Vasopressin

Question 30

Phenoxybenzamine - Non-selective _______ antagonist - Blockage at _______ is greater than Alpha 2 - Used primarily for Chronic medical control of patients with _______ - _______’s disease by reversing vasoconstriction in the hands Phentolamine (Regitine) - _______ alpha antagonist: smooth muscle relaxation, which leads to peripheral vasodilation, decreased BP (alpha 1) and _______ (alpha 2). - Most common S/E: Reflex tachycardia & postural _______ - Dosage: 1 – 5 mg bolus - Used to treat _______ of alpha agonist, 5 – 10 mg locally infiltrated to prevent tissue necrosis. - Valley pg 187 Q5

Answer 30

Answers: 1. Alpha 2. Alpha 1 3. pheochromocytoma 4. Raynaud’s 5. Competitive 6. reflex tachycardia 7. hypotension 8. extravasation

Question 31

Prazosin (Minipress) - Alpha 1 receptor antagonist - Dilates both arterioles and veins - Decreases SVR and Preload - Virtually no tachycardia secondary to lack of alpha 2 _______(1) → bc selective for alpha 1 - *Doxazosin is effective for BPH and HTN - *Tamsulosin is for BPH only but may cause _______(2). Clonidine (Catapress) - Central acting on Alpha 2 agonist receptors located in the _______(3) of the spinal cord - Decreases outflow of the sympathetic nervous system by reducing plasma catecholamine levels - ______(a) chronotropic effects; decreases CO, SVR and BP - Sedative and analgesic effects decrease anesthesia requirements - Effective in suppressing the signs and symptoms of _______(4) from opioids - Adverse effect is _______(5) when abruptly discontinued → bc _______(6) than _______(7) - Transdermal 0.1 - 0.3 mg/released QD - Intrathecal 75 – 150 mcg - Intravenous 1 – 3 mcg/kg - PO 3 – 5 mcg/kg Dexmedetomidine (Precedex) - Greater affinity for the alpha 2 receptor, than clonidine (1600:1 alpha 2:alpha 1 ) - Sympatholytic effects → means slow down - Sympathetic outflow is reduced - Minimal respiratory depression; may see hypotension and bradycardia - Loading dose of 0.5 – 2 mcg/kg over 10 minutes followed by infusion (0.2 – 0.7 mcg/kg/hr) - Know the differences of effect on peripheral and central alpha-2 receptors. - Stimulation of central alpha-2 receptors in the brain reduces sympathetic nervous system activity, leading to decreased blood pressure and heart rate. In contrast, activation of peripheral alpha-2 receptors generally inhibits norepinephrine release, which can cause vasodilation, but if vascular smooth muscle alpha-2 receptors are stimulated, vasoconstriction can occur. The overall effect on blood pressure is a net result of these opposing actions, typically resulting in decreased blood pressure due to the dominant central effect.

Answer 31

Answers: 1. antagonistic 2. orthostatic hypotension 3. dorsal horn a. Negative 4. withdrawal 5. rebound hypertension 6. less selective 7. precedex

Question 32

Beta Antagonists (Blockers) * Blocks the effects of catecholamines on the heart and lungs. * β-Blockers produce important _______(1) effects and are a first-line therapy for patients with ST- and non–ST-segment elevation, myocardial infarction in the absence of cardiogenic shock, hemodynamically significant bradyarrhythmias, or reactive airway disease. * Blockers bind to β1-adrenoceptors and inhibit the actions of circulating catecholamines and norepinephrine released from _______(2) sympathetic neurons. * The decrease in heart rate produced by β-blockers prolongs diastole, increases coronary blood flow to the LV, enhances coronary collateral perfusion to ischemic myocardium, and improves oxygen delivery to the coronary microcirculation. ◦ These combined effects serve to reduce myocardial oxygen demand while simultaneously increasing supply. * β-Blockers have also been shown to inhibit _______(3).

Answer 32

Answers: 1. anti-ischemic 2. post-ganglionic 3. platelet aggregation

Question 33

Inderal (Propranolol) * Nonselective Beta 1 and Beta 2 antagonist (Beta 1 > Beta 2) – prototypical B-Blocker (“gold standard”) * Decreases HR and CO, which decreases myocardial oxygen requirements * Decreases myocardial contractility * Decreases spontaneous _______(1) node firing; slows _______(2) conduction; particularly effective in slowing ventricular rate in SVT * Uses: Afib/Aflutter/SVT * Dosage: 1 - 3 mg IV in 0.5 mg increments Q 2 minutes * Side effect: may cause _______(3) * Excellent for _______(4) Metoprolol (Lopressor) * Selective _______(5) antagonist * Action: Decreases HR and CO * Cardioprotective * Uses: Afib/Aflutter, HTN, SVT * Dosage: 15 mg IV - given in 5 mg increments Q 2 - 3 minutes * Elimination half-life: 3-4 hours

Answer 33

Answers: 1. SA 2. AV 3. bronchospasm 4. Public Speaking Anxiety 5. Beta 1

Question 34

Atenolol / Tenormin * _______(1) selective antagonist * Similar to metoprolol in that it is relatively cardioselective * The lack of first pass metabolism results in a more predictable blood level following oral dosing * Use: Mostly PO for HTN – long acting * Dosage: 5 mg IV over 10 minutes * 50 mg PO QD – primary advantage once a day Esmolol (Brevibloc) * Selective _______(2) antagonist, ultra-short acting * Action: Decreases HR and CO * Dosage: 10 mg IVP * Infusion: Load with 250 mcg/kg over 5 minutes f/b 25 – 50 mcg/kg/min * Metabolism: hydrolysis by RBC’s and plasma esterases to inactive metabolites. ◦ The half life is ~_______(3) minutes.

Answer 34

Answers: 1. Beta 1 2. Beta 1 3. 9

Question 35

Mixed Alpha and Beta antagonists * Labetalol (Trandate) ◦ Action: Blocks Alpha 1, Beta 1 and Beta 2 ◦ Ratio of alpha to beta blockage is _______(1) ◦ Decreases PVR, BP and HR ◦ CO slightly depressed or unchanged ◦ Lowers BP without reflexive increase in HR* ◦ Use with caution in patients with reactive a/w ◦ Dosage: 0.1 - 0.5 mg/kg IV ◦ Half-life 3 - 8 hours Timolol (Blocadren) * Mostly used to decrease _______(2) by decreasing formation of aqueous humor * Non-selective beta blocker * Used in the treatment of _______(3)

Answer 35

Answers: 1. 1:7 (IV) 2. IOP 3. glaucoma

Question 36

Phosphodiesterase Inhibitors * PDE Inhibitors have pharmacologic properties approaching the characteristics of the ideal inotropic agent. * They do not rely on stimulation of beta or alpha receptors and selectively inhibit phosphodiesterase III, the enzyme that breaks down cAMP. Increased levels of cAMP results in vasodilation, decreased PVR and promotes ventricular filling (i.e., increased preload). ◦ Amrinone ◦ Milrinone – currently, the most popular _______(1) * Alters intracellular Ca2+ regulation to enhance myocardial contractility without affecting catecholamine release or activation of beta1-adrenoceptors * PDE III inhibitors cause pronounced arterial and venous vasodilation by _______(2) cGMP-metabolism and facilitating the actions of this second messenger in vascular smooth muscle. * Intravenous or _______(3) administration of PDE III inhibitors also reduces ______(a) * The use of PDE III inhibitors is contraindicated for the treatment of _______(4), however these drugs continue to be of central importance for the treatment of acute LV dysfunction during cardiac surgery and in the intensive care unit

Answer 36

Answers: 1. PDEI 2. blocking 3. inhalational a. pulmonary vascular resistance 4. chronic heart failure

Question 37

Milrinone * Used extensively for inotropic support during and after _______(1) * Milrinone enhances myocardial contractility and causes arterial and venous vasodilation, improving the likelihood of successful weaning of patients with poor LV function from cardiopulmonary bypass Vasopressin * Peptide hormone released from _______(2) * Regulates water reabsorption in the kidney and exerts potent hemodynamic effects _______(3) of adrenoceptors * Receptors (V1 [_______(4)], V2, & V3) are five-subunit helical membrane proteins coupled to G proteins * Activation of subtype triggers second messengers to increase intracellular smooth muscle _______(5). * Effective for conditions where relative vasopressin deficiency exists: catecholamine-refractory hypotension, vasodilatory shock, sepsis, cardiac arrest * Uses: ◦ Intraoperative hypotension due to ACEIs & ARBs refractory to admin of catecholamines or sympathomimetics ◦ Anaphylaxis ◦ Vasoplegia: severe hypotension after prolonged CPB ◦ Cardiac arrest resulting from Vfib, PEA, Asystole * Combined use with other vasoactive medications reduces overall dose of vasopressin * Sustained admin at higher doses may produce _______(6) ischemia, peripheral vascular insufficiency, and cardiac arrest

Answer 37

Answers: 1. cardiac surgery 2. posterior pituitary 3. independent 4. cell membrane of vascular smooth muscle 5. cell 6. mesenteric

Question 38

Nitroglycerin (NTG or Nitrate) * Relaxes vascular smooth muscle * _______(1) dilatation predominates over arterial dilatation, which leads to decreased myocardial oxygen demand. * Decreases preload * Mechanism of action is similar to sodium nitroprusside (i.e., metabolism of NO) * Relieves myocardial ischemia by redistributing coronary blood flow to ischemic areas of the subendocardium. * May relieve coronary artery spasm * Rebound hypertension after discontinuation is _______(2) as compared to Nipride * Available 50 or 100mg in 250ml glass bottle * Infusion: 0.5 – 10 mcg/kg/min Metabolism of NTG * Undergoes rapid reduction hydrolysis in the _______(3) * One metabolic product is _______(4), which can convert hemoglobin (Fe+2) to methemoglobin (Fe+3) * Methemoglobinemia rarely occurs. * Treat with _______(5) over 5 minutes

Answer 38

Answers: 1. Venous 2. less likely 3. liver and blood 4. nitrate 5. methylene blue 1 - 2mg/kg

Question 39

Sodium Nitroprusside (Nipride) * Metabolism releases nitric oxide - a naturally occurring potent vasodilator released by the endothelial cells. * Vascular smooth muscle relaxation dilation of arterial and venous vascular beds reduces both preload and afterload; resulting in decreased myocardial workload and ischemia. * Inhaled NO used to treat _______(1) * Decreases BP by decreasing _______(2) * Available as 50 mg/250 ml * Infusion 0.5 – 10 mcg/kg/min * Rapid onset within 1 - 2 minutes * Protect infusion from _______(3) * Vascular steal syndromes ◦ _______(4): shunts blood away from compromised coronary leading to worsening ischemia and infarction ◦ _______(5): similar mechanism * Avoid in patients with ______(a) and increase in _______(6) * _______(7) can occur with sudden discontinuation

Answer 39

Answers: 1. pulmonary hypertension 2. SVR (Systemic Vascular Resistance) 3. sunlight 4. Coronary steal 5. Cerebral steal a. cerebral ischemia 6. ICP (Intracranial Pressure) 7. Rebound hypertension

Question 40

Nipride metabolism * Nipride enters red blood cells and receives an electron from the iron of oxyhemoglobin (Fe+2) * This electron transfer results in an unstable nitroprusside radical and _______(1) (Fe+3) * Nitroprusside radicals decompose into cyanide ions. * Cyanide ions bind to tissue cytochrome oxidase which interferes with normal oxygen utilization and prevents oxygen from being released by the tissues. Acute Cyanide Toxicity * Signs and symptoms ◦ Metabolic acidosis ◦ Tachyphylaxis ◦ Increased mixed venous O2 (secondary to inability to metabolize O2) ◦ Also cardiac dysrhythmias * ______(a) ventilate with 100% _______(2) * Administer _______(3) over 15 minutes * Thiosulfate converts cyanide to _______(4), which is cleared via the _______(5).

Answer 40

Answers: 1. methemoglobin a. Mechanically 2. oxygen 3. sodium thiosulfate 150mg/kg 4. thiocyanate 5. kidneys

Question 41

Hydralazine * Relaxes _______(1) smooth muscle * Decreases _______(2) vascular resistance * Decreases BP * Increases HR and CO * Interferes with _______(3) utilization * Used for intraoperative hypertension * Administer 5 – 20 mg IV (Give lower dose and _______(4)) * Onset _______(5); duration 2 - 4 hours. * Elimination half life 4 h, but effective half life 100 h * DOC for _______(6) Hypertension; Pressure at rest Calcium Channel Blockers (CCB) * Selectively interfere with inward calcium ion movement across the cell membranes * Decreases myocardial oxygen demand by decreasing afterload, contractility, HR, and conduction through the _______(7) node. * Cause small muscle relaxation and vasodilation * Uses include treatment of HTN, SVT, coronary artery spasm, angina and cerebral artery vasospasm Nifedipine (Procardia) * Most potent _______(a) * Coronary and peripheral arterial vasodilation * Potential for hypotension and reflex _______(b) * Uses: most specific application is for _______(c); HTN, angina * Dosage SL or PO 10-20 mg * CCB; a derivative of _______(d)

Answer 41

Answers: 1. arteriolar 2. systemic 3. calcium 4. WAIT 5. 15 - 20 minutes 6. Diastolic 7. AV a. CCB (Calcium Channel Blocker) b. tachycardia c. coronary vasospasm d. papaverine

Question 42

Nicardipine (Cardene) * CCB; can be titrated IV * Smooth muscle relaxation produces vasodilation of peripheral and coronary arteries * Rapid onset; Half life, _______(1) minutes * Minimal cardiodepressant effects ◦ does not decrease the rate of _______(2) or slow AV conduction * Uses: HTN (Use cautiously in patients with acute ischemia.) * Available: 25mg in 250ml * Infuse 1 - 4 mcg/kg/min; titrate to achieve BP Clevidipine * Ultra-short-acting dihydropyridine Ca2+ channel antagonist * Plasma half-life of ~_______(3) * Pronounced effects at the less negative resting membrane potentials typically in smooth muscle cells → highly selective for arterial vascular smooth muscle; devoid of _______(4) effects * Good for patients with LV _______(5)/AHF * Decreases SVR & ABP, no effect LV preload * Metabolism by _______(6) * Used for acute hypertension in cardiac surgery, pheochromocytoma, acute intracerebral hemorrhage, spinal surgery

Answer 42

Answers: 1. 15 2. sinus node pacemaker 3. 2min 4. chronotropic or inotropic 5. dysfunction 6. plasma and tissue esterases

Question 43

Nimodipine (Nimotop) * CCB; primary use is to prevent cerebral artery _______(1) following subarachnoid hemorrhage, which can occur ~_______(2) days after initial event. * Enters CNS and may block influx of calcium * Now available only as an oral medication; may be administered via NG tube Diltiazem (Cardizem) * CCB; similar in chemical structure to verapamil * Selective coronary vasodilation * Uses: Angina, HTN, SVT, Afib, Aflutter * 0.25mg/kg IV slowly may repeat in 15 min Infusion: _______(3)/hr * Half life 3-5 hours Verapamil * CCB; a derivative of _______(4) * Depresses transmission of impulses via _______(5) by slowing HR and reducing contractility. * Do not use it in _______(6) or other ventricular dysfunction conduction abnormalities as it inhibits the intrinsic conduction pathway. * Use with caution in patients who are beta-blocked. * Uses: SVT, Afib, Aflutter, chronic HTN * Dosage: 5mg IV

Answer 43

Answers: 1. vasospasm 2. 4 – 14 3. 5-15mg 4. papaverine 5. SA node and AV node 6. WPW (Wolff-Parkinson-White syndrome)

Question 44

ACE inhibitors * Significantly reduced cardiovascular mortality for patients with Heart Failure. * Block the conversion of angiotensin I to angiotensin II in the _______(1) * Prevents angiotensin II mediated vasoconstriction * Examples: Captopril, enalapril, lisinopril * Uses: HTN, CRI, Chronic heart failure * 20% of patients develop a _______(2) Angiotensin II Receptor Antagonists * Increasing numbers of hypertensive patients being treated with ARBS are being scheduled for surgery. * Hypotensive episodes occur more frequently after anesthetic induction in patients receiving ARBS than other antihypertensive drugs and can be _______(3) to treatment with ephedrine and phenylephrine. ARBS * Angiotensin II Receptor Antagonists ◦ Candesartan (Atacand) ◦ Eprosartan (Teveten) ◦ Irbesartan (Avapro) ◦ Losartan (Cozaar) ◦ Olmesartan (Benicar) ◦ Telmisartan (Micardis) ◦ Valsartan (Diovan) ARBS Combination Products * Amlodipine/Olmesartan (Azor) → CCB/ARB * Amlodipine/Valsartan (Exforge) * HCTZ/Candesartan (Atacand HCT) → Thiazide diuretic/ARB * HCTZ/Eprosartan (Teveten HCT) * HCTZ/Irbesartan (Avalide) * HCTZ/Losartan (Hyzaar) * HCTZ/Olmesartan (Benicar) * HCTZ/Telmisartan (Micardis HCT) * HCTZ/Valsartan (Diovan)

Answer 44

Answers: 1. lungs 2. dry, chronic cough 3. refractory

Question 45

Antiarrhythmic Agents * Critical treatment steps before administration of any antiarrhythmic agent: ◦ Manage electrolyte abnormalities ◦ Treat underlying disease processes – i.e., myocardial ischemia ◦ Beta Adrenergic receptor antagonists are very effective but often underused in the perioperative period. ◦ Many arrhythmias are _______(1)-mediated, versus vagally-mediated. Class I: ______(2) Channel Blockers * Common property of inhibiting the fast inward depolarizing current carried by the sodium ion; subgroups based on the diversity of other effects. Find a quick way to memorize this table Class IA - Quinidine - Procainamide - Disopyramide Class IB - Lidocaine - Mexiletine - Tocainide Class IC - Flecainide - Propafenone - Moricizine

Answer 45

Answers: 1. adrenergically 2. Sodium

Question 46

Class II: Beta Adrenergic Antagonists * Very effective antiarrhythmics in patients during the perioperative period, or patients who are critically ill, primarily because they are adrenergically-mediated. ◦ Propranolol ◦ Metoprolol ◦ Esmolol Class III ______(1) Channel Blockers * Agents that block potassium channels, thereby prolonging _______(2) ◦ Amiodarone ◦ Bretylium ◦ Sotalol (also has Class II Beta adrenergic blocking activity) Class IV ______(3) Channel Antagonists * Calcium channel antagonists prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Also called calcium channel blockers, they relax and widen blood vessels by affecting the muscle cells in the arterial walls. ◦ Verapamil ◦ Nifedipine ◦ Diltiazem

Answer 46

Answers: 1. Potassium 2. repolarization 3. Calcium

Question 47

Other antiarrhythmic agents: * Digoxin – digitalis glycoside for CHF and to control supraventricular cardiac dysrhythmias * Adenosine – endogenous nucleotide * Potassium – to maintain electrolyte balance * Magnesium Phosphodiesterase Inhibitors * PDE Inhibitors have pharmacologic properties approaching the characteristics of the ideal inotropic agent. * They do not rely on stimulation of beta or alpha receptors and selectively inhibit _______(1), the enzyme that breaks down cAMP. ◦ Increased levels of cAMP results in vasodilation, decreased _______(2) and promotes ventricular filling (i.e., increased preload). * Amrinone * Milrinone – currently, the most popular PDEI Study the CV Monitoring and Oxyhemoglobin Disassociation Curve (ChatGPT is unable to recognize this image)

Answer 47

Answers: 1. phosphodiesterase III 2. PVR (Pulmonary Vascular Resistance

Question 48

Oxyhemoglobin Disassociation Curve Left Shift * Hypocapnia * ↓ H+ ions * Hypothermia * Hg molecule binds more tightly to O2 Right Shift * Hypercapnia * ↑ H+ ions * Hyperthermia * Decreases the affinity of Hb for O2 * Unloads O2 from Hb to tissues The SpO2 measured by pulse oximetry is not the same as the arterial saturation (SaO2) measured by a laboratory co-oximeter because: On the steep part of the curve, a predictable correlation exists between SaO2 and partial pressure of oxygen (PaO2). In this range, the SaO2 is a good reflection of the extent of hypoxemia and the changing status of arterial oxygenation. For PaO2 greater than ______(1) mmHg, the SaO2 reaches a plateau and no longer reflects changes in PaO2. Coexisting medical conditions, such as hypercapnia, acidosis, and hyperthermia, cause the oxyhemoglobin dissociation curve to shift to the ______(2) and decrease the affinity of hemoglobin for oxygen. This change favors the unloading of oxygen from hemoglobin to peripheral tissues. The SPO2 measured by pulse oximetry is not the same as the arterial saturation (SaO2) measured by a laboratory co-oximeter. Why?

Answer 48

Answers 1. 75 2. right

Question 49

NIBP * Based on oscillometry * Measures changes in amplitude of oscillations o Onset of oscillations = _______(1) o Greatest oscillations = _______(2) o Algorithm extrapolates = _______(3) Disadvantages * Less reliable with o High heart rates o Irregular rhythms o Hypovolemia o Inappropriate sizing: err on too big o Arm position above or below level of heart o Obese or cone-shaped arm o Bladder not over artery o Cuff not applied snugly * ______(a) nerve damage if applied incorrectly * Bruising from long-term frequent measurements Proper Sizing * Width of cuff should exceed diameter of extremity by ______(b) * Length should be 80% (prodigy) * Too small cuff _______(4) BP more than too large cuff _______(5)

Answer 49

Answers: 1. SBP (Systolic Blood Pressure) 2. MAP (Mean Arterial Pressure) 3. DBP (Diastolic Blood Pressure) a. Ulnar b. 20-50% 4. over-estimates 5. underestimates

Question 50

Arterial lines * Indications o Unstable condition o Use of vasoactive drugs o Need for multiple arterial blood draws o Deliberate hypotension/hypothermia o Severe cardiopulmonary disease o Major cases ▪ High EBL ▪ Intracranial ▪ Fluid shifts ▪ Metabolic derangements Arterial BP * Radial SBP > _______(1) o The more _______(2) the site * Steeper anacrotic limb/higher SBP * Further off the heart causes an _______(3) in amplitude Reprinted from Gorny,^9 with permission.

Answer 50

Answers: 1. aortic 2. distal 3. increase

Question 51

Arterial Waveform * Rate of upstroke reflects _______(1) * Downstroke reflects _______(2) * Dicrotic notch: ______(a) Closing (End of Systole, Start of Diastole) possible t/f qs? o ______(b) on the dicrotic limb = ↑ CO/SV o ______(c) on the dicrotic limb = ↓ CO/SV * Area under curve = _______(3) * What does the dicrotic notch mean? Rate of rise on the left indicates contractility. Reprinted from Darovic,^9 with permission.

Answer 51

Answers: 1. contractility 2. PVR (Pulmonary Vascular Resistance) a. Aortic Valve b. High c. Low 3. MAP (Mean Arterial Pressure)

Question 52

Pulsus Alternans * Alternating beats of larger and smaller pulse pressure * Sign of severe _______(1) dysfunction ◦ Often with _______(2) * Distinguish from _______(3)

Answer 52

Answers: 1. LV (Left Ventricular) 2. AS (Aortic Stenosis) 3. bigeminy

Question 53

Pulsus Paradoxus * Spontaneous respiration (arrows point to onset of inspiration) * Inspiration normally decreases _______(1) ^ in pulmonary venous capacitance exceeds increase in venous return * Decrease in _______(2) > _______(3) Hg = P. Paradoxus * Common in _______(4)

Answer 53

Answers: 1. SBP (Systolic Blood Pressure) 2. SBP 3. 10mm 4. tamponade or pericardial constriction

Question 54

Systolic Pressure Variation * Positive pressure ventilation * Normal variation SBP ≈ _______(1) * Variations > _______(2) indicate hypovolemia o Even in presence of near normal HR and BP 2° compensation via vasoconstriction * Decreases venous return to the right side of the heart and output to the pulmonary system. * Research has revealed that preanesthetic SVV is significantly correlated with a decrease in _______(3) during anesthesia induction; studies have found that patients with lower preanesthetic SVV had a lower incidence and significantly slower onset of decreased CO than those with higher SVV values and that SVV is a reliable diagnostic tool when evaluating patients’ fluid responsiveness in both the operating room and intensive care settings. o 74-76 In mechanically ventilated patients, the range for normal SVV is _______(4) to _______(5). Values higher than _______(6) to _______(7) imply patients will respond positively to an increase in preload. Arterial Waveforms with Pathology A = normal B = Aortic stenosis C= AI Aortic Insufficiency = Aortic regurgitation D = IHSS/HOCM Idiopathic hypertrophic subaortic stenosis/Hypertrophic obstructive cardiomyopathy

Answer 54

Answers: 1. 10mmHg 2. 10mmHg 3. cardiac output 4. 10% 5. 13% 6. 12% 7. 13%

Question 55

Arterial Lines * Allen’s Test o Unreliable but you should know how to perform it! ▪ Possible qs? Describe the allen test procedure * Size o 20g adults o 22g pediatrics * Monitor circulation in the extremity (i.e. SpO2) * Overdamping o Kinks o Air/clots o Long tubing o Hypotension/hypovolemia * Underdamping o Same as above except hyperdynamic/ hypertension * Before and After Dampening Device * Dynamic Response CVP * Indications o Fluid management o Adequate IV access o Infusion of TPN or pressors o Aspiration of air * Contraindications o TV ______(a)? ▪ What’s this? o ______(b) patients o Ipsilateral carotid ______(c) * Limitations o Unhealthy hearts (right sided values don’t _______(1) left sided values) T/F q? ▪ Pulmonary HTN ▪ Right or left heart failure ▪ Tricuspid regurgitation o Positive-pressure ventilation with PEEP > 10 cm H2O

Answer 55

Answers: a. vegetation b. Anticoagulated c. endarterectomy 1. reflect

Question 56

CVP waveform * A wave = atrial contraction (1st wave after p wave) * C wave = TV tenting into RA during isovolumic _______(1) * V wave = ______(a) filling (during _______(2) systole) * x descent = atrial _______(3) * y descent = atrial _______(4) (passive) * Z point = use if _______(5) or unable to discern a wave * Cannon A waves 2° av dissociation/jct. rhythm CVP Risks * Arrhythmias * Infection * Clot formation * Air embolism * RA or RV perforation * _______(6)

Answer 56

Answers: 1. contraction a. atrial 2. ventricular 3. relaxation 4. emptying 5. afib 6. Pneumothorax

Question 57

PA Catheter (No Questions) * Indications ◦ Need for SvO2 monitoring ◦ Cardiac output and preload ◦ Patients at high risk for instability * Contraindications ◦ WPW ◦ _______(1) PA Catheter Distances | Insertion Site | RA | RV | PA | | --- | --- | --- | --- | | RIJ | 20 | 30 | 45 | | LIJ | 25 | 35 | 50 | | SC | 15 | 25 | 40 | | Femoral | 30 | 40 | 55 | Know pressures should you see at sites with RIJ insertion? Floating PA Catheter (study)

Answer 57

Answers: 1. LBBB (Left Bundle Branch Block)

Question 58

Giant V Waves * Giant V waves 2° to severe _______(1) * PA catheter can easily be in unrecognized _______(2) position PCWP * Indirect measure of LA pressure (preload) | Perfect world | PCWP < LVEDP | PCWP > LVEDP | PCWP=LVEDP±LVEDV | | --- | --- | --- | --- | | PCWP = LVEDP = LVEDV | AI ↓LV compliance | ↑LV compliance MS/MR+ pressure ventilation with peep | Ischemia Infarction hypertrophy | AI: Aortic Insufficiency LV: Left Ventricle MS: Mitral Stenosis MR: Mitral Regurgitation PEEP: Positive End-Expiratory Pressure LVEDP: Left Ventricular End-Diastolic Pressure LVEDV: Left Ventricular End-Diastolic Volume PCWP: Pulmonary Capillary Wedge Pressure

Answer 58

Answers: 1. MR (Mitral Regurgitation) 2. wedge