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112 Cards in this Set
- Front
- Back
What is the normal range for CO?
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4-8 L/min
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What is the normal range for Cardiac Index?
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2.5-4
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What is the normal range for systemic vascular resistance? and systemic vascular resistance index?
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800-1400, 1500-2400
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What is the normal PCWP?
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11 +- 4
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What is the normal CVP?
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7 +- 2
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What is the normal pulmonary artery pressures?
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20-30/6-15
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What is the normal mixed venous oxygen saturation SvO2?
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75+-5
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What percentage of CO does the following organs get? kidney, brain, heart
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25, 15, 5 respectively
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What is the formula for MAP?
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CO x SVR
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What is the formula for ejection fraction?
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stroke volume/EDV
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Cardiac output increases with HR up to 120-150 bpm, then starts to go down, why?
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decreased diastolic filling time
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Atrial kick accounts for what % of LVEDV?
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15-30%
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Automatic increase in contractility secondary to increase in afterload. What is this effect called? What about automatic increase in contractility secondary to increased HR?
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Anrep effect
Bowditch effect |
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What is the normal O2 delivery-to-consumption ratio? What increases to keep this ratio constant?
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5:1, CO
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What is the normal SvO2?
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75%
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What measurement can be thrown off by pulmonary htn, aortic regurg, mitral stenosis, mitral regurg, high PEEP, porr LV compliance?
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Wedge
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What is the only way to measure pulmonary vascular resistance?
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swan
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Which zone of the lung do you place a swan?
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zone III (lower lung)
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Hemoptysis after flushing Swan. Name three interventions.
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increase PEEP to tamponade the pulmonary artery bleed
mainstem intubate the nonaffected side, try to place a Fogarty down the affected side, may need thoracotomy and lobectomy |
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Name two relative contraindications to a swan.
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previous pneumonectomy, LBBB
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In this pulmonary artery wedge tracing, wedge pressure is measured at end expiration. Which point is for spontaneous breathing pts and which is for pts undergoing positive pressure ventilation?
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A is for spontaneous, B is for vent
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What are the two primary determinants of myocardial O2 consumption -> can lead to myocardial ischemia?
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increased ventricular wall tension and HR
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Why is LV blood 5 mmHg of PO2 lower than pulmonary capillaries?
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unsaturated bronchial blood empties into pulmonary veins
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What is the normal alveolar-arterial gradient in a non ventilated pt?
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10-15 mmHg
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Where is blood with the lowest venous saturation located?
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coronary venous blood (30%)
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Cardiovascular collapse; characteristically unresponsive to fluids and pressors.
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Acute adrenal insufficiency
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hyperpigmentation, weakness, weight loss, GI sx, increased K, decreased Na, fever, hypotension.
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chronic adrenal insufficiency
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Steroid potency:
1x - cortisone, hydrocortisone ___ - prednisone, prednisolone, methylprednisolone ___ - dexamethasone |
5x
30x |
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Neurogenic shock - loss of sympathetic tone. Usually have decreased HR, decreased BP, warm skin. Tx?
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give volume 1st, then phenylephrine after resuscitation; give steroids for blunt spinal trauma with deficit
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What is the initial alteration in hemorrhagic shock?
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increased diastolic pressure
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What is the tx for cardiac tamponade?
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fluid resuscitation initially; need pericardial window or pericardiocentesis
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What is the CO and SVRI in hemorrhagic shock (increased or decreased)? and septic shock?
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CO is decreased, SVRI is increased in hemorrhagic shock
CO is increased, SVRI is decreased in septic shock |
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What is the triad of hyperventilation, confusion and respiratory alkalosis?
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early sepsis triad
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What is the insulin and glucose in early vs late gram-negative sepsis?
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Early is decreased insulin and increased glucose due to impaired utilization
Late is increased insulin and increased glucose due to insulin resistance |
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When does hyperglycemia occur in sepsis?
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just before pt becomes clinically septic
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What is activated protein C (Xigris) used for and what is the mechanism?
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used for sepsis; mechanism is fibrinolysis
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What stain can be used to find fat in sputum in urine to help dx fat emboli?
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sudan red
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PA systolic pressures >40, decreased PO2 and PCO2, respiratory alkalosis, chest pain, cough, dyspnea, increased HR
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PE
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What is the tx for air emboli?
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place pt head down and roll to left to keep air in RV and RA then aspirate air out with central line or PA catheter to RA/RV
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When is IABP used? what is the contraindication? what does it improve?
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cardiogenic shock, aortic regurgitation, improves coronary perfusion
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Name the receptor:
vascular smooth muscle constriction; gluconeogenesis, glycogenolysis |
Alpha 1
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Name the receptor:
venous smooth muscle constriction |
Alpha 2
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Name the receptor:
mycocardial contraction and rate |
Beta 1
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Name the receptor:
relaxes bronchial smooth muscle, relaxes vascular smooth muscle; increases insulin, glucagon, rennin |
Beta 2
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Name the receptor:
relax renal and splanchnic smooth muscle |
dopamine
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Name the three receptors and associated effects for dopamine at low (0-5 ug/kg/min), medium (6-10), and high (>10) doses.
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low - dopamine receptors (renal)
medium - beta-adrenergic (heart contractility) high - alpha-adrenergic (vasoconstriction and increased BP) |
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What receptors and affects does dobutamine affect at low (5-15 ug/kg/min) and high (>15) doses.
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low - beta-1 (increased contractility)
high - beta 2 (vasodilation, increased HR) |
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Name the drug that is a phosphodiesterase inhibitor (Increases cAMP). Results in increased Ca flux and increased myocardial contractility. Also causes vascular smooth muscle relaxation and vasodilation.
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Milrinone
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What receptor does Phenylephrine affect?
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alpha-1, vasoconstriction
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What receptors does Norepinepherine affect at low and high doses?
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Low - beta-1 (increased contractility)
High - alpha-1 and alpha-2 |
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What receptors does Epinephrine affect at low and high doses?
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Low - beta 1 and beta 2 (increased contractility and vasodilation). Can decrease BP at low doses.
High - alpha-1 and alpha-2 (vasoconstriction). Increased cardiac ectopic pacer activity and myocardial O2 demand. |
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Name the drug that hits Beta-1 and beta-2 receptors, increasing HR and contractility, vasodilates. Side effects: extremely arrhythmogenic; increased heart metabolic demand (rarely used); may actually decrease BP.
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Isoproterenol
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Name the Vasopressin receptor:
vasoconstriction of vascular smooth muscle |
V-1
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Name the vasopressin receptor:
water reabsorption at collecting ducts |
V-2 (intrarenal)
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Name the vasopressin receptor:
mediate release of factor VIII and vWF |
V-2 (extrarenal)
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What is the concern with Nipride (arterial and venous dilator)?
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Cyanide toxicity at doses ?3 ug/kg/min for 72 hrs; check thiocyanate levels and signs of metabolic acidosis
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How does nitroglycerin decrease myocardial wall tension?
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decreasing preload
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What is the MOA of hydralazine?
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alpha blocker
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What is the formula for compliance? What does high compliance lungs mean?
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change in volume/change in pressure.
easy to ventilate |
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Pts with ARDS, fibrotic lung disease, reperfusion injury, pulmonary edema all have reduce what?
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pulmonary compliance
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Which part of the lungs has the highest V/Q ratio? the lowest?
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highest in upper, lowest in lower
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On a ventilator what can be increased to improve oxygenation (alveoli recruitment) -> improves FRC
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increased PEEP
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On a ventilator what 2 things can be increased to decrease CO2?
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increased rate or volume
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Normal weaning parameters:
negative inspiratory force (NIF) > ___, FiO2 < ___% PEEP ___ (physiologic) pressure support 5, RR < ___ HR < ___ Po2 > ___ PCO2 < ___ pH 7.35-7.45 sats > 93% off pressors, follows commands, can protect airway |
negative inspiratory force (NIF) > 20,
FiO2 < 35% PEEP 5 (physiologic) pressure support 5, RR < 24 HR < 120 Po2 > 60 PCO2 < 50 pH 7.35-7.45 sats > 93% off pressors, follows commands, can protect airway |
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Barotrauma on vent - high risk if plateus >___ and peaks >___ -> consider prophylactic ___
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30,50, chest tubes
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What does pressure support on a vent do?
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decreases the work of breathing (inspiratory pressure is held constant until minimum volume is achieved)
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Excessive PEEP complications include decreased RA filling, decreased CO, decreased renal blood flow and decreased urine output and increased ___
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pulmonary vascular resistance
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What 3 types of pts where high frequency ventilation is used?
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kids, tacheoesophageal fistula, bronchopleural fistula
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Why is inverse ratio ventilation used? (normal 1:2 I:E phase; go to 2:1)
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helps reduce barotrauma
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What is the formula for minute ventilation?
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TV x RR
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What class of lung disease is represented by decreased TLC, decreased RV, decreased FVC, FEV1 can be normal or increased?
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restrictive lung disease
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What class of lung disease is represented by increased total lung capacity, increased residual volume and decreased FEV1?
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obstructive lung disease
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What is the most common cause of ARDS?
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sepsis
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Acute Lung Injury is defined by acute onset, bilateral pulmonary infiltrates, PaO2/FiO2 < 300, PAOP < 18 mmHg or no clinical evidence of LAH. What one additional criteria defines acute respiratory distress syndrome?
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PaO2/FiO2 < 200
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What two cytokines mediate SIRS?
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TNF-alpha and IL-1
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What are the 4 SIRS criteria?
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Temp >38 or <36
RR >20 or Pco2 < 32 WBC >12,000 or <4000 HR >90 |
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SIRS -> Sepsis -> Septic Shock -> ___
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MOD (Progressive but reversible dysfunction of 2 or more organs arising from an acute disruption of normal homeostasis)
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What is the name of the syndrome of chemical pneumonitis from aspiration of gastric secretions.
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Mendelson's
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Most common cause of fever in the first 48 hours after operation?
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atelectasis
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What effect does the following have on the lungs?
bradykinin, PGEi, prostacyclin (PGI2), nitric oxide |
pulmonary vasodilation
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What effect does the following have on the lungs?
histamine, serotonin, TXA2, epinephrine, norepinephrine, hypoxia, acidosis |
pulmonary vasoconstriction
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What effect does alkalosis have on pulmonary vasculature? and acidosis?
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alkalosis - pulmonary vasodilator
acidosis - pulmonary vasoconstrictor |
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What does nitroprusside, nitroglycerine, and nifedipine do to the pulmonary vasculature?
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pulmonary shunting
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What is the most common cause of postoperative renal failure?
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hypotension
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What percentage of nephrons need to be damaged before renal dysfunction occurs?
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70%
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What is the best test for azotemia?
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FeNa
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What are the three steps to treating Oliguria?
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1st make sure pt is volume loaded (CVP 11-15 mmHg), 2nd try diuretic trial (Lasix or butanamide)
3rd dialysis if needed |
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Renin is released in response to decreased pressure sensed by ___ in kidney. Also in response to increased Na concentrations sensed by ___
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juxtaglomerular apparatus, macula densa
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What does renin do?
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converts angiotensinogen to angiotensin I
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What converts angiotensin I to angiotensin II?
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angiotensin converting enzyme in the lung
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What structure releases aldosterone in response to angiotensin II?
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adrenal cortex
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What specifically does aldosterone do to the kidney?
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Acts on distal convoluted tubule ATPase to increase resorption of water and sodium and secretion of potassium.
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What does atrial natriuretic peptide do to the kidney? to the blood vessels?
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inhibits Na and water resorption at the collecting ducts
vasodilator |
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What specifically does ADH do to the kidney? the blood vessels?
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Acts on the collecting ducts for water resorption
vasoconstrictor |
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How do NSAIDs cause renal damage?
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Inhibit prostaglandin synthesis, resulting in renal arteriole vasoconstriction
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How do aminoglycosides cause renal damage?
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direct tubular injury and later renal vasoconstriction
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Myoglobin causes direct renal tubular injury. What is the tx?
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alkalinize urine
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Contrast dyes cause direct tubular injury. What is the tx?
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premedicate with N-acetylcysteine and volume
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The following things preclude what diagnosis?
uremia, temp <30, BP <70/40, desaturation with apnea test, drugs, metabolic derangements |
brain death
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How long must the following exist to declare brain death:
unresponsive to pain, absent caloric oculovestibular reflexes, absent oculocephalic reflex, positive apnea test, no corneal reflex, no gag reflex, fixed and dilated pupils. |
6-12 hours
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What two testing modalities can be used to prove absence of brain activity?
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EEG - electrical silence
MRA - will show no blood flow to brain |
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Apnea test – disconnected from ventilation; CO2 >___ mm Hg or increase in CO2 by ___ is a positive test for apnea. If arterial pressure drops to <60 or patient desaturates, the test is terminated
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60, 20
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Can you still have deep tendon reflexes with brain death?
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yes
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What does carbon monoxide do to a pulse oximeter?
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Can falsely increase reading
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What does carbon monoxide do to hemoglobin?
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binds hemoglobin directly creating carboxyhemoglobin
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What is an abnormal carboxyhemoglobin level? and in smokers?
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>10%, >20%
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What is tx for carbon monoxide poisoning?
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100% O2 on a ventilator; may need hyperbaric O2 if really high
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Methemoglobinemia can occur from nitrites such as Hurricaine spray; nitrites bind Hgb. What is the O2 saturation? What is the tx?
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85%, methylene blue
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Critical illness polyneuropathy – motor > sensory neuropathy; occurs with ____; can lead to failure to wean from ventilation
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sepsis
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In endothelial cells, forms toxic oxygen radicals with reperfusion, involved in reperfusion injury. Also involved in the metabolism of purines and breakdown to uric acid
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Xanthine oxidase
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When do seizures occur with ETOH withdrawal?
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48 hrs
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ICU (or hospital) psychosis generally occurs after which postoperative day? What do you need to rule out?
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3rd, metabolic and organic causes
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