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Basics of Anesthesia II > Final > Flashcards

Final Flashcards

1
Q

What provides motor innervation to all intrinsic muscles except the cricothyroid?

A

RLN

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2
Q

Who is most at risk for latex allergy?

A

healthcare workers and spina bifida

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3
Q

What are some disadvantages for regional anesthesia of the eye?

A

potential for complications, usually need deep sedation for placement

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4
Q

What kind of murmur is caused by aortic regurgitation?

A

decrescendo diastolic at 2nd ICS RSB

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5
Q

What is the functional unit of the kidney?

A

nephron

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6
Q

The Laser-Flex tracheal tube (Nellcor) is flexible, stainless steel that is resistant to CO2 and KTP lasers- in the event of proximal cuff rupture, what happens?

A

distal cuff maintains tracheal seal and prevents anesthetic gases from leaking into path of laser beam

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7
Q

What are some risk factors for intraop awareness?

A

female, young (not children), obese, clinical experience, previous awareness, after normal hours operations, emergency procedures, OB/cardiac/thoracic cases, use of nondepolarizing relaxants

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8
Q

What are some things that reduce the effectiveness of hypoxic pulmonary vasoconstriction?

A

alkalosis, excessive TV or PEEP, hemodilution, hypervolemia, hypocapnia, hypothermia, prostacyclin, shunt fraction <20% or >80%, vasodilators, PDEIs, CCBs, volatile anesthetics >1.5 MAC

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9
Q

Why should you avoid hypotension in a patient with AS? What should you use to treat hypotension?

A

have to maintain coronary perfusion pressure; use neo

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10
Q

What are some complications of thoracic surgery?

A

ALI, low cardiac output from hemorrhage, hypovenolemia, R HF, heart hernation; bronchopleural fistula, thoracic duct injury, nerve injury (phrenic, spinal, RLN)

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11
Q

Which anesthesia drugs are known to decrease NK function?

A

propofol, thiopental, opioids, volatile agents

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12
Q

What is bleomycin known to cause?

A

blebs- pulmonary toxicity

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13
Q

What are effects on the lungs during establishment of pneumoperitoneum?

A

decreased VC, FRC, compliance

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14
Q

What are the components of an RCA?

A

what, where, who, when, how many

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15
Q

What are some some symptoms of hypocalcemia?

A

hyperexcitability of nerve and muscles due to lowered threshold potential- muscle cramps, paresthesias, hyperactive DTRs, tetany, restless, irritability, larygospasm, Chvostek and Trousseau

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16
Q

What is thromboxane a2?

A

COX product of arachadonic acid in platelets that is synthesized due to vascular damage- potent vasoconstrictor and stimulus for platelet aggregation (inhibits AC and CAMP)

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17
Q

What does vitamin D deficiency cause?

A

poor ingested calcium- rickets in children, osteomalacia in adults

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18
Q

How much can you increase tolerated apnea time by when preoxygenating an OSA patient with 100% FiO2 and 5-10 of CPAP?

A

50%

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19
Q

At what size is a thoracic aneurysm at risk of rupture in someone with Marfan syndrome or other connective tissue disease?

A

4-4.5 cm

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20
Q

What happens in the collecting duct?

A

water reabsorption under influence of ADH

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21
Q

What are some goals/anesthetic management for thoracic surgery?

A

maintain normovolemia, keep MAC <1.5, avoid N2O, ABGs as needed, air/O2 mix to maintain adequate PO2, minimize narcotics, extubate at the end of the case

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22
Q

What are some things that are neurotoxic to peds patients?

A

iso, sevo, propofol, barbiturates, nitrous, versed, ketamine

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23
Q

What vessels branch off of the aortic arch?

A

innominate/brachiocephalic, L common carotid, left subclavian

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24
Q

What things affect LV compliance?

A

structural properties of heart muscle, as well as state of contraction and relaxation (?)

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25
Q

Who is the second victim?

A

practitioner involved in unanticipated adverse event who becomes victimized and traumatized

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26
Q

What are some things that increase GFR?

A

afferent arteriole dilation, increased renal BF, efferent arteriole constriction

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27
Q

What is plasminogen?

A

proenzyme that is synthesized in the liver- it is incorporated into the clot as it is being formed but lays dormant until it is activated

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28
Q

What are the 3 requirements for fire to occur?

A

flammable agent (alcohol, benzoin, drapes, ETT, hair), source of ignition (lasers, light sources defibrillator), gas that supports combustion (oxygen, nitrous)

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29
Q

What does cryo contain and what do we give it for?

A

fibrinogen, factors V, VIII, XIII, vWF- hypofibrinogenemia, massive hemorrhage

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30
Q

How do you avoid airway fire?

A

keep FiO2 at a minimum (may discontinue temporarily during laser use), avoid N2O, vent excess O2 from under drapes

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31
Q

What does protamine do?

A

reverses effects of heparin

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32
Q

What drug should you avoid if a patient is on cyclophosphamide?

A

succs

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33
Q

What is the first thing you do with AAA rupture?

A

control the bleeding- establish large bore PIV and give blood

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34
Q

What provides motor innervation to the cricothyroid?

A

SLN

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35
Q

What allows excessive pressure to be vented out of the middle ear?

A

eustachian tube

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36
Q

What are some goals for a patient with sickle cell disease?

A

maintain normothermia, hydration, O2, and prevent acidosis and vascular stasis- maintain Hct 30-35%, manage pain (avoid drugs that impair renal function)

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37
Q

Between what range is autoregulation of the kidney maintained?

A

50-180

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38
Q

What gas may cause an acceleration in metastasis?

A

nitrous oxide

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39
Q

What does the RAA system result in?

A

Na/H20 reabsorption and vasoconstriction

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40
Q

What is sickle cell disease?

A

hereditary hemoglobinopathy- autosomal recessive abnormality of beta globin gene codes for production of variant hemoglobin, Hgb S

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41
Q

Are laser-resistant tubes laser-proof?

A

No- carry inherent risk of ignition

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42
Q

What does pRBCs contain and what do we give it for?

A

RBCs- symptomatic anemia, massive hemorrhage, decreased O2 carrying capacity

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43
Q

What are the forces that determine GFR?

A

pressure inside glomerular capillaries, pressure inside Bowman’s capsule, colloid oncotic pressure inside capillary

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44
Q

What compensatory response happens if the blood flow to the kidney is decreased?

A

afferent arteriole dilation

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45
Q

What happens to an obese patient’s lungs when you lie them flat?

A

abdominal contents pushed up –> decreased FRC, compliance, impaired gas exchange

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46
Q

What is TF? What does it do?

A

cofactor from coagulation cascade- activates clotting cascade pathway when vessel injury occurs

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47
Q

What percentage of emergency and elective AAA patients undergoing OAR have an MI?

A

emergency- >50%, elective- >25%

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48
Q

At what size is a descending thoracic aneurysm at risk for rupture?

A

> 6.5 cm

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49
Q

How does celecoxib work?

A

COX 2 inhibitor (antiplatelet)

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50
Q

What are absolute indications for OLV?

A

isolate 1 lung to prevent contamination, control distribution of ventilation, unilateral bronchopulmonary lavage

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51
Q

How many posterior and anterior spinal arteries are there? What supplies motor function?

A

2 posterior, 1 anterior; anterior provides motor function and receives most BF

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52
Q

What are some disadvantages of general anesthesia for eye procedures?

A

most invasive, PONV, sore throat, dental injury

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53
Q

Describe HIT type 1

A

heparin induced platelet aggregation 1-4 days after a large heparin dose which resolves spontaneously even if heparin is continued

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54
Q

Describe naturally active immunity

A

immune response generated after antigen/pathogens enter body (chicken pox)

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55
Q

What are some things you can do to improve intubating conditions in someone with OSA?

A

preoxygenate for 5 minutes with 100% O2 and CPAP, use ramp, minimize preop sedation, have an extra set of hands

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56
Q

Why might local anesthetics be beneficial for cancer patients?

A

they prevent tumor proliferation

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57
Q

What is vWD?

A

inherited or acquired coagulable disease characterized by lack or dysfunctional vWF- lifelong bleeding episodes, prolonged bleeding time

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58
Q

What are some things that may contribute to metastasis during surgery?

A

tumor manipulation, most anesthesia medications (especially opioids), stress response

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59
Q

What are some risk factors for OSA?

A

male, obese, micro/retrognathia, large tongue, large tonsils, large neck circumference, HTN

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60
Q

What happens in the loop of henle?

A

establishment of osmotic gradient

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61
Q

What are some complications of sickle cell disease?

A

vaso-occlusive crisis, acute chest syndrome, sequestration crisis, aplastic crisis, pneumococcal disease, pulmonary HTN

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62
Q

What are elements of good communication?

A

clear and concise, include context and intent, receive information (show listening), identify and address barriers

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63
Q

What kind of murmur is mitral stenosis?

A

diastolic rumbling murmur- heard best at apex

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64
Q

Describe the order of the intrinsic pathway

A

1) blood trauma/exposure to collage activates factor XII (Hageman)
2) Factor XII activates XI (PTA)- requires kininogen and is accelerated by prekallikrein
3) Factor XI activates IX (Christmas)
4) Factor IX and VIII (antihemophilic) activate X (SPF)
5) prothrombin activator and tissue phospholipids activate thrombin (factor II)- identical to last step of extrinsic pathway

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65
Q

How does desmopressin (DDAVP) work?

A

stimulates factor VIII and vWF release

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66
Q

What does desmopressin do?

A

stimulates release of vWF

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67
Q

What can methotrexate cause?

A

hepatic and renal toxicity

68
Q

What does nitric oxide do?

A

potentiates prostacyclins which inhibits platelet adhesion, aggregation, and binding of fibrinogen between GpIIb/IIIa complexes; causes muscle relaxation and vasodilation; increases BF to wash away procoagulant mediators

69
Q

What are some arteries that branch off the abdominal aorta?

A

celiac, superior mesenteric, renal, inferior mesenteric, common iliac, internal and external iliac, femoral

70
Q

How does warfarin work?

A

vitamin K antagonist (anticoagulant)

71
Q

Where does the artery of Adamkiewicz arise from?

A

radicular branches of the intercostals, T8-T12 (sometimes T5-L5)

72
Q

What should you do if an airway fire occurs?

A

stop ventilation, disconnect circuit, remove ETT and place in a bucket of water, extinguish flame debris in pharynx with water or saline

73
Q

What type of vWD is characterized by a complete absence of vWF? What should you give them?

A

type 3- cryo or purified vWF

74
Q

What is vWF?

A

necessary cofactor for adherence of platelets to subendothelial layer

75
Q

What factors lie in the vessel intima (endothelial layer)?

A

vWF, TF, prostacyclin, and nitric oxide

76
Q

What are the risks in % of AAA rupture at certain sizes?

A

0.5-5% at 4-4.9 cm
3-15% at 5-5.9 cm
10-20% at 6-6.9 cm
20-40% at 7-7.9 cm

77
Q

The LaserTubus (Rusch) is soft, white rubber that is resistant to argon, YAG, and CO2 lasers- the lower 17 cm is covered with laser guard wrap that does what? What can you do to decrease ignition potential? Who should you avoid this tube in?

A

dissipates laser light and prevents backscatter; soak the tube in water; latex allergy

78
Q

What are some advantages of EVAR over OAR?

A

shorter procedure, fewer blood loss/fluid shifts/hemodynamic changes, less ischemia and end organ damage, fewer complications

79
Q

When a surgeon deflates a leg tourniquet, what will you expect?

A

fall in core temperature, metabolic acidosis, fall in central venous oxygen, release of acid metabolites in systemic circulation, increase in end tidal CO2

80
Q

What are relative indications for OLV?

A

surgical exposure, pulmonary edema after removal of PE, severe hypoxemia d/t unilateral lung disease

81
Q

What are some things you can do to avoid metastasis?

A

avoid hypothermia, avoid giving blood, use regional technique when available, keep FiO2 <80%

82
Q

What are the final cells of the lymphoid pathway?

A

T and B cells, NK cells

83
Q

What does vitamin K do?

A

required for production of factors II, VII, IX, X and protein C and S (reverses effects of warfarin)

84
Q

How does clopidogrel work?

A

ADP receptor inhibitor (antiplatelet drug)

85
Q

What vessels branch off of the ascending aorta?

A

coronary arteries

86
Q

At what size is an ascending thoracic aneurysm at risk for rupture?

A

> 5.5 cm

87
Q

When do episodes of intraop awareness occur most often?

A

during maintenance of anesthesia

88
Q

What are some connective tissue disorders? Specifically which one did Abe Lincoln have?

A

Marfan (Abe Lincoln), Ehlers Danlos, Loeys-Dietz

89
Q

How do aminocaproic acid (amicar) and tranexamic acid (TXA) work?

A

plasminogen activation inhibitors

90
Q

Describe naturally passive immunity

A

antibodies passed from mother to baby (short lived)

91
Q

With a DLT, which lung is getting ventilated?

A

The dependent lung (nondependent lung is getting operated on and will be isolated)

92
Q

After platelets aggregate, what completes a clot?

A

fibrin is incorporated into the platelet plug, and activated FSF (XIIIa) facilitates cross linkage of fibrin fibers

93
Q

What were the problems with the metallic foil wraps around ETTs to protect them from lasers?

A

laser reflection damage, exposed tube, unprotected cuff, need for smaller ID tube, airway damage

94
Q

How long from exposure may a latex allergy show a reaction?

A

30 minutes

95
Q

What are the cellular elements of innate immune pathways?

A

neutrophils, macrophages, NK cells, monocytes

96
Q

What does Vitamin K do?

A

stimulates action of factors II, V, VII, IX

97
Q

What are some other anesthetic considerations for AAA rupture besides establishing lines and giving blood?

A

intubate immediately if LOC, do RSI with etomidate and succs, avoid coughing/bucking which can increase rate of bleeding

98
Q

What should you place proximal to the ETT cuff during laser surgery?

A

saline moistened cotton gauze

99
Q

What is one of the problems with the Bivona Fome-Cuf (Portex) laser resistant ETT?

A

inability to deflate the foam after cuff rupture

100
Q

How does heparin work?

A

inhibits factor 2 and 10a (anticoagulant)

101
Q

How long should you wait before a laser is used after reinflation of an ETT or repositioning for correction of a leak?

A

1 minute

102
Q

Which has lower periop risk, EVAR or OAR? What about 2 year mortality?

A

EVAR has lower periop risk, but same 2 year mortality

103
Q

What factors does Coumadin affect, and in what order?

A

Indirectly blocks the manufacturing of Vitamin K dependent factors (II, VII, IX, X, Protein C and S)

104
Q

What are some advantages of general anesthesia for eye procedures?

A

useful for uncooperative patients and for longer surgeries, complete ocular anesthesia

105
Q

What are the final cells of the myeloid pathway?

A

monocytes, macrophages, dendritic cells, eosinophils, mast cells, basophils, platelets

106
Q

What might the use of nitrous oxide cause in middle ear procedures?

A

graft disruption, tympanic membrane rupture, N/V, serous otitis media, stapes disarticulation and hearing loss

107
Q

What do platelets contain and what do we give it for?

A

platelets and clotting factors- thrombocytopenia, massive hemorrhage, platelet function deficit

108
Q

How is plasminogen activated, and what does its activated form do?

A

tissue plasminogen activator (tPA) activates plasminogen into plasmin, which dissolve thrombi and restore blood flow

109
Q

What is the lateral rectus muscle innervated by and what does it do?

A

supplied by CN 6 and causes abduction of the eye

110
Q

What are some ways to minimize aspiration in someone with esophageal disorders?

A

NPO for 8 hours, prokinetics (Reglan), H2 blockers, PPIs, antacids, RSI if necessary, cuffed ETT, decompress stomach with NG if necessary

111
Q

What is normal GFR?

A

125 ml/min

112
Q

How soon should N2O be stopped before graft placement in a middle ear procedure?

A

30 minutes

113
Q

What does the cricothyroid muscle do?

A

tenses and elongates the cords

114
Q

What do the juxtaglomerular cells release in response to hypotension?

A

renin

115
Q

How do argatroban and bivalrudin work?

A

inhibit thrombin (anticoagulant)

116
Q

What happens in the proximal tubule?

A

sodium reabsorption

117
Q

Describe HIT type 2

A

antiplatelet antibodies (IgG) attack factor 4 immune complexes which causes platelet aggregation and is resistant to heparin anticoagulation- this occurs after any heparin dose 5-14 days after administration and can lead to a hypercoagulable state with high risk of amputation and death

118
Q

What are anesthetic considerations for mediastinoscopy?

A

2 large bore IVs, type and cross, A line or pulse ox on right, standard induction if asymptomatic, if obstruction- minimize preop sedation, do awake FOB, maintain spontaneous ventilation

119
Q

What is a consideration of the cuffs of laser resistant ETTs? What should you confirm before a laser is used?

A

cuff rupture is often the prelude to airway fire- fill them with saline and possibly methylene blue to alert surgeon of cuff rupture; absence of air leak

120
Q

What is adriamycin (doxorubicin) known to cause?

A

cardiac toxicity

121
Q

How do aspirin and NSAIDs work?

A

COX 1-2 inhibitor (antiplatelet)

122
Q

If a patient is getting an endovascular aortic repair, how would you treat hypertension? What drug should you avoid?

A

beta blocker before vasodilator (vasodilators change radius of vessel); sodium nitroprusside (associated with worse outcomes)

123
Q

What can be facilitated by anesthesia during thoracic surgery?

A

isolate the movement of one lung during ventilation and create a quiet surgical field

124
Q

How low can platelets drop with HIT type 2? What do you need to do?

A

<50k; need to d/c heparin and anticoagulate with direct thrombin inhibitor like bivalirudin or argatroban

125
Q

Which type of immunity has a more delayed onset but is capable of developing memory and specific antigenic responses?

A

adaptive immunity

126
Q

What are some advantages for regional anesthesia of the eye?

A

more complete anesthesia, eye is more likely to be immobile, less invasive

127
Q

What is hemophilia?

A

X linked recessive disorder characterized by unpredictable bleeding patterns- either deficient in factor VIII or factor IX

128
Q

How does abceximab work?

A

GpIIb/IIIa receptor antagonist (antiplatelet drug)

129
Q

What are some indications for thoracic surgery?

A

tumor, infection, lavage, lung reduction sx, vascular sx, cardiac sx, spine sx

130
Q

What does a TEG measure?

A

process of clot formation over time- gives indication of clot strength, platelet number and function, intrinsic pathway defects, thrombin formation, and rate of fibrinolysis

131
Q

Which types of LeFort fractures are of concern to the anesthesia provider?

A

II and III- avoid nasal intubation due to possible disruption of cribiform plate

132
Q

What are the different forms calcium exists in the body?

A

9% bound to anions, 41% bound to proteins, 50% ionized

133
Q

What does FFP contain and what do we give it for?

A

all coag factors- warfarin bleeding, massive transfusion, TTP, coag factor deficiencies, ATIII deficiency

134
Q

What are some arteries that branch off the descending thoracic aorta?

A

esophageal, bronchial, mediastinal, intercostals

135
Q

What are physiologic effects of aortic cross clamping?

A

increased afterload (HTN), often increases in CVP and PAP, increased MAP and sVR, increased LV work (decreased CO), tissue ischemia

136
Q

What is innate immunity?

A

immunity that is genetically determined

137
Q

What do you want to ensure as far as IVs in robotic surgery?

A

2 IVs and possibly A-line established before tucking arms (make sure they work)

138
Q

What is atrial natriuretic factor?

A

secreted by atria in response to stretch- acts as diuretic (antagonizes ADH)

139
Q

What substances are released during the surgical stress response that may contribute to immunosuppression?

A

cortisol, cytokines

140
Q

What is the only tube wrap that has FDA approval for ETT protection from lasers?

A

Merocel Laser-Guard

141
Q

Where do we get Vitamin D? Where is it converted to its active form?

A

ingested food and ultraviolet light; liver and kidneys

142
Q

What do the kidneys release in response to hypoxia?

A

EPO

143
Q

Describe the order of the extrinsic pathway

A

1) tissue trauma liberates TF, which activates pathway
2) TF activates factor 7 (stable), which activates factor X (SPF) in presence of factor IV (Ca)
3) prothrombin activator and platelet phospholipids activate factor II (thrombin), and factor V (labile) acts as positive feedback mechanism that accelerates the continued production of prothrombin activator

144
Q

Describe artificially active immunity

A

immunity developed from a vaccine

145
Q

What provides sensory innervation to the superior epiglottis and base of the tongue?

A

glossopharyngeal

146
Q

What factors lie in the vessel media (subendothelial layer)?

A

collagen and fibronectin

147
Q

What are some triggers for sickle cell crisis?

A

pain, hypothermia, hypoxemia, acidosis, dehydration

148
Q

What are elements of team working?

A

support, solving conflicts, exchanging info, coordinating activities

149
Q

What are the most common allergens used in anesthesia?

A

NMBs (roc and succs), antibiotics (beta lactams, sulfas, vancomycin, quinolones), latex

150
Q

What does active vitamin D do?

A

increases Ca, Mg, and phosphate ion concentrations by promoting their absorption across the intestinal epithelium to the ECF

151
Q

What medication may stimulate NK cell activity and be a good drug of choice for cancer patients?

A

tramadol

152
Q

When do you open fluids during robotic surgery?

A

when anastamosis are complete

153
Q

What are some potential complications of EVAR?

A

failed deployment/malposition, rupture/dissection, contrast reactions, plaque embolization, ischemia, endoleak, infection, graft migration or thrombosis, postimplantation syndrome

154
Q

Describe artificially passive immunity

A

preformed antibodies given via antiserum or antivenom (short lived)

155
Q

How does tPA and streptokinase work?

A

activates plasminogen (fibrinolytic)

156
Q

What are some concerns when doing a shared airway for head and neck surgery?

A

the bed may be 90-180 away (may need second anesthesia provider to monitor ventilation), ETT will be smaller, potential for neck flexion/extension and movement of ETT, need to use circuit and line extensions

157
Q

What does prostacyclin do? How is it made?

A

powerful vasodilator that interferes with platelet formation and aggregration; derived from arachadonic acid and is synthesized by endothelial cells

158
Q

What drugs have antiangiogenic and antitumor properties?

A

COX 2 inhibitors

159
Q

What do you give someone with vWD?

A

depends on what type- desmopressin, vWF, immunoglobulins, plasma exchange

160
Q

What supplies sensory innervation to the laryngeal mucosa below the vocal cords?

A

RLN

161
Q

What happens in the distal tubule?

A

sodium reabsorbed in exchange for K under influence of aldosterone

162
Q

What are the afferent and efferent limbs of the oculocardiac reflex?

A

afferent- trigeminal (CN V)

efferent- vagus (CN X)

163
Q

What supplies sensory innervation to the laryngeal mucosa above the vocal cords?

A

SLN (internal branch)

164
Q

What is the oculocardiac reflex? How do you treat it?

A

bradycardia and asystole caused by stimulus to the eye- stop stimulus, give anticholinergics (glyco, atropine)

165
Q

Where is cancer ranked in leading causes of death?

A

2nd

166
Q

What is the most common closed claim about anesthesia care outside the OR?

A

respiratory complications

Basics of Anesthesia II (9 decks)

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