Introduction: Safe and effective prescribing of intravenous fluids requires understanding of the physiology of fluid and electrolyte homeostasis, physiological responses to injury and disease, as well as knowledge of the … Continue reading Fluid Therapy
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OSCE 23
Regarding Midazolam
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OSCE- 10 Answer
1. Scalars-Plots of pressure, flow, or volume against time. Loops-Plots of pressure, flow, or time against each other. Time is not graphed.
2. A pressure deflection below baseline right before a rise in pressure.
3. The PIP will increase while the Pplat stays the same.
4. Airway obstruction.
5. Air trapping
6. It causes it to widen.
7. That a leak is present.
8. Increased compliance.
9. The expiratory part of the loop does not return to the starting point. 10. Square and decelerating
A , Prolonged phase II, increased α angle, and steeper phase III suggest bronchospasm or airway obstruction.
B , Expiratory valve malfunction resulting in elevation of the baseline, and the angle between the alveolar plateau and the downstroke of inspiration is increased from 90°. This is due to rebreathing of expiratory gases from the expiratory limb during inspiration.
C , Inspiratory valve malfunction resulting in rebreathing of expired gases from inspiratory limb during inspiration (reference 5 for details).
D , Capnogram with normal phase II but with increased slope of phase III. This capnogram is observed in pregnant subjects under general anesthesia (normal physiologic variant ).
E , Curare cleft: Patient is attempting to breathe during partial muscle paralysis. Surgical movements on the chest and abdomen can also result in the curare cleft.
F , Baseline is elevated as a result of carbon dioxide rebreathing.
G , Esophageal intubation resulting in the gastric washout of residual carbon dioxide and subsequent carbon dioxide will be zero.
H, Spontaneously breathing carbon dioxide waveforms where phase III is not well delineated.
I , Dual capnogram in one lung transplantation patient. The first peak in phase III is from the transplanted normal lung, whereas the second peak is from the native disease lung. A variation of dual capnogram (steeple sign capnogram – dotted line) is seen if there is a leak around the sidestream sensor port at the monitor. This is because of the dilution of expired PCO2with atmospheric air.
J , Malignant hyperpyrexia where carbon dioxide is raising gradually with zero baseline suggesting increased carbon dioxide production with carbon dioxide absorption by the soda lime.
K , Classic ripple effect during the expiratory pause showing cardiogenic oscillations. These occur as a result of to-and-for movement of expired gases at the sensor due to motion of the heartbeat during expiratory pause when respiratory frequency of mechanical ventilation is low. Ripple effect like wave forms also occur when forward flow of fresh gases from a source during expiratory pause intermingles with expiratory gases at the sensor.
L , Sudden raise of baseline and the end-tidal PCO2(PETCO2) due to contamination of the sensor with secretions or water vapor. Gradual rise of baseline and PETCO2occurs when soda lime is exhausted.
M , Intermittent mechanical ventilation (IMV) breaths in the midst of spontaneously breathing patient. A comparison of the height of spontaneous breaths compared to the mechanical breaths is useful to assess spontaneous ventilation during weaning process.
N , Cardiopulmonary resuscitation: capnogram showing positive waveforms during each compression suggesting effective cardiac compression generating pulmonary blood. O , Capnogram showing rebreathing during inspiration. This is normal in rebreathing circuits such as Mapleson D or Bain circuit
OSCE 8: Answser:
Remifentanil
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OSCE 6: ANSWER
First, note that pH, PCO2, calculated HCO3 and serum CO2 are all normal (and, in this case, the venous CO2 = arterial HCO3 -). At first glance it appears there is no acid-base disorder, and that the only obvious abnormality is the markedly elevated BUN and creatinine. However, by going through the steps outlined in this section, a different picture emerges.
Step 1: Anion gap
AG = Na + – (Cl-+ CO2) = 149 – (100 + 24) = 25
This high an AG indicates an anion gap metabolic acidosis.
Step 2: Delta anion gap
Calculated AG 25 mEq/L
normal AG = 12 mEq/L
25 – 12 = 13 mEq/L; this is the excess or delta anion gap
Step 3: Delta serum CO2
= normal CO2 – measured CO2 =27 (average normal venous CO2) – 24 = 3 mEq/L
Step 4: Bicarbonate Gap
= delta AG – delta CO2
= 13 – 3 = 10 mEq/L (Normal BG is about + or – 6 mEq/L)
This means the measured bicarbonate is 10 mEq/L higher than expected from the excess AG, indicating (in this case) a metabolic alkalosis. Thus this patient, with normal pH and PaCO2 , has BOTH metabolic acidosis and metabolic alkalosis. The patient was both uremic (causing metabolic acidosis) and had been vomiting (metabolic alkalosis).
ANSWER:
The body needs oxygen molecules, so oxygen content takes precedence over partial pressure in determining degree of hypoxemia.
In this problem the amount of oxygen molecules contributed by the dissolved fraction is negligible and will not affect the answer. Also, the PaCO2 and pH are not needed to answer the question.
Patient A: Arterial oxygen content = .95 x 7 x 1.34 = 8.9 ml O2/dl
Patient B: Arterial oxygen content = .85 x 15 x 1.34 = 17.1 ml O2/dl
Patient A, with the higher PaO2 but the lower hemoglobin content, is more hypoxemic.
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