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introduction to criticAl cAre ● 445 Figure 28.1 Oxyhemoglobin dissociation curve. This curve defines the relationship between partial pressure of oxygen in the blood and the percent of hemoglobin that is saturated with oxygen. The position of this curve is influenced by factors such as H + concentration, P a CO 2 , temperature, and 2-3-diphosphoglycerate (DPG). (Image Courtesy J. Ehrenfeld). less affinity for oxygen, and thus more oxygen will be released to the tissues. As the curve shifts to the left, hemoglobin binds oxygen more tightly and releases less to the tissues. During periods of stress (such as metabolic acidosis), the curve is shifted to the right to allow more oxygen to be delivered to the tissues. Markers of Oxygen Balance and Tissue Perfusion Lactate When the body’s oxygen balance is such that oxygen demand exceeds oxygen supply, cells become hypoxic and convert to anaerobic metabolism. Lactic acid (lactate) is a by-product of anaerobic metabolism and can be measured in the blood. Elevated lactate levels are associated with tissue hypoperfusion and
446 ● AnesthesiA student survivAl Guide poor oxygenation. Although other factors can affect lactate levels, the presence of elevated lactate can therefore be used as an indirect marker of poor tissue perfusion and shock. Central Venous and Mixed Venous Blood Oxygen Saturation When a central venous catheter is in place, blood can be drawn from the superior vena cava (distal port) and sent to the lab for measurement of central venous blood oxygen saturation. Central venous blood oxygen saturation (ScvO 2 ) has been shown to correlate well with mixed venous blood oxygen saturation (SvO 2 ) in most circumstances, and can be used to reflect tissue oxygenation. Normal ScvO 2 is approximately 70% (compared to normal SvO 2 of approximately 65%). Lower than normal ScvO 2 or SvO 2 is an indication of poor tissue oxygenation and the need for improved oxygen delivery and perfusion. Hemodynamic Monitoring (also see Chap. 11) Goals The goals of hemodynamic monitoring in the critically ill patient are to optimize perfusion and oxygen delivery to tissues, ensure rapid detection of changes in clinical status, and monitor for response to treatment. Although noninvasive monitors (such as a blood pressure cuff) are associated with less risks and complications, it is often necessary to use invasive monitoring techniques to achieve these goals. Invasive Arterial Blood Pressure Monitoring A common cause of admission to the intensive care unit is hypotension, which may be due to any number of etiologies (see Shock section below). Occasionally, blood pressure monitoring with a noninvasive cuff is adequate, but if the blood pressure is significantly low, it may be undetectable or inaccurate by a cuff. In addition to being the most accurate form of blood pressure monitoring, arterial cannulation allows continuous beat-to-beat monitoring. It also serves as a site for obtaining lab measurements of oxygenation, ventilation, and acid-base status. The most common sites for arterial cannulation are radial or femoral arteries, but other arteries may be used if necessary (see Chap. 15, IV, Arterial & Central Line and Gastric Tube Placement Techniques). Complications associated with arterial cannulation and precautions to decrease the incidence of complications are listed in Table 28.1. Volume status can be assessed by evaluating the arterial pressure height during controlled mechanical ventilation. Positive pressure ventilation will lead
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Table 14.6 Advantages, disadvantage
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Table 14.11 Transfusion of bloodpro
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Page 434 and 435: Perioperative Acute and Chronic Pai
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Page 464 and 465: Introduction to Critical Care Bever
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Page 490 and 491: Chapter 29 Professionalism, Safety,
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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