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SRNA3CoExisting > Exam 2 Study Guide > Flashcards

Exam 2 Study Guide Flashcards

1
Q

Symptoms of ARDS

A

Arterial hypoxemia

➢ May include tachypnea, bronchospasm, and acute pulmonary hypertension

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2
Q

What is ARDS?

A

Inflammatory injury to the lung that manifests clinically as acute hypoxemic respiratory failure

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3
Q

Clinical disorders and risk factors associated c/ the development of ARDS include

A

events that cause direct lung injury as well as those that lead to indirect injury to the lungs in the setting of a systemic process

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4
Q

Sepsis is associated c/ the

A

highest risk of progression of acute lung injury to ARDS

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5
Q

DIRECT LUNG INJURY

PAPFaNI

A
  1. Pneumonia
  2. Aspiration of gastric contents
  3. Pulmonary contusion
  4. Fat emboli
  5. Near drowning
  6. Inhalational injury
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6
Q

INDIRECT LUNG INJURY

STMCDA

A
  1. Sepsis
  2. Trauma associated c/ shock
  3. Multiple blood transfusions
  4. Cardiopulmonary bypass
  5. Drug overdose
  6. Acute pancreatitis
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7
Q

Signs and Symptoms : First sign of ARDS

A

• Arterial hypoxemia resistant to treatment with supplemental oxygen is usually the first sign

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8
Q

ARDS Death often result of

A

sepsis or multiple organ failure rather than respiratory failure

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9
Q

Lung volume expansion maneuvers

A

Incentive spirometry,

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10
Q

Leads to pneumonia to ARDS,

A

Intraoperative aspiration

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11
Q

ARDS Radiographic signs

A

may appear before symptoms develop

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12
Q

ARDS Diagnosis 2

A
  • Presentation of acute refractory hypoxemia

* Diffuse infiltrates on chest radiograph consistent c/ pulmonary edema

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13
Q

Resp parameters Ratio in ARDS

A

Decreased arterial PaO2/FIO2 ratio

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14
Q

Decreased arterial PaO2/FIO2 ratio:

Mild ARDS:

A

Ratio is 201–300

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15
Q

Decreased arterial PaO2/FIO2 ratio:

Moderate ARDS:

A

Ratio is 101–200

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16
Q

Decreased arterial PaO2/FIO2 ratio:

Severe ARDS:

A

Ratio is <101

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17
Q

Treatment of Acute Respiratory Distress Syndrome

POT GOD RICAN

A

Positive end-expiratory pressure
Oxygen supplementation
Tracheal intubation/Mechanical ventilation
Glucocorticoid therapy (?)
Optimization of intravascular fluid volume
Diuretic therapy
Removal of secretions
Inotropic support
Control of infection
Administration of inhaled β2 -adrenergic agonists
Nutritional support

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18
Q

Anesthesia Considerations for ARDS
Battling ventilation strategies: Protective Ventilation
Vt?

A
  • Protective ventilation
  • Prevents ventilator-induced lung injury
  • Low Vt (6 mL/kg) = 22% mortality benefit, less inflammatory mediators
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19
Q

ARDS anesthesia considerations what are the 2 types of battling ventilation strategies:

A

Protective ventilation and OPEN lung ventilation

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20
Q

Anesthesia Considerations for ARDS: Battling ventilation strategies: OPEN Ventilation (PSN)

A
  • PEEP titrated to highest value possible while keeping plateau pressure below 28–30 cm H2O
  • Significantly more ventilator-free days and organ failure–free days
  • No change in mortality
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21
Q

ARDS Prone positioning

A

• Exploits gravity and repositioning of heart in thorax to recruit lung units and improve ventilation/perfusion
matching

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22
Q

ARDS additional treatment

A

Extracorporeal membrane oxygenation (ECMO)

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23
Q

3 features of Asthma (CRB)

A
  • Chronic airway inflammation
  • Reversible expiratory airflow obstruction
  • Bronchial hyperactivity
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24
Q

What is Status Asthmaticus?

A
  • Life threatening bronchospasm that persists despite treatment.
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25
Q

ASTHMA Characterized by (BHC)

A

Bronchoconstriction
Hyperactivity
Chronic airway inflammation.

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26
Q

Asthma PREOPERATIVE TESTS

ACE- FA

A

ABG and Chest Radiography • ECG

FEV:FVC = < 80% AUSCULTATION

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27
Q

Characteristics of Asthma to be EVALUATED preoperatively?
AAA THF CCNS
asthma

A 
Age of onsent
Alllergies
Anesthetic history
Triggering events
Hospitalization of asthma 
Frequency of ED visits
Need for intubation and mechanical 
    ventilation
Sputum characteristics
Cough
Current medications
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28
Q

Short acting Bronchodilators used for asthma (SABA) – LAMP

A

Levalbuterol (xopenex)
Albuterol (Proventil)
Metaproterenol
Pirbuterol (Maxair)

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29
Q

MOA of short acting bronchodilators

A

B2 Agonist: stimulates beta 2 receptors in tracheobronchial tree

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30
Q

Adverse effects of bronchodilators

TTD hypo

A

Tachycardia
Tremors
Dysrhythmias
HYPOKALEMIA

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31
Q

Long term treatment of asthma

ILIcLMeMa

A
  1. Inhaled Corticosteroids
  2. Long-Acting Bronchodilators
  3. ICS and LABA
  4. Leukotriene Modifiers
  5. Methylxanthines
  6. Mast Cell Stabilizers
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32
Q

Asthma INTRAOPERATIVE CONSIDERATIONS INDUCTION
GETA vs LMA vs REGIONAL
2 things to know

A
  • GETA OR LMA VS. REGIONAL
  • Airway reflexes must be suppressed to avoid bronchoconstriction in response to mechanical stimulation of hyper-reactive airways
  • Stimuli that do not ordinarily evoke airway responses can precipitate life-threatening bronchoconstriction in patients c/ asthma
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33
Q

GETA INDUCTION for asthma

A

Propofol or Ketamine
• LaryngotrachealAnesthesia (LTA) 4%Lidocaine
• Sevoflurane (BETTER) vs Desflurane

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34
Q

LMA induction for asthma

A

No GERD or aspiration risk
• Better method of airway management – less
instrumentation

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35
Q 
MAINTENANCE of ASTHMA
• Opioids = 
• Neuromuscular blocking agents.
• Hydration
• Ventilation:
• Slow inspiratory flow rate (at least 2 seconds)
• Sufficient exhalation time. (I:E)
• Humidification/warming of inspired gases
A

suppress cough reflex vs. histamine release and chest rigidity. Use fentanyl

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36
Q

Ketamine for asthma may cause

A

Increase in secretion and drooling

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37
Q

Asthmatic patient start bucking and coughin

A

deepen anesthesia, may get bronchospasm if not deep enough

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38
Q

2 meds help reduce cough reflex for asthma

A

Sevoflurane and lidocaine

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39
Q

Meds to avoid with asthma as far as NMB

A

Atracurium and Mivacurium because they are associated with Histamine release

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40
Q

Asthma continue bronchodilators till ______and if they take glucocorticoids?

A

Day of surgery ; they should receive supplementation during surgery

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41
Q

Asthma induction use

A

Propofol and fentanyl

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42
Q

Intraoperative bronchospasm shows as

A

Increase PEAK inspiratory pressure

Delayed rise of the expiratory end tidal CO2

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43
Q

Tx of intraoperative bronchospasdm

A

Increase concentration of inhaled agent
Administer aerosol bronchodilator
Reduce TV
Increase expiratory time

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44
Q

I: E ratio 10 BPM

A

60/10 =6

2:4 → 1:2

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45
Q

I: E ratio 8 BPM

A

60/8 = 7.5 seconds/breath

2:5.5 -> 1:3

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46
Q

I: E ratio 6 BPM

A

60/6 = 10 sec/breath
Inspiration of at least 2 = Expiration 8
I:E 1:4

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47
Q

I: E ratio of 12 BPM

A

60/12 = 5 seconds
inspiration of at least 2 exp 3
1:1.5

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48
Q

Asthma Emergence

A

Deep extubation unless contraindicated.

• IV Lidocaine (again).

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49
Q

AVOID THE FOLLOWING DRUGS PROVOKING
ASTHMA SYMPTOMS:
ABS SAN MS

A
  1. ASPIRIN
  2. BETA ANTAGONISTS (labetalol)
  3. SOME NSAIDS: KETORALAC (?)
  4. SULFITES
  5. Atracurium
  6. Neostigmine
  7. Morphine
  8. Succinylcholine
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50
Q

PERIOPERATIVE COMPLICATIONS

A
  • Laryngospasm
  • Bronchopasm
  • Status Asthmaticus
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51
Q

Laryngospasm CXR:

A

** pink frothy sputum = Negative Pressure Pulmonary
Edema
** Coarse breath sounds

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52
Q

Treatment of Laryngospasm

in 24 hrs but mayrequire mechanical vent.___laryngeal edemaTX_ nebulized racemic epinephrineIV corticosteroids

A
  • Increase Fi02
  • CPAP/PEEP
  • Reintubation
    0.5-1 mg/kg Lasix IV
    = will self correct c/in 24 hrs but may require mechanical vent.
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53
Q

Treatment of Laryngospasm

ICR L

A
  • Increase Fi02
  • CPAP/PEEP
  • Reintubation
    0.5-1 mg/kg Lasix IV
    = will self correct c/in 24 hrs but may require mechanical vent.
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54
Q

***Laryngeal edema TX

A
  • nebulized racemic epinephrine

- IV corticosteroids

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55
Q

TREATMENT of bronchospasm first step

A

R/O obstruction d/t migration of ETT, secretions, and kinking

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56
Q

Bronchospasm, Most definitive is through

A

fiberoptic.

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57
Q

Status asthmaticus ANESTHESIA CONSIDERATIONS

A

• Life-threatening bronchospasm that doesn’t resolve despite treatment

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58
Q

CO2 in status asthmaticus

A

Hypercarbia (PaCO2 > 50 mm Hg) requires tracheal intubation and mechanical ventilation

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59
Q

Extreme cases of status asthmaticus may need GA c/

A

Volatile agent to produce bronchodilation

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60
Q

For status asthmaticus Expiratory phase must be

A

prolonged to allow for complete exhalation and to prevent self generated or intrinsic positive end-expiratory pressure (auto-PEEP, AKA breath stacking)

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61
Q

What are the ACUTE INTRINSICE RESTRICTIVE LUNG DISEASE (PULMONARY EDEMA) AANORUCH

A

ARDS
Aspiration
Neurogenic Problems
Opioids Overdose

Reexpansion of collapsed lung
Upper airway obstruction (negative pressure)
CHF
High Altitude

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62
Q

What are the CHRONIC INTRINSICE RESTRICTIVE LUNG DISEASE (INTERSTITIAL LUNG DISEASE)
SHEALD

A 
Sarcoidosis
Hypersensitivity pneumonitis
Eosinophillic granuloma
Alveolar proteinosis
Lymphangioleiomyoomatosis
Drug induced pulmonary fibrosis
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63
Q

DISORDERS OF THE CHEST WALL, PLEURA and MEDIASTINUM

KAF PPP MMNNDD SG

A 
Kyphoscoliosis
Ankylosing spondylitis
Deformities of the sternum
Deformities of the costovertebral skeletal structures
Flail chest

Pleural Effusion
Pneumothorax
Pneumomediastinum

Mediastinal mass
Muscular dystrophies
Neuromuscular disorders
Neuromuscular transmission
Spinal cord transaction
Guillain barre syndrome
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64
Q

Other disorders on chart

A

OPA

Obesity, Pregnancy, Ascites

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65
Q

Pulmonary Edema Pathophysiology

A

Vigorous inspiratory efforts against an obstructed upper
airway ➔ post-extubation laryngospasm, epiglottitis,
tumors, obesity, hiccups, or obstructive sleep apnea in
spontaneously breathing patients ➔causes ↑ negative intrapleuralpressure ➔NEGATIVE PRESSURE PULMONARY EDEMA

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66
Q

Pulmonary edema Onset:

A

minutes to 3 hours

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67
Q

Signs/Symptoms of Pulmonary Edema

A
  • Tachypnea
  • Cough
  • Failure to maintain oxygen saturation above 95% despite high FiO2
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68
Q

Treatment of Pulmonary Edema (MAO

A

• Maintenance of a patent upper airway
• Administration of supplemental oxygen
• Occasionally brief Mechanical
ventilation

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69
Q

Acute Intrinsic Restrictive Lung Disease

ARDD results in LAP

A

• Aspiration
• Aspirated acidic gastric fluid
• Rapidly distributed throughout the lung
• Destruction of surfactant-producing cells
• Damages pulmonary capillary endothelium
Results in:
• Leakage of intravascular fluid into the lungs
• Atelectasis
• Producing capillary permeability pulmonary edema

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70
Q

Clinical picture of Acute Intrinsic Restrictive Lung

A

Disease is similar to that of ARDS
• Arterial hypoxemia
• May include tachypnea, bronchospasm, and acute pulmonary hypertension

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71
Q

Intraoperative aspiration and pulmonary Edema

A

Atelectasis➔ Leakage of intravascular fluid into the lungs➔ Producing increased capillary permeability
➔ pulmonary edema

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72
Q

Aspiration = is the

A

active (vomiting) or passive (regurgitation) passage of

material from the stomach, esophagus, pharynx, mouth, or nose to the trachea

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73
Q

Aspiration AVERAGE HOSPITAL STAY IS

A

21 DAYS c/ ICU

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74
Q

Aspiration Complications:

A

bronchospasm, pneumonia to ARDS, lung abscess and

empyema.

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75
Q

Aspiration Mortality is

A

5%

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76
Q

Causes of Aspiration

A

• Food or any foreign body
• Fluids (blood, saliva, GI contents = pH <2.5
and content >25 mls)

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77
Q

Instraoperative Aspiration Acidic Aspirates →

AIH

A

alveolar-capillary breakdown
→ interstitial edema, intra-alveolar hemorrhage, increased airway resistance
→ hypoxia.

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78
Q

Instraoperative Aspiration Acidic Aspirates Non acidic fluid

A

→ destroys surfactant → alveolar collapse and atelectasis → hypoxia.

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79
Q

Instraoperative Aspiration Acidic Aspirates Particulate/food matter → (PAH)

A

physical obstruction & later inflammatoryresponse

→ alternating areas of atelectasis and hyper-expansion → hypoxia, hypercapnia.

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80
Q

S/sx of Intraoperative Aspiration and %

A
  • Fever (90%)
  • Tachypnea
  • Rales in 70% of cases
  • Cough, cyanosis & wheezing (30-40%)
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81
Q

INTRAOPERATIVE ASPIRATION Anesthetic considerations Prevention.Preoperative

A

Recognize risks in preop. (Coexisting, fasting times, preop meds

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82
Q

INTRAOPERATIVE ASPIRATION

Anesthetic considerations DOLP

A
  • Delay elective surgery
  • Optimize cardiorespiratory function
  • Large pleural effusions need to be drained
  • Persistent hypoxemia may require mechanical ventilation and PEEP
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83
Q

INTRAOPERATIVE ASPIRATION

Anesthetic considerations- INDUCTION

A

RSI. However, ETT does not guarantee that no aspiration will occur.

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84
Q

INTRAOPERATIVE ASPIRATION

Anesthetic considerations- POST OP AFTER THE FACT

A

Supportive care
• Bronch/Suction asap.
• FiO2 x 100%
• PEEP/CPAP

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85
Q

INTRAOPERATIVE ASPIRATION: Maintenance

Anesthetic considerations: VT use and Why?

A

Use low Vt (6 mL/kg), compensatory increase in ventilatory rate (14 to 18 breaths per minute) while attempting to keep the end-inspiratory plateau pressure at less than 30 cm H2O ➔ avoid BAROTRAUMA.

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86
Q

Intraoperative aspiration fluids and pulmonary

A

Monitor fluid and CV status

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87
Q

2 unhelpful interventions for Intraoperative aspiration

A
  • Antibiotics and corticosteroids still controversial

* Lavage trachea c/ sodium bicarbonate = not shown to be helpful.

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88
Q

Pulmonary lavage is done for

A

obstruction (not c/ aspiration).

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89
Q

INTRAOPERATIVE ASPIRATION:Rigid Bronchoscopy =

A

only when removing solid particles

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90
Q

COPD- Ventilator –> VENTILATION

A
  • Controlled mechanical ventilation is useful for optimizing oxygenation
  • Slow respiratory rates (6 to 10 breaths per minute) provide sufficient time for complete exhalation
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91
Q

COPD and Positive pressure ventilation (adverse effect)

A

Insufficient expiratory time ➔ air trapping or dynamic

hyperinflation ➔ barotrauma

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92
Q

COPD and Tidal volumes

A

Tidal volumes of 6 to 8 mL/kg combined c/ slow inspiratory flow rates minimize turbulent airflow and help maintain optimal ventilation/perfusion matching

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93
Q

Ventilation strategies for Asthma (SSH)

A
  • Slow inspiratory flow rate (at least 2 seconds)
  • Sufficient exhalation time. (I:E)
  • Humidification/warming of inspired gases
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94
Q

Mitral Stenosis Heart Sound

A

Opening snap at early diastole

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95
Q

Mitral Stenosis Auscultate At

A

Apex in left axilla

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96
Q

Cause of mitral stenosis

Most common cause is

A

Rheumatic Heart Disease (most common)

• Stress (tachycardia [fever & sepsis])

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97
Q

Mitral stenosis as a result leads to

A

➔decrease Stroke Volume, leads to Pulmonary Edema d/t high left atrial pressure

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98
Q

Mitral Stenosis complication leads to those symptoms

DOPR

A

➔ dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea➔ Right sided heart failure

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99
Q

PREOPERATIVE CONSIDERATIONS for Mitral stenosis

The normal mitral valve orifice area is

A

4 to 6 cm2

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100
Q

ECG changes seen with Mitral stenosis

A 
Broad and notched P waves (LA enlargement)
Atrial Fibrillation (30% of patients) = thromboembolism
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101
Q

ECG changes seen with Mitral stenosis

A

Broad and notched P waves (LA enlargement)

P-mitrale

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102
Q

Mitral stenosis arrhytmia associated with is and treatment

BCDW , range

A 
Atrial Fibrillation (30% of patients) = thromboembolism
Beta Blockers, or Calcium Channel Blockers • Digoxin, Warfarin is administered to a target INR of 2.5-3.0
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103
Q

Mitral stenosis Cardiac Catheterization:

Transvalvular gradient and treatment

A

Transvalvular pressure Gradient is > 10 mmHg (normal < 5 mmHg) ➔increased left atrial pressures
• Diuretics

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104
Q 
INTRAOPERATIVE CONSIDERATIONS
***goals: MITRAL STENOSIS avoid
Avoid 4 (AHHHH_
A
  1. Avoid A-fib with RVR and/or tachycardia (reduces cardiac output)
  2. Avoid hypotension (drug induced decreases in SVR)
  3. Avoid head-down position (increase in central blood volume)
  4. Avoid hypoxemia & hypercarbia (exacerbates pulmonary hypertension)
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105
Q

INTRAOPERATIVE CONSIDERATIONS
***goals: MITRAL STENOSIS avoid
Avoid 4 (AHHHH)
4Hs A

A
  1. Avoid A-fib with RVR and/or tachycardia (reduces cardiac output)
  2. Avoid hypotension (drug induced decreases in SVR)
  3. Avoid head-down position (increase in central blood volume)
  4. Avoid hypoxemia & hypercarbia (exacerbates pulmonary hypertension)
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106
Q

Mitral Stenosis INTRAOPERATIVE CONSIDERATIONS

Regional Anesthesia: acceptable? which one is better?

A

is acceptable (Epidural > Spinal).

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107
Q

DO NOT use this induction agent for Mitral stenosis and why.

A

No Ketamine (tachycardia)

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108
Q

Ketamine do not use in this valvular disorder

A

Mitral stenosis

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109
Q

DO NOT use this volatile agent for Mitral stenosis and why.

A

Nitrous Oxide ➔ pulmonary hypertension

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110
Q

Mitral Stenosis : What kind of anesthesia (light or deep and why

A

DEEP BETTER because Light anesthesia ➔ tachycardia & HTN (pulmonary and systemic)

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111
Q

Mitral stenosis and fluid management how and why?

A

Slowly titrate IV fluids (fluid overload [left atrial enlargement]) ➔ pulmonary edema.

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112
Q

Mitral stenosis and hemodynamic monitoring

A

Invasive monitoring: A line, PAP (manipulation = rupture)

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113
Q

Mitral stenosis and paralytics

A

Reverse paralytics slowly

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114
Q

Mitral Stenosis POSTOPERATIVE CONSIDERATIONS

A
  1. Avoid pain and hypoventilation (respiratory acidosis and hypoxemia) ➔ increasing HR and PVR
  2. Decreased pulmonary compliance and increased
    work of breathing ➔ mechanical ventilation (major
    thoracic or abdominal surgery)
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115
Q

Mitral Regurgitation Heart sounds (murmur)

A

Pan-systolic murmur

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116
Q

Apex; radiates to the axilla

A

Mitral regurgitation

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117
Q

Apex; radiates to the LEFT axilla

A

Mitral stenosis

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118
Q

Mitral Regurgitation Causes: (RIMP)

A

Rupture of chordae tendinae)
Ischemic Heart Disease
Mitral annular dilation
Papillary muscle dysfunction

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119
Q

Mitral Regurgitation can cause ________

which can be compensated or decompensated

A

➔Can cause decreased LV SV and CO

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120
Q

Mitral Regurgitation can cause Can cause decreased LV SV and CO : Compensated

A

➔Compensated: LVH & increased compliance of LA

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121
Q

Mitral Regurgitation can cause Can cause decreased LV SV and CO : DECompensated

A

Increased LA volume ➔ pulmonary edema AND cardiogenic shock

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122
Q

MITRAL REGURGITATION PREOPERATIVE

CONSIDERATIONS : what is severe MR

A

Regurgitant fraction > 0.5

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123
Q

Auscultation: Holosystolic Apical Murmur (radiation to the axilla)

A

Mitral Regurgitation

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124
Q

PAOP mitral Regurgitation

A

Prominent V wave

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125
Q

Mitral Regurgitation Symptomatic patients:

A

Ace Inhibitors or Beta- Blockers (Carvedilol) & Biventricular Pacing ➔ improvement.

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126
Q

Tall v wave associated with

A

Mitral regurgitation

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127
Q

Mitral regurgitation and pulmonary circuit

A

Increase pressure in the pulmonary circuit and produce pulmonary congestion

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128
Q

Pansystolic murmur

A

Mitral Regurgitation

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129
Q

Mitral REGURGITATION OVERALL ANESTHESIA CONSIDERATIONS GOALS:
3 things to PREVENT (BIM)

A

Prevent
Bradycardia
Increases in SVR
Myocardial depression

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130
Q

Mitral Regurgitation and Volatile anesthetics good or bad? why?

A

Good,
Decrease in SVR
Increases heart rate
Minimal negative inotropic effects).

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131
Q

Mitral Regurgitation: Vent Settings

A

Sufficient expiratory time (adequate venous return).

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132
Q

Types of Anesthesia for Mitral Regurgitation and why?

A 
Neuraxial Anesthesia (decrease SVR).
Invasive monitoring
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133
Q

For MS vs MR LV preload

A

Both Keep normal to increase

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134
Q

For MS vs MR : Heart rate

A

MS keep low

MR keep High

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135
Q

For both MS and MR things to maintain (RCA)

A

Rhythm: NS
Contractility
Avoid increase in PVR

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136
Q

For mitral stenosis how should you keep SVR?

A

Normal

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137
Q

For mitral regurgitation how should you keep SVR?

A

Decreased

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138
Q

MVP as a valvular disease

• S/sx: anxiety, orthostatic symptoms,
palpitations, dyspnea, fatigue, and atypical
chest pain.

A

• Most common form of valvular heart disease (1%-2% of US).

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139
Q

MVP severity CIS DD

A 
Benign but➔ 
CVA
infective endocarditis, 
severe MR, 
dysrhythmias (Beta blocker therapy), and death.
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140
Q

MVP: OVERALL ANESTHESIA CONSIDERATIONS

Murmur (MSC LSM)

A

Auscultation: mid systolic click and a late systolic

murmur

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141
Q

MVP Same anesthesia management as MR

No BHM

A 
No brady, HTN, and myocardial depression) &amp; FAST
FORWARD FLOW (FFF)
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142
Q

MVP anesthesia : avoid what?

A

Regional Anesthesia (avoid decrease in SVR; give fluids).

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143
Q

What are the causes of Aortic Stenosis

ABRI

A
  1. Aging
  2. Bicuspid aorticvalve (30 to 50 yo)
  3. RHD
  4. Infective endocarditis
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144
Q

Infective Endocarditis Causes

A

(Frequent Exposure to Bacteremia) DGG

  1. Dental
  2. GI
  3. Genitourinary Tract procedures
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145
Q

Prophylaxis for Infective Endocarditis

A
  • Maintenance of good oral health & oral hygiene (chewing, brushing, flossing, use of toothpicks, etc.) is better than prophylactic antibiotics.
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146
Q

Major changes in the updated AHA guidelines for infective endocarditis prophylaxis are these:
(1) Antibiotic prophylaxis for infective endocarditis is recommended

A

only under a very few conditions

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147
Q

For Infective ENDOCARDITIS (4) Antibiotic prophylaxis is NOT RECOMMENDED

A

genitourinary or gastrointestinal tract procedures

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148
Q

For INFECTIVE ENDOCARDITIS (3) Antibiotic prophylaxis is recommended for (Skin)

A 
invasive procedures (those that involve 
incision or biopsy of the respiratory tract or
infected skin, skin structures, or musculoskeletal tissue)
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149
Q

2) Antibiotic prophylaxis is recommended for dental procedures that involve

A

manipulation of gingival tissues or the
manifpulation of the periapical regions of the teeth,
or perforation of the oral mucosa

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150
Q

PREOPERATIVE ASSESSMENT

A
  1. Normal aortic valve area is 2.5 to 3.5 cm2
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151
Q

Severe AS aortic valve area

A

(0.8 cm2)

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152
Q

Aortic Stenosis Cardiac Catheterization: Transvalvular

pressure gradients

A

> 50 mmHg

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153
Q

Aortic Stenosis Hypertrophy type _______leading to

A

Concentric LVH & compression of subendocardial blood vessels ➔ (SAD) Angina Pectoris, syncope, dyspnea on exertion (CHF like).

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154
Q

Systolic murmur (radiate to neck/mimic carotid bruit).

A

Aortic stenosis

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155
Q

mimic carotid bruit

A

Aortic stenosis systolic murmur (think sad neck)

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156
Q

Majority area symptomatic.

A

Aortic stenosis

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157
Q

AORTIC STENOSIS
PERIOPERATIVE MANAGEMENT
Goal: Avoid (hemodynamics )

A

hypotension and decreasing cardiac output.

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158
Q

Rhythm to maintain for Aortic stenosis

A

Maintain Normal Sinus Rhythm

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159
Q

Why 2 situations do we avoid with the HR with Aortic stenosis and why?

A

a. Avoid Bradycardia ➔ LV overdistention

b. Avoid Tachycardia ➔ reduced Cardiac Output (worse!

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160
Q

Aortic Stenosis SVR and why ?

A

Maintain or slightly ↑ SVR and Cardiac Output

a. Optimize preload (fluids) for LV filling.

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161
Q

Aortic Stenosis when CPR is performed is it effective?

A

CPR is not effective.

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162
Q

Regional anesthesia is contraindicated with this valvular disorder ? and why?

A

Aortic Stenosis (significant hypotension)

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163
Q

Best Induction agents for Aortic stenosis

A

Etomidate & Benzodiazepines

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164
Q

Intraop Maintenance for aortic stenosis include

A

a. N20/volatile/opioids combo.

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165
Q

When a patient with Aortic Stenosis is TACHY which agent is preferred?

A

Phenylephrine > Ephedrine (Tachy)

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166
Q

When a patient with Aortic Stenosis has Junctional Rhythm and Bradycardia, treat with (RAE)

A

Robinul, Atropine, or Ephedrine

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167
Q

Patients with Aortic Stenosis with Persistent Tachycardia

A

Beta Blockers: Esmolol

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168
Q

Monitoring Modalities for Aortic Stenosis include :

A

A line, CVP, PAC, or TEE (dependent on severity of AS &

type of surgery).

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169
Q

AORTIC REGURGITATION

Causes: (ABRID)

A 
Aortic Dissection (Immediate Surgery)
Bicuspid Aortic Valve
RHD
Infective endocarditis
Drug-Induced (Phen-Fen)
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170
Q

Leaflets and Aortic Regurgitation (A- DAH)

A

There is Aortic Leaflet Coaptation Failure leading to
➔Decreased Cardiac Output
➔Acute Volume Overload (LVH)
➔Heart Failure

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171
Q

AORTIC REGURGITATION PREOPERATIVE CONSIDERATIONS Pathophysiology

A
  1. Angina Pectoris (reduced coronary blood flow➔ coronary ischemia
  2. Pulmonary Edema (LVEDV increased➔LV failure).
  3. Normal EF unless LV dysfunction: dyspnea, orthopnea, fatigue
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172
Q

Aortic Regurgitation Pulse

A

Widened pulse pressure
decreased diastolic pressure
Bounding pulses.

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173
Q

Aortic Regurgitation Auscultation: murmur type and where?

A

Diastolic Murmur (Right Sternal Border)

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174
Q

Systolic murmur with crescendo, decrescendo

A

Aortic Stenosis

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175
Q

Aortic Stenosis is a a SCD murmur heard best at

A

Right upper sternal border

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176
Q

Mitral Valve Prolapse murmur

A

Mid-systolic click followed by late systolic murmur

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177
Q

MVP best heard at

A

Apex

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178
Q

Aortic Regurgitation: INTRAOPERATIVE ANESTHETIC CONSIDERATIONS: Main 3 Goals

A
  1. Decreasing systolic HTN and LV wall stress
  2. Improving LV function (also LV failure)
  3. Maintain forward LV SV (FFF): Avoid Bradycardia, Increased SVR, and Decreasing myocardial depression.
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179
Q

Aortic Regurgitation, Decreasing systolic HTN and LV wall stress how

A

a. Long term therapy (with good EF):
i. Nifedipine
ii. Hydralazine

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180
Q

Aortic Regurgitation: LV function (also LV failure)

how?

A

a. IV infusion:
i. Dobutamine (inotropic drug)
ii. Nitroprusside (vasodilation)

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181
Q

Maintain forward LV SV (FFF): Avoid bradycardia, increased SVR, and decreasing myocardial depression What GETA? and why?

A 
a. Iso/Sevo/Des:
Increases HR (HR > 80 bpm), decreases SVR, with minimal myocardial depression.
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182
Q

Aortic Regurgitation: Bradycardia or Junctional Rhythm, Give

A

IV Atropine

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183
Q

May not need invasive monitoring.

A

Aortic Regurgitation

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184
Q

Aortic Regurgitation High opioid anesthesia

A

severe LV dysfunction

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185
Q

Parameters check : AS vs AR → LV Preload

A

For Aortic stenosis maintain LV preload ↑

For Aortic Regurgitation maintain LV preload NORMAL to ↑

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186
Q

Parameters check : AS vs AR → HR

A

For Aortic Stenosis maintain HR → normal to slow ↓

For Aortic Regurgitation maintain HR → Modest ↑

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187
Q

Parameters check : For BOTH AS and AR

Maintain those 3(CNP) c no problem

A

Maintain

Contractility, NSR, PVR

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188
Q

Parameters check : AS vs AR → SVR

A

For Aortic Stenosis maintain SVR modest ↑

For Aortic Regurgitation maintain SVR ↓

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189
Q

Keep this parameter low with Aortic Regurgitation

A

SVR

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190
Q

TRICUSPID STENOSIS

How frequent and most common cause

A

• Rare in adults• RHD: most common cause

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191
Q

TRICUSPID STENOSIS Usually with co-existing (TRMA)

A

Tricuspid regurgitation and often mitral or aortic valve disease

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192
Q

Tricuspid Stenosis Pathophysiology

A

Increased RAP and increases the pressure gradient between the right atrium and right ventricle

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193
Q

In Tricuspid Stenosis: Right atrial dimensions

A

are increased, but the right ventricular dimensions are determined by the degree of volume overload from concomitant tricuspid regurgitation

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194
Q

RV dimensions in tricuspid stenosis depend onfactors

A

degree of volume overload from concomitant tricuspid regurgitation

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195
Q

Tricuspid stenosis Heart sound

A

Pre-systolic murmur

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196
Q

Best place to listen for tricuspid stenosis

A

Left sternal edge at 4th ICS

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197
Q

Pre-systolic murmur

A

Tricuspid stenosis

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198
Q

TRICUSPID REGURGITATION Causes (functional)

A

Functional: RV enlargement or pulmonary HTN

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199
Q

TRICUSPID REGURGITATION DISEASES Causes

CIA RET

A 
Carcinoid syndromea
Infective endocarditis (IV drug use)
AV or MV disease.
RHD
Ebstein’s anomaly
TV prolapse
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200
Q

Disease causing TR lead to

A

RA volume OVERLOAD

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201
Q

Tricuspid Regurgitation Signs and symptoms (JHAP)

A
  1. Jugular venous distention
  2. Hepatomegaly
  3. Ascites
  4. Peripheral Edema
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202
Q

TRICUSPID REGURGITATION PERIOPERATIVE ANESTHESIA CONSIDERATIONS
Goals: FLUIDS

A

Maintenance of IV fluid volume & CVP in high normal range (facilitate adequate RV preload & LV filling).

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203
Q

Avoid in Tricuspid Regurgitation Maintenance of IV fluid volume & CVP in high normal range (facilitate adequate RV preload & LV filling). by

A
  • Avoid PPV and vasodilating drugs (reduces venous return)

* Avoid hypoxemia and hypercarbia ➔ increased PAP

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204
Q

Tricuspid Regurgitation: venous return and vasodilation

A

Produce pulmonary vasodilation & maintain venous return
Avoid Nitrous Oxide
Avoid air in IV fluids (systemic air embolism)

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205
Q

Pulmonic stenosis is usually

A

congenital and detected and corrected in childhood

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206
Q

Pulmonic stenosis : An acquired form can be due to (PRIC)

A

Previous surgery or other interventions
Rheumatic fever
Infective endocarditis,
Carcinoid syndrome, or

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207
Q

Pulmonic stenosis : Significant obstruction can cause

A

syncope,angina, right ventricular hypertrophy, and

right ventricular failure

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208
Q

PULMONIC VALVE REGURGITATION

• Pulmonic valve regurgitation results from

A

pulmonary hypertension with annular dilatation of the pulmonic valve

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209
Q

Pulmonic valve regurgitation causes include

A

connective tissue diseases, carcinoid syndrome, infective endocarditis, and rheumatic heart disease

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210
Q

Pulmonary regurgitation is

A

rarely symptomatic

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211
Q

Pulmonic Valve Regurgitation Heart sounds (DDM)

A

Decrescendo diastolic murmur

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212
Q

Pulmonic Valve Regurgitation Heart sounds BEST HEARD

A

Left upper sternal border

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213
Q

Pulmonic Stenosis Heart sounds (CDEM)

A

Crescendo-decrescendo ejection murmur

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214
Q

2 murmurs HEART beast at Left upper sternal border

A

Tricuspid Regurgitation

Pulmonic stenosis

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215
Q 
Aortic Stenosis (SU)
Aortic Regurgitation (RS)
A

Right upper sternal border

Right sternal border

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216
Q

Strove volume loss

A

Acute Aortic Regurgitation

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217
Q

Post CABG compllications

CAM CVM

A

Cardiac Dysrhythmias: Vfib, afib a flutter, sinus block
Acute Pericarditis
Mitral Regurgitation (from inferior wall MI or complete rupture of a papillary muscle
Ventricular septal rupture (holosystolic murmur)
Cardiogenic shock
Myocardial rupture

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218
Q

What is the role of IV nitroprusside and/or intraaortic balloon pump?

A

Decrease LV afterload

Increase Forward flow

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219
Q

Ischemic Heart disease Heart anesthetic management Goals

A

Prevent ischemia
Monitor for myocardial injury
Treat myocardial ischemia or infaction

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220
Q

Ischemic heart disease shivering on awakening

A

Abrupt and dramatic increases in myocardial oxygen requirements up to 500% increase

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221
Q

Sub-endocardial ischemia → Lead will show

A

ST segment depression

T-wave inversion

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222
Q

Coronary Vasospasm ➔Variant angina/Prinzmetal Angina

A

ST segment elevation

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223
Q

Leads = simplest, most effective (80%)

A

• II & V5

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224
Q

Post op CABG those things can lead to increase Myocardial oxygen demand

A

Pain, hypoxemia, hypercarbia, sepsis, hypovolemia, hypotension, and hemorrhage

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225
Q

Six independent predictors of major cardiac complications[1] TIHCMS

A
  • High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures)
  • History of ischemic heart disease (history of myocardial infarction or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)
  • History of heart failure
  • History of cerebrovascular disease
  • Diabetes mellitus requiring treatment with insulin
  • Preoperative serum creatinine >2.0 mg/dL (177 micromol/L)
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226
Q

Six independent predictors of major cardiac complications DO NOT DO THIS

A

do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)

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227
Q

Lead abnormalities in ACS

A

ST segment elevation, depression or inverted T wave

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228
Q

Lead II, III, AVF

Artery responsible

A

RCA

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229
Q

Lead II, III, AVF

Area of myocardium that may be involved (RSIA)

A

RA, RV
SA node
Inferior aspect of LV
AV node

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230
Q

I,avL artery

A

Circumflex coronary artery

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231
Q

I,avL Area of myocardium that may be involved

A

Lateral aspect of LV

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232
Q

V3 , V5 Artery

A

LAD coronary artery

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233
Q

V3, V5 Area of myocardium that may be involved

A

Anterolateral aspect of LV

234
Q

Most sensitive for coronary ischemia

A

TEE

235
Q

TEE picks up on

A

New regional Ventricular wall abnormalities

236
Q

Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy
1 PCI without STENTING

A

> 2 weeks

237
Q

Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy
Bare Metal stent

A

> 30 days (ideal 12 weeks)

238
Q

Elective surgery after cardiac revascularization: Recommendation w/ DUAL antiplatelet therapy Drug-Eluting Stent

A

> 1 year

239
Q

Procedure and TIME TO WAIT for ELECTIVE SURGERY :

Angioplasy without stenting

A

2-4 weeks

240
Q

Procedure and TIME TO WAIT for ELECTIVE SURGERY :Bare metal stent placement

A

AT least 30 days; 12 weeks preferable

241
Q

Procedure and TIME TO WAIT for ELECTIVE SURGERY :CABG

A

At least 6 weeks; 12 weeks preferable

242
Q

Procedure and TIME TO WAIT for ELECTIVE SURGERY: Drug ELUTING STENT Placement

A

At least 12 months

243
Q

Evaluation and management of high cardiac risk

A

Recent MI < 60 days or unstable angina
Recent PCI (risk for death, MI, stent thrombosis, need for REPEAT REVASCULARIZATION
Urgent emergency surgery (EVEN if on antiplatelet therapy)
High cardiac risk surgical procedures

244
Q

The goals of management of a patient c/ IHD includes:

A
  1. Determining extent of IHD and any previous interventions
  2. Assessing severity and stability of disease
  3. Reviewing medical therapy and identifying any drugs that can increase the risk of surgical bleeding or
    contraindicate a particular anesthetic technique
245
Q

The goals of management of a patient c/ IHD includes →The need of emergency surgery

A

takes precedence over the need for additional workup

246
Q

MAJOR clinical risk factors require intensive preoperative management (DUSS)

A

Decompensated heart failure
Unstable coronary syndrome
Significant dysrhythmias
Severe valvular heart disease

247
Q

MINOR clinical risk factors do not independently increase cardiac risk and do not need a work up(4 HLNH)

A

Hypertension
Left bundle branch block
Nonspecific ST-T wave changes
History of stroke

248
Q

Minor clinical risk factors do not

A

independently increase cardiac risk and do not need a work up

249
Q

Ischemic Heart disease anesthetic management medication

A

Maintain adequate IV volume, Hgb concentration, heart rate, and BP (Labetalol is ok).

250
Q

Mechanism of perioperative ACS = ischemia (rather than acute coronary or stent thrombosis) • Optimize

A

O2 delivery, minimize demand

251
Q

Mechanism of perioperative ACS = ischemia (rather than acute coronary or stent thrombosis)• Hemodynamic goals:

A
  • Low/normal HR (50-80bpm)
  • Normal/high normal BP: 20% baseline, MAP 75-95 mmHg, diastolic 65-85 mm Hg
  • Severe HTN increases myocardial O2 supply
252
Q

Mechanism of perioperative ACS• Intraop HoTN defined:

A

SBP < 90 mmHg for > 10 min

253
Q

Mechanism of perioperative ACS

LVEDV level and why?

A
  • Normal LVEDV

* Distention = fluid overload = increase wall stress and O2 demand

254
Q

Mechanism of perioperative ACS Arterial O2 content HGb threshold and temperature

A

Adequate arterial O2 content and Hgb (threshold < 9 g/dL c/recent MI or UA, otherwise < 8 g/dL)
• Normothermia = favors tissue release of O2

255
Q

Preop med management Ischemia HD

• Beta blockers

A

Maintain
• Do NOT withdraw current therapy
• Do NOT initiate new therapy

256
Q

Preop med management Ischemia HD• Statins

A

Maintain

257
Q

Preop med management Ischemia HD• Aspirin

A

Depends on surgery and if receiving dual antiplatelet therapy

258
Q

Preop med management Ischemia HD• ACEI/ARB

A

Continued with heart failure

• Always held with hemodynamic instability, hypovolemia, acute creatinine elevation

259
Q

Preop med management Ischemia HD• Clonidine

A

• Continued if chronically administered (rebound HTN)

260
Q

Preop med management Ischemia HD• Continue other CV meds

A

• CCB, digoxin, diuretics

261
Q

Revascularization (CABG/PCI) is indicated when

A

optimal medical therapy fails to control Angina
Pectoris (AP) or
• Left main stenosis > 50%
• 70% or greater stenosis in a coronary artery
• CAD with EF < 40%

262
Q

ABG is preferred over PCI in patients with

STP

A
  • significant left main artery disease,
  • those c/ three-vessel coronary artery obstruction, and - - patients c/ diabetes who have two- or three-vessel coronary artery disease
263
Q

ACS PATHOPHYSIOLOGY

A

Focal disruption of atheromatous (atherosclerotic) plaques ➔plaque rupture➔coagulation cascade is triggered➔ thrombus➔ occluded coronary artery
➔ ACS.

264
Q

ACS characteristics

A
  1. Angina at rest (>20 mins)
  2. Chronic Angina Pectoris
  3. New Onset Angina
265
Q

NSAID lasts

A

(lasts platelet’s lifespan [7 days]).

• Aspirin 81 mgs vs. 325 mgs

266
Q

Angina Pectoris, Thienopyridines (CPT)

A

(lasts platelet’s lifespan) •
Clopidogrel (Plavix) •
Prasugrel (Effient)
• Ticlopidine (Ticlid)

267
Q

Platelet Glycoprotein IIb/IIIa Inhibitors (TEA)

A

• Tirofiban • Eptifibatide• Abciximab

268
Q

ANGINA PECTORIS

A

Metabolic O2 demand > supply• Myocardial O2
consumption > coronary blood flow➔ Angina Pectoris
➔ CHF, Cardiac Dysrhythmias, & Myocardial Infarction

269
Q

Angina Pectoris: Stress Test

• Negative stress test does not

A

exclude CAD.

270
Q

Angina Pectoris: Exercise (Treadmill)

A

• 1 mm of horizontal or downsloping ST-segment depression during or c/in 4 minutes of exercise.

271
Q

Angina Pectoris: Stress test. Nuclear (Adenosine)

A

• Assesses coronary perfusion & measures LVEF

272
Q

Angina Pectoris: Chemical stress test, meds and what they assess

A

(Atropine or Dobutamine)

• Assesses new ventricular wall motion abnormalities, valvular function, and EF.

273
Q

Angina Pectoris: Gold Standard

A

Coronary Angiography

274
Q

Angina Pectoris: Coronary angiography

Significance of left main CAD

A

• Greater than 50% stenosis of the left main coronary artery is associated c/ a mortality rate of 15% per year•

275
Q

Angina Pectoris: Coronary angiography →The most dangerous CAD (widow maker)

A

Left main coronary artery disease is the most dangerous anatomic lesion (widow maker).

276
Q

Angina Pectoris Preop Optimization

Lifestyle modification

A

Optimization prior to surgery is key, via:(e.g., smoking cessation & regular aerobic exercise)

277
Q

Angina Pectoris Preop Optimization ↓ of risk factors

A

(e.g., diet, weight reduction)

278
Q

Angina Pectoris Preop Optimization Pharmacologic management

A

(e.g., anti HTN, anti cholesterol, ASA)

279
Q

Angina Pectoris Preop Optimization Identification and treatment of

A

diseases that can precipitate or worsen the ischemia.

280
Q

Angina Pectoris Preop Optimization Revascularization procedure

A

(e.g., CABG, Percutaneous Coronary Intervention [PCI], with or without intracoronary stents).

281
Q

Common causes of acute chest pain cardiac (RAPA)

A

Angina
Rest or unstable angina
Acute MI
Pericarditis

282
Q

Common causes of acute chest pain Vascular (APA)

A

Aortic dissection
PE
Pulmonary HTN

283
Q

Common causes of acute chest pain: Pulmonary (PTS)

A

Pleuritis/PNA
Tracheobronchitis
Spontaneous Pneumo

284
Q

Common causes of acute chest pain:GI

A

Peptic ulcer
Pancreatitis
Esophageal reflux
Gallbladder disease

285
Q

Common causes of acute chest pain: Musculoskeletal

A

Costochondritis
Cervical disk disease
Trauma or strain

286
Q

Common causes of acute chest pain: Infectious/psych

A

Herpes zoster

Panic disorder

287
Q

Thrombolytic Therapy (e.g, tPA):

A

a. start 30-60 mins of hospital arrival, and

b within 12 hours of symptom onset.

288
Q

Aka Percutaneous Coronary Angioplasty (PTCA)

• Treatment of choice for _____ and must be done

A

severe heart failure and/or
pulmonary edema (when tPA is contraindicated)
• Must be done 90 minutes of arrival and c/in 12 hours
of symptom onset

289
Q

Functional capacity or exercise tolerance can be

expressed in metabolic equivalent of the task

A

MET) units• O2consumption (O2) of a 70-kg, 40-year-old

man in a resting state is 3.5 mL/kg/min = 1 MET

290
Q

Perioperative cardiac risk is increased when a

patient is unable to meet a

A

4-MET demand during normal daily activities
• Bicycling lightly, walking 3mph, calisthenics, sexual
activity, golfing

291
Q

• Surgery-specific risk of non-cardiac procedures are

graded as High (EAPP)

A

Emergency major surgery,
Aortic and other major vascular surgery
Peripheral vascular surgery, and prolonged surgery c/ large fluid shifts and/or blood loss)

292
Q

Surgery-specific risk of non-cardiac procedures are

graded as Medium (CHEPOI)

A 
Carotid endarterectomy
Head and neck surgery
Endovascular aortic surgery
Prostate surgery)
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
293
Q

Surgery-specific risk of non-cardiac procedures are

graded as LOW

A

Endoscopic surgery
Superficial surgery,
Cataract surgery, Breast surgery, and Ambulatory
surgery)

294
Q

Under-secreting thyroid tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

High (b/c few hypothalamus receptors are bound)
High
Low

295
Q

Over-secreting thyroid tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

Low
Low
High

296
Q

If problem is TSH, we don’t bother injecting TSH, we just give hormone that is lacking:

A

Thyroid hormone.

297
Q

Under-secreting pituitary tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

High
Low
Low

298
Q

Over-secreting pituitary tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

Low
High
High

299
Q

Under-secreting hypothalamic tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

Low
low
low

300
Q

Over-secreting hypothalamic tumor
Hypothalamus (TSH-RH)
Pituitary (TSH)
Thyroid (TH)

A

High
High
High

301
Q

Cortisol Under-secreting adrenal gland tumor
ACTH-RH
ACTH
Cortisol

A

High
High
Low

302
Q

Cortisol Over-secreting adrenal tumor
ACTH-RH
ACTH
Cortisol

A

Low
Low
High

303
Q

ACTH Under-secreting pituitary tumor
ACTH-RH
ACTH
Cortisol

A

High
Low
Low

304
Q

ACTH Over-secreting pituitary tumor
ACTH-RH
ACTH
Cortisol

A

Low
High
High

305
Q

Under-secreting hypothalamic tumor
ACTH-RH
ACTH
Cortisol

A

Low
Low
Low

306
Q

Over-secreting hypothalamic tumor
ACTH-RH
ACTH
Cortisol

A

High
High
High

307
Q

So when ACTH is elevated, and body cannot make enough cortisol what happens

A

aldosterone will ↑, and testosterone will be made in females instead, and estrogens will be made in males. High blood glucose and high blood pressure, and
females develop facial hair while males develop
breasts.

308
Q

ACTH Over-secreting pituitary tumor CUSHING

A

Low
High
High

309
Q

ACTH Over-secreting adrenal tumor CUSHING

A

Low
Low
High

310
Q

Cortisol Under-secreting adrenal gland tumor

A

High
High
Low

311
Q

PRIMARY ADRENAL INSUFFICIENCY

A

(adrenal gland is problem)

312
Q

SECONDARY ADRENAL INSUFFICIENCY

A

(pituitary is problem)

313
Q

Secondary Adrenal Insufficiency Pituitary ACTH levels are____cortisol is _____ and hypothalamus ACTH-RH is

A

low, low,high.

314
Q

Difference between primary and secondary

adrenal insufficiency is

A

ACTH level

315
Q

Primary Adrenal Insufficiency Pituitary ACTH levels are____cortisol is _____ and hypothalamus ACTH-RH is

A

High, low, High

316
Q

Cushing’s Syndrome

A

(1° adrenal hyperplasia) Adrenal gland is problem

317
Q

Thyroid hormone is

A

permissive for growth hormone (you need thyroid hormone in order for GH to work).

318
Q

Not enough thyroid hormone →

A

stunted growth, even if enough growth hormone is

present.

319
Q

Hormonal Trigger

A

◦ Endocrine gland releases a hormone that stimulates another endocrine gland to release its hormone.

320
Q

◦ Hypothalamus releases a hormone that causes pituitary gland to

A

release TSH, which causes thyroid gland to release thyroid hormone.

321
Q

Thyroglobin T4 is

◦ T3 gets used first by body cells.

A

most abundant form, but it is inert (inactive).

322
Q

T3 has

A

robust activity in cell.

323
Q

◦ T4 takes longer

A

to be ready; one iodine has to drop off.

324
Q

As T3 is used up, T4 is being converted by

A

iodinase to more T3.

325
Q

To make thyroid hormone, you need

A

iodine in your body. Iodized salt has enough to meet this need.

326
Q

Iodine is brought into

A

follicular cells, gene expression occurs, thyroglobulin is made.
Without enough iodine in diet, thyroid hormone cannot be made, no matter how much TSH is present.

327
Q

Thyroid Gland role in synthesis

A

Building block of TH = chemically attaching Ito tyrosine.

In plasma, TH needs a “carrier molecule” or it will be cleared from body

328
Q

Diabetes insipidus main issue

A

◦ Not enough ADH (anti-diuretic hormone; a diuretic takes out excess fluid from body)
◦ Because they lack ADH, person urinates frequently (polyuria), so they are thirsty and drink a lot of water (polydipsia). Their blood glucose is normal.

329
Q

Synthetic form of ADH is

A

vasopressin

330
Q

• Hypersecretion of GH in children

A

◦ Gigantism (overall growth)

331
Q

• Hypersecretion of GH in adults

A

◦ Acromegaly: enlarged hands and feet, and big chin, nose, and forehead

332
Q

Hyposecretion of GH

A

◦ Pituitary dwarfism

◦ Proportions are normal, overall size is small

333
Q

GH needs thyroid hormone (TH) to be present.

GH stimulates all cells to

A

↑ protein synthesis,

fat utilization, and gluconeogenesis.

334
Q

Gigantism vs acromegaly

A

result of excess GH during pre-puberty and acromegaly is result of excess GH after growth plates closed.

335
Q

Acromegaly Anesthesia Considerations

A 
Distorted face = hard to mask ventilate
Enlarged tongue/epiglottis
Overgrowth of mandible
Edematous vocal cords = smaller glottic
opening
◦ Assess for hoarseness/stridor
Skeletal changes associated with acromegaly
may make use of regional anesthesia
technically difficult or unreliable
336
Q

Syndrome of Inappropriate Antidiuretic Hormone

Secretion (SIADH)

A

Too much ADH → hyponatremia from dilution
◦ Water reabsorbed by renal tubules
◦ Ectopic = small cell lung carcinoma, carcinoid tumors

337
Q

SIADH Can result from

A

CNS trauma, infections, medications, hypothyroidism, major surgery

338
Q

S/S of SIADH

A

N/V, weakness, lethargy, confusion, depressed mental status, seizures

339
Q

SIADH diagnosis (RHIN)

A

Reduced serum osmolality (<270 mOsm/L
Hyponatremia (<130 mEq/L),
Inappropriately increased urine osmolality (hypertonic relative to plasma).
Normal or increased urine Na excretion (>20 mEq/L), and

340
Q

SIADH Fluid restriction

A

(< 1L/day)

341
Q

Democlocydine action

A

Demeclocycline inhibits action of ADH @ distal tubule

342
Q

Conivaptan is a ______used in the treatment of

A

vasopressin-2 receptor antagonist, may be effective; SIADH

343
Q

SIADH Severe hyponatremia

A

(<115 mEq/L) may require 3% hypertonic saline

344
Q

NA Rate of correction should be

A

0.5mEq/L/h until Na+ 125 mEq/L Then proceed more slowly to prevent central
pontine myelinolysis

345
Q

SIADH Anesthesia management:

A

◦ Careful monitoring and administration of fluids and
electrolytes
◦ Can have delayed awakening from anesthesia
◦ Can wake up confused after anesthesia

346
Q

Flluid resuscitation of SIADH

A

◦ Fluid resuscitation should be done with 0.9%NS

347
Q

Thyroid hormones All cells respond to thyroid hormone,

increasing their

A

metabolic rate (heart speeds up, beats c/ greater force, more nutrients are used, etc).

348
Q

Too much thyroid hormone is hyperthyroidism; these ppl are

A

people are thin and active.

349
Q

When levels of TH are too low, it is called

hypothyroidism; these people are

A

overweight, move slowly, have no energy.

350
Q

When there is too much TH, they get

A

muscles tremors and ↑ blood glucose levels (hyperglycemia).

351
Q

W/ not enough TH, they lose interest, become

A

sluggish, they get low blood glucose levels

hypoglycemia

352
Q

Major stimulus for release of thyroid

hormone is

A

hormonal (TSH from pituitary tells thyroid gland that it needs to make more thyroid hormone).

353
Q

What happens when TSH is released?

A

Every step in process of making TH is ↑: Follicular
cells become larger, metabolism ↑: ↑ in O2 use (especially in mitochondria), heat is generated.
TSH causes stimulation of sympathetic (beta)
receptors in heart, causing ↑ force of contraction and ↑ heart rate

354
Q

Since thyroid hormone is partly made of

iodine, if a person doesn’t eat enough iodine,can’t make thyroid hormone. how does hypothalamus response

A

can’t make thyroid hormone.
Hypothalamus responds by putting out more
TSH-RH.
Pituitary will respond by releasing TSH. But thyroid can’t respond by releasing TH if it does not have iodine to make hormone, so it size of follicle grows → gland grows → GOITER.

355
Q

Hyperthyroidism Anesthesia Management for elective cases

A

Euvolemia for elective cases

356
Q

Dexamethasone action

A

2mg IV q6h ↓hormone release and T4→T3 conversion

357
Q

Hyperthyroidism Anesthesia Management

A

Consider airway difficulties
Will need more anesthesia to control SNS response
Protect eyes

358
Q

Hyperthyrodisim Medications to

A

Avoid things that stimulate SNS (ketamine, pancuronium, atropine, ephedrine, epinephrine)

359
Q

Vasopressors to use with hyperthyroidism

A

Use direct acting vasopressors

◦ Indirect can result in an exaggerated response

360
Q

Hypothyroidism Anesthesia Management

Airway issues:

A

swollen oral cavity, edematous vocal cords, goiter

361
Q

Hypothyroidism and Aspiration

A

↓Gastric emptying = regurgitation/aspiration

362
Q

Hypothyroidism and CV

A

Normally have↓ CO, SV, HR, baroreceptor reflex

363
Q

↓vent response to hypoxia/hypercarbia (enhanced with

anesthesia)

A

hypothyroidism

364
Q

Hypoventilate in general, so mechanically ventilate

A

Hypothyroidism

365
Q

Hypothermia common with

A

Hypothyrodism

366
Q

Hematologic complications with Hypothyroidism

A

anemia, dysfunctional plt/coag factors (esp. factor VIII), electrolyte imbalances (hyponatremia), hypoglycemia

367
Q

Hypothyroidism narcotics

A

Very sensitive to narcotics and anesthetics in general

◦ Can have significant hypotension

368
Q

Hypotension with hypothyroidism

A

◦ BEST treated with ephedrine, dopamine, or epi NOT
phenylephrine (opposite of hyperthyroidism)
◦ If unresponsive, give steroids

369
Q

Hypothyroidism ◦ Beta receptors may be

A

less numerous and less sensitive

◦ Use phosphodiesterase inhibitor

370
Q

People c/ hyperthyroidism can take a drug

called______which does what?

A

PTU (Propylthiouracil), which inhibits TH production by blocking peroxidase enzyme that joins iodine to tyrosine
→results in lower thyroid hormone levels.

371
Q

HYPERTHYROIDISM

(Most commonly caused by

A

Graves Disease, which is an autoimmune disease)

372
Q

Signs include HYPERTHYROIDISM (GRAVE”S)

A

thinness, eyes that stick out like a bug (exophthalmoses).

◦ Leads to nervousness, weight loss, sweating, and rapid heart rate.

373
Q

Hyperthyroidism

◦ Graves’ Disease is when

A

hyperthyroidism is caused by an autoimmune disorder.

374
Q

You can have thyroid oblated (killed off) by drinking

radioactive iodine

A

◦ Kills just thyroid tissue.
◦ As metabolic rate slows, gains weight again.
◦ Can’t be around people for 5 days, and they set
off Geiger counters for months afterwards.
◦ Then start on artificial thyroxin, need to figure
out what their set point is for normal.

375
Q

Another way is to have thyroid gland surgically

removed.

A

◦ Parathyroid glands are often damaged or removed
during this surgery.
◦ Often intentionally leave some thyroid tissue
behind, in hopes of leaving enough parathyroid
glands there.
◦ If too many of parathyroid glands are removed,
calcium levels go down, can go into cardiac arrest.
◦ Now patient has to have two hormones
replaced.

376
Q

Hypothyroidism This can be caused by

A

Hashimoto’s thyroiditis (autoimmune)
Iodine deficiency
Tumor
Defective enzyme in thyroid.

377
Q

– Hashimoto’s Thyroiditis - adult hypothyroidism

A

◦ Antibodies attack and destroy thyroid tissue
◦ Low metabolic rate and weight gain are
common symptom

378
Q

◦ Myxedema:

A

non-pitting edema associated c/ hypothyroidism

379
Q

Cretinism –

A

Hypothyroidism in children
Short, disproportionate body, thick tongue and
mental retardation

380
Q

Cretinism (diminished mental ability)

A

This term describes babies whose MOTHER had lack of iodine.
Baby now cannot get iodine, and baby will have reduced growth and intellectual ability.
Once it is born and gets a healthy diet, it still
won’t go back to normal because TH is necessary for proper myelination and synaptic formation.

381
Q

Congenital hypothyroidism is term for a
baby
◦ Problem is only

A

whose thyroid gland is not working correctly (not secreting enough TH). c/ baby, not c/ mom.

382
Q

Congenital hypothyroidism and cretin babies

have similar symptoms.

A

◦ Child will stay tiny because GH does not work

c/out TH.

383
Q

Parathyroid hormone is released by a

A

Humoral mechanism.
◦ If blood calcium levels are low, parathyroid
hormone is released.
◦ If blood calcium levels are high, parathyroid
hormone stops being released.

384
Q

Hyperparathyroidism
◦ Hypercalcemia
◦

A

◦ Skeletal muscle weakness, polyuria, ↓GFR, ↑PR interval,
↓ QT interval, HTN, decreased pain sensation
◦

385
Q

NMB unpredictable

A

Hypercalcemia

386
Q

Hypoparathyroidism

◦ Hypocalcemia

A

Neuronal irritability, skeletal muscle spasms, tetany, and

possibly seizures

387
Q

◦ Acidosis and calcium

A

increases serum calcium

388
Q

Alkalosis and serum calcium.

A

Decreases serum calcium

389
Q

Acute hypocalcemia can present with

A

stridor and apnea

390
Q

◦ Congestive heart failure, hypotension, and decreased

responsiveness to β-agonists may occur

A

Hypocalcemia

391
Q

◦ Prolonged QT interval

A

Hypocalcemia

392
Q

Cushing’s syndrome/Disease

A 
◦ Hypersecretion of cortisol
◦ High blood glucose
◦ High blood pressure
◦ Features of opposite sex
◦ Round “moon” face and “buffalo hump”
393
Q

Addison’s disease

A

◦ Hyposecretion of cortisol
◦ Low blood glucose
◦ Low blood pressure results
◦ Also get hyperpigmentation

394
Q

In Cushing’s Syndrome, all adrenal cortical

hormones (

A

cortisol, androgens, and
aldosterone) are elevated, but ACTH-RH and
ACTH levels are lo

395
Q

Cushing’s Disease- pituitary tumor

Cushing’s Syndrome

A

(excess ACTH)

396
Q

•Ectopic Cushing ACTH producing tumor

A

(lungs)

397
Q

•Iatrogenic Cushing

A

(side-effect of some medical treatment)

398
Q

Cushing is a

A

primary hyperadrenalism

•Over-secreting adrenal tumor-, all adrenocortical hormones elevated

399
Q

Cushing Signs/symptoms:

A

buffalo hump, moon face, muscle loss/weakness, thin skin c/ striae, hyperglycemia, immune suppression

400
Q

Cushing Perioperative management of HTN,

A

hyperglycemia, intravascular fluid volume (usually elevated), and electrolytes (hypokalemia is common) necessary Pneumothorax is possible during adrenal
surgery

401
Q

Cushing Preoperative diuresis with

A

spironolactone is helpful

402
Q

Cushing When bilateral adrenalectomy is performed,

A

fludrocortisone will be necessary in the postoperative period

403
Q

Congenital adrenal hyperplasia (CAH) in a
female fetus causes
These babies have a _______________
some enzyme is not expressed which is
required to convert________
Boys are not affected; girls need__________
If presence of ACTH is driving pathway, and
it is blocked at this enzyme, ACTH can only
be used to make androgens

A 
clitoris to enlarge and
labia majora fuse into a scrotal sac.
mutation in a gene,
cholesterol into corticosteroids, so cholesterol is shunted to pathway that is not compromised: androgen
production 
a surgery
and cortisol for life, will be fine..
404
Q

Leads to overstimulation of adrenal androgen pathways.

A

Congenital Adrenal Hyperplasia (CAH)

405
Q

Addison’s disease Also called

A

Primary Adrenal Insufficiency and
hypoadrenalism; low glucose, low blood
pressure, and hyperpigmentation in hands,
fingers, and gums.

406
Q

Addison’s disease may be caused by anything

that

A

disturbs production of adrenal hormones (e.g., Tuberculosis).

407
Q

In Addison’s disease, adrenal cortex

A

does not respond to pituitary orders. Cortisol levels are low, but pituitary ACTH and
hypothalamus ACTH-RH hormones are high.

408
Q

Secondary adrenal insufficiency deficiency

A

◦ Deficiency of ACTH

409
Q

Primary Adrenal Insufficiency: Addison’s Disease

◦ Primary hypoadrenalism;

A

entire adrenal gland is destroyed due to atrophy or autoimmunedisorder
◦ Tuberculosis –disease attacks adrenal gland
◦ ACTH is ↑

410
Q

Adrenal Gland deficiencies Signs/symptoms:

A

Water/salt imbalance,
plasma volume depletion, low blood glucose,
pigmentation, Addisonian crisis (low blood
pressure, low blood glucose, need to go to
hospital)

411
Q

Addison’s Disease Anesthesia Considerations
Treat cause, give _______
replace _________________________

A

Administer glucocorticoids,

water/Na+ deficits (can be up to 3L)

412
Q

Addisons’ electrolyte imbalance

A

Metabolic acidosis and hyperkalemia usually

resolve with fluid and steroid administration

413
Q

Addison’s and Etomidate

A

Etomidate transiently inhibits Cortisol synthesis and should be avoided in this patient population

414
Q

Addison and Anesthetics

A

Minimal doses of anesthetic agents and drugs are recommended, since myocardial
depression and skeletal muscle weakness are
frequently part of the clinical presentation.

415
Q

Conn’s syndrome (hyperaldosteronism)

A

Too much aldosterone is secreted.
Too much salt and water is reabsorbed, person
develops high blood pressure.
Cortisone levels are not effected, so they do not
have elevated blood glucose.

416
Q

High incidence of ischemic heart disease

A

Conn’s syndrome

417
Q

Anesthesia considerations Conn’s syndrome:

A

Anesthesia considerations:
◦ Preoperative restoration of intravascular
volume, electrolyte levels (K+ supplementation), renal function, and control of hypertension
◦ Na+ restrictions
◦ Spironolactone
◦ Preop echo if hx chronic HTN

418
Q

DIABETES INSIPIDUS

A

◦ Pituitary gland does not secrete antidiuretic hormone, or kidney does not respond to hormone.
◦ It can be caused by damage to pituitary or kidney

419
Q

DIABETES MELLITUS

◦ Hereditary lack of

A

insulin secretion in pancreas, or resistance to insulin by body’s cells.

420
Q

◦ Type I diabetes(insulin dependent, develops in children)

A

◦ Destruction of pancreatic islets by autoimmune
disorders.
◦ Need insulin injections daily throughout life.

421
Q

◦ Type II diabetes (not insulin dependent, develops in

adults)

A

◦ Consequence of obesity: cells are less sensitive to insulin.
◦ Initially treated c/ diet and exercise.
◦ Oral medicines or injected insulin may be need

422
Q

DI Goal: plasma

A

osmolality is less than 290 mOsm/L◦ Isotonic fluids should be used for volume resuscitation.

423
Q

DI Anesthesia management Preoperative dose of

DDAVP

A

desmopressin intranasally or an IV bolus of 100 mU (0.1 unit) of aqueous vasopressin followed by a continuous infusion of 100–200 mU/h (0.1–0.2 units/h)

424
Q

DI ◦ If plasma osmolality exceeds 290 mOsm/L,

A

hypotonic fluid should be used for resuscitation
and the vasopressin infusion should be
increased above 200 mU/h.

425
Q

DI tx since Since vasopressin causes

A

vasoconstriction of arteriolar beds, close monitoring for myocardial ischemia is recommended

426
Q

DM
needs to be worked up (silent)________
◦ Gastroparesis = at risk for 2 things

A

◦ MI
aspiration
Autonomic neuropathy → dysrhythmias, hypotension

427
Q

DM Anesthesia Insulin

A

◦ Night before surgery, 1/3 NPH dose

428
Q

DM Pump rate decreased by

A

30% overnight, can run basal rate during surgery

429
Q

Oral hypoglycemics =

A

hold 24-48 hrs

430
Q

DM Avoid in entire periop period ; why?

A

Sulfonylureas block myocardial ATP channels responsible forischemia/anesthesia-induced preconditioning

431
Q

Intraoperative glycemic control

A

120- 180 mg/dL

432
Q

BG > 200 =

A

glycosuria, dehydration, inhibited wound healing

433
Q

1 unit of insulin

A

↓ glucose approximately 25- 30 mg/dL

434
Q

BG Best sample =

A

venous, cap + art come out 7% higher, and whole blood is 15% lower than serum values

435
Q

• Hypoglycemia treatment

A

treat c/50 mL 50% dextrose in water

• ↑BG 100mg/dL or 2mg/dL/mL

436
Q

Postop control

A
  • Critically ill = 140-180 mg/dL

* Initiate insulin therapy if > 180 mg/dL

437
Q

Rigid bronchoscopy

A

To examine the lung airways

Diagnostic, therapeutic, interventional

438
Q

Flex vs rigid Thinner and longer

Diagnostic and therapeutic procedures

A

Flexible

439
Q

Flex vs rigid Access to lower airways such as third order bronchioles

A

Flexible

440
Q

Disadvantage: Foreign object or thick mucus cannot be removed through the lumen

A

Flexible

441
Q

Flex vs rigid Topical anesthesia and/or sedation

A

Flexible

442
Q

Flex vs rigid Proximal airways

Interventional procedures

A

Rigid and larger

443
Q

General Anesthesia

A

Rigid

444
Q

Flex vs rigid

Disadvantage Potential soft tissue damage & inability to visualize deeper bronchioles

A

Rigid

445
Q

Instruments of choice for Bronchoscopy: RIGID

FEMVS

A 
Foreign bodies
Massive Hemoptysis
Vascular tumors 
Small children
Enbobronchial resections
446
Q

Fiberoptic Flexible

A 
Mechanical problem of neck
Upper lobe and peripheral lesions
Limited hemoptysis
PNA for culture
DLT posiion
Difficult intubation
checking position of ET
bronchial blockade
447
Q

Anesthesia for Flexible bronchoscopy Local Anesthesia/MAC

For patient who is awake, cooperative, and breathing spontaneously

A

Glycopyrrolate 0.2mg to 0.3 mg IV 15-20 minutes prior
Sedatives for patient comfort
Lidocaine & Tetracaine – commonly used
Nebulizer spray – oropharynx and base of the tongue

448
Q

Anesthesia for Flexible bronchoscopy Block Superior Laryngeal Nerve Internal Branch

A

Tongue held forward, pledgets in each piriform fossa using Krause forceps

449
Q

Transtracheal Anesthesia by

A

Transtracheal injection of local anesthetics

Spraying vocal cords and trachea under direct vision with laryngoscope

450
Q

Anesthesia for Flexible bronchoscopy Alternative to depress gag reflex

A

Superior laryngeal nerve block by external approach
Glossopharyngeal block
These blocks depresses airway reflexes, patient to remain NPO for several hours

451
Q

Anesthesia for Flexible bronchoscopy Transnasal Approach

A

4% Cocaine topically applied to nasal mucosa or viscous lidocaine
Phenylephrine or Afrin spray can be mixed with lidocaine for vasoconstriction

452
Q

Most widely used mode of ventilation for rigid bronchoscopy

A

Jet ventilator

453
Q

Rigid Bronchoscope
Place
Suction
Reverse with
Patient may cough violently to clear secretions and blood
_______________ decrease airway reactivity

A

Place ETT or LMA
Suction
Reverse with Neostigmine and Glycopyrrolate and fully before extubation
Patient may cough violently to clear secretions and blood
Lidocaine 1mg/kg to decrease airway reactivity
Wake up from remifentanil tends to be smoother
Postop O2 supplementation preferably humidified

454
Q

Rigid Bronchoscope Wake up from tends to be smoother

A

remifentanil

455
Q

Rigid Bronchoscope Post op O2 supplementation preferably

A

humidified

456
Q

POST OP RIGID BRONCHOSCOPOY

A

CXR – in PACU to check for atelectasis, pneumothorax, and mediastinal emphysema

457
Q

Rigid Bronchoscope Induction

Maintenance

A

Preoxygenate well
Consider short-acting paralytics
Succinylcholine 1mg/kg or rocuronium 0.3-0.6 mg/kg
Minimal Opioids use, consider remifentanil 1mcg/kg to avoid postop respiratory depressiong

458
Q

Rigid Bronchoscope Maintenance

A 
Sevoflurane or Isoflurane and 100% O2
TIVA alternative – (no gas leaks)
Propofol 50-150 mcg/kg/min
Remifentanil 0.1-0.3 mcg/kg/min
Paralytics
Short acting NDNMB (atracurium or rocuronium)
459
Q

Rigid bronchoscope Jet Ventilation –

A

allows for uninterrupted ventilation and may shorten the length of the procedure (fewer interruptions)
Variable FiO2 secondary to entrainment of air
No EtCO2 available – difficult to determine adequacy of ventilation
Intermittent ABG for prolonged procedure or use of transcutaneous CO2 monitor
Restrict IV fluids to avoid fluid overload

460
Q

Rigid Bronchoscope complications

A 
Mechanical trauma to the teeth
Hemorrhage
Bronchospasm
Bronchial or tracheal perforation
Subglottic edema
Barotrauma
Airway obstruction
Pneumothorax
*Note: To avoid some of these complications, it is advised to intubate with an ETT after bronchoscopy under general anesthesia
461
Q

Rigid Bronchoscope *Note: To avoid some of these complications, it is advised to

A

intubate with an ETT after bronchoscopy under general anesthesia

462
Q

Advantages of Bronchial Blockers

Disadvantages:

A

Can be dislodge and become life threatening
May be difficult to place
Cost more than double lumen tubes

463
Q

Double Lumen Tubes

A

Allows a single lumen tube to be placed
Ideal for long cases because of no tube exchange post-operatively, and expected post-operative mechanical ventilation
Can be used to isolate individual lobes

464
Q

Post op care rigid

A

A single chest tube usually is placed at the end of case and connected to a sealed drainage unit for postop chest drainage
Pain management:
IV, IM, continuous IV, PCA
Epidural, intercostal blocks, NSAID

465
Q

When the surgeon says to reinflate the operative lung,

A

unclamp the lumen and manually ventilate until the lung is inflated. Then change the ventilator settings back to the original, 2 lung ventilation settings to a PRESSURE control setting, be sure to limit peak pressures to < 40 cm H20. When using a smaller Tv, a higher rate will be needed.

466
Q

Blocks for Bronchoscope

A

Epidural, Intercostal block, paraveterbral block and/or intrapleural local anesthetic intercostal nerve blocks are performed when other regional techniques are contraindicated

467
Q

Coming off Post-bypass low cardiac output

Low pulmonary artery pressure:

A

give volume, increase preload

468
Q

Coming off Post-bypass low cardiac output

Low ejection fraction:

A

increase contractility with inotropes

469
Q

Coming off Post-bypass High afterload (SVR > 1200):

A

decrease afterload, can use sodium nitroprusside

470
Q

Coming off Post-bypass Low heart rate:

A

increase heart rate, program pacemaker

471
Q

Coming off Post-bypass Arrythmias

A

Atrial/ventricular pacing, intra-aortic balloon pump set at 1:1

472
Q

Coming off Bypass Post-bypass hypotension : assess

A

Assess LV volume and function

Check CVP, PAD, CO/CI, and TEE for wall movement abnormalities

473
Q

Coming off Post-bypass HYPOTENSION Treat with

A

volume, calcium, vasopressors, or inotropes as needed
Alpha agonists may be needed
A ventricular assist device may be needed for the right or left ventricle, or both ventricles

474
Q

Coming off BYPASS Post-bypass hypertension

A

Assess if the anesthesia level is deep enough
Treat with narcotics and volatile agents as necessary
Some patients may need vasodilators

475
Q

Off pump CABG

What should be available?

A

Coronary artery bypass grafting may be done without cardiopulmonary bypass
Patient should be prepped and draped to go on bypass at any time

476
Q

Best candidate for OFF PUMP BYPASS

A

Best for hemodynamically stable patients with coronary arteries that can be stabilized on the anterior wall of the heart
Promoted in patients at increased risk for stroke, severe lung disease, severe vascular disease, and renal dysfunction

477
Q

POST BYPASS PERIOD Protamine

A

1.3-1.5 mg/100 units of heparin given can be administered once
Hemostasis is controlled
The aortic and vena cava cannulas have been removed
Hemodynamic stability is achieved
Give protamine slowly to prevent hypotension or pulmonary hypertension

478
Q

POST BYPASS PERIOD ACT

A

Check ACT 3 minutes after giving protamine – it should be the same or less than baseline

479
Q

POST BYPASS Anaphylaxis risk

A

is increased for patients with diabetes who have received NPH insulin and/or vasectomized males
Epinephrine 10 mcg/ml to treat reactions

480
Q

POST BYPASS Uncontrolled bleeding may be caused by

A 
Inadequate surgical control of bleeding
Inadequate heparin reversal
Thrombocytopenia
Platelet dysfunction
Hypothermia if the patient's body temperature is < 35 c
Newly acquired coagulopathy
481
Q

Treatment of Post BYPASS BLEEDING

A 
More protamine
FFP
Platelets
DDAVP
Factor VII
482
Q

POST bypass bleeding Do this before cell saver?

A

Finish giving protamine before starting to give cell-saver blood, then give blood products

483
Q

Total neck dissection Thyroidectomy pre-op

A

Hypertension must be controlled pre-op • Extra risk of exaggerated hemodynamic responses post -op d/t dissection near carotid body and vagus nerve

484
Q

Intraop total neck dissection BP control

• Gases should be humidified to avoid mucus plugs in this population

A

Deliberative relative hypotension is desirable for these
surgeries, with aggressive treatment of increased BP
• MAP of 60–70 mmHg, use of remifentanyl
• Laryngeal edema may occur

485
Q

Total neck dissection intraop important to Avoid administering _____why?

A

paralytics until after large mandibular nerve and CN XI have been identified

486
Q

Total neck dissection why do you get bradycardia •

A

transient bradycardia

487
Q

Neck dissection Decrease in HR and BP treatment:

A

stop surgery, lidocaine infiltration of carotid sinus by surgeon, atropine

488
Q

POST op BP and HR

• Facial nerve injury: facial droop • Recurrent laryngeal nerve injury

A

Increased Secondary to carotid sinus

denervation • Aggressive pharmacological intervention

489
Q

Thyroidectomy Thyroid Storm = life threatening!

•

A
  • Hyperthermia
  • Tachycardia
  • Widened pulse pressure
  • Anxiety
  • Neuro changes
490
Q

• Tx thyroid storm :

A

• ↑FiO2, fluids, e- replacement, cooling blanket, etc.

491
Q

Thryroid storm CAN BE MISTAKEN FOR

A

MALIGNANT HYPERTHERMIA!
• When in doubt –> dantrolene
• Can be beneficial for bot

492
Q

Thyroidectomy – Anesthesia Considerations

• Local anesthetic

A

with epinephrine injection into neck

• Monitor EKG changes (increased HR, ST-segment changes)

493
Q

• May want to avoid LA with epi in those patients

A

hyperthyroid patients

494
Q

• If hyperthyroidism, have these available

A

ave beta blockers available

• HTN, tachycardia, or SNS response

495
Q

Thyroidectomy - Indications

A

Performed to correct either a benign or malignant process affecting the thyroid gland
• Hyperthyroidism (Graves disease, goiter, toxic adenoma)
• Thyroid cancerDissection near carotid body and vagus nerve may result in
• Noncancerous enlargement of thyroid (goiter)
• Benign or suspicious
nodules

496
Q

Hyperthyroidism Cause: May be commonly secondary to

A

Graves’ disease, toxic multinodular goiter, thyroid

adenomas, TSH-secreting tumor (rare), or overdose of thyroid hormone

497
Q

Hyperthyroidism Common sx:

A

• Hypermetabolism & SNS overstimulation
• Fatigue, sweating, intolerance to heat, weight
loss or gain
• Thyroid goiter, exophthalmos
• Increased appetite, HR, BP, pulse pressure,
and temperature
• Tremor, anxiety, nervousness

498
Q

• CHF and Atrial Fibrillation are common in these

patients

A

Hyperthyroidism

499
Q

Untreated hyperthyroidism leads to

A

Thyroid storm

500
Q

Review
- Hypothyroid
• Cause:

A

iatrogenic or autoimmune thyroiditis

501
Q

Common sx Hypothyroidism

Cold, metabolism, cardiac resp function, HR, CO, DTR

A

Intolerance to cold • Decreased metabolism • Depressed cardiac and respiratoryfunction
• Bradycardia, decreased CO, pulse pressure, temp, mental reflexes, and DTR
• Lethargy, anorexia, weight gain or loss, constipation

502
Q

• Decreased ventilatory response to hypoxia and hypercarbia

A

hypothyroidism

503
Q

These patients are dehydrated

• need volume repletion

A

• Hyperthyroid:

hypermetabolism, sweating, diarrhea

504
Q

• Hypothyroid:

A

adrenal insufficiency (untreated)

505
Q

Thyroidectomy – Anesthetic Concerns

Hyperthyroid

A
  • Increased:
  • HR
  • Atrial fibrillation
  • Palpitations
  • CHF
  • Caution using beta blockers
506
Q

Hypothyroid CV CHAnge

A
  • Bradydysrhythmias,
  • Diastolic HTN or dysfunction
  • Pericardial effusions
  • ECG changes
  • ST and QT changes, TdP
507
Q

• Caution w/ volume expansion with LV dysfunction

A

Hypothyroidism

508
Q

Complications of Thyroidectomy• Injury to recurrent laryngeal nerves (RLN) • Bilateral: • Unilateral:

A
  • Will require reintubation

- experience hoarseness.

509
Q

Thyroidectomy – Anesthesia

• Check with surgeon if needing:

A

• Muscle relaxant

510
Q

Thyroidectomy – Anesthesia Avoid

A

histamine releasing paralytics

Atracurium , Mivacurium

511
Q

IONM Line up electrodes to

A

vocal cords

512
Q

IONM vocal cords aligned with The electrodes, connected to a monitor, sense

A

EMG (electromyographic) activity from the thyroarytenoid

muscles

513
Q

Thyroidecomty no _______ why?

A

• NO muscle relaxants or topical laryngeal
anesthesia!
• to obtain appropriate signals during surgery

514
Q

Increasing your body weight by 10% causes how much of an increase in OSA risk?

A

10%

515
Q

Pickwickian syndrome is named after a character in what famous author’s book?

A

Charles Dickens

516
Q

Which of the following is not an adverse effect of Albuterol

A

Hyponatremia

517
Q

If you are ventilating at rate of 10, what should your I:E be?

A

1:2

518
Q

If you are ventilating at rate of 8, what should be your I:E be?

A

1:3

519
Q

If you are ventilating at rate of 6, what should be your I:E be?

A

1:4

520
Q

Which commonly used anesthetic agent can exacerbate asthma?

A

Neostigmine

521
Q

Which intervention may help with negative pressure pulmonary edema?

A

Add 8cm H2O PEEP

522
Q

Which lung volume is not significantly affected by breathing irregularities?

A

Tidal volume

523
Q

What is an average hospital stay for patient who aspirate?

A

21 days

524
Q

What is the gold standard for assessing angina related to CAD?

A

Coronary angiography

525
Q

What type of medication is abciximab?

A

Glycoproteins IIb/IIIa inhibitor

526
Q

What might you hear with CHF?

A

S3 sound

527
Q

When does thrombolytic therapy need to be administered by for ACS?

A

12 hours

528
Q

Which papillary muscle of the mitral valve has the highest chance of rupturing?

A

Posteromedial

529
Q

When is CABG preferred over a PCI?

A

Three vessel coronary artery obstruction

530
Q

How much heparin would you give for a CABG about to go on bypass?

A

400units/kg

531
Q

Upon arriving to the hospital, how long do you have to do a PCI?

A

90 min

532
Q

What is the O2 consumption at 2 METS?

A

7ml/kg/min (3.5ml/kg/min at 1 METS)

533
Q

What is the highest level serum glucose can rise to during cardiac surgery?

A

180mg/dL

534
Q

After a radial neck dissection, a patient is restless in PACU. What might be occurring?

A

Hypercarbia

535
Q

Which hormone is released via a neuronal trigger?

A

ADH

536
Q

The release of thyroid hormone is a result of what kind of trigger?

A

Hormonal

537
Q

What is the highest pressure you can deliver during jet ventilation via cricothyrotomy?

A

50PSI

538
Q

Which hormone is released via humoral trigger?

A

Glucagon

539
Q

Growth hormone requires which other hormone to function?

A

Thyroid hormone

540
Q

Excessive testosterone production in the adrenal cortex will has what affect on males?

A

Nothing

541
Q

How long can a keep a cricothyrotomy in for?

A

5 days

542
Q

What hormone is released from the neurohypophysis?

A

ADH

543
Q

What is necessary to diagnose SIADH?

A

Concentrated Urine

544
Q

When should you initiate 3% NS in a patient with SIADH? 115mEq/L (when will you hold surgery?

A

Less than 125)

545
Q

What enzyme facilitates iodination of tyrosine?

A

Peroxidase

546
Q

What breakdowns T4 to T3

A

Iodinase

547
Q

Subglottic stenosis may result from what surgical procedure?

A

Cricothyrotomy

548
Q

What medication can decrease the conversion of T4 to T3?

A

Dexamethasone

549
Q

What is the largest pure endocrine gland?

A

Thyroid

550
Q

If you have an over-secreting pituitary tumor, which body part will reduce its signaling?

A

Hypothalamus

551
Q

Decreased TSH-RH, decreased TSH, and increased TH indicates what?

A

Over-secretion by thyroid

552
Q

Which childhood disease is a result of hypothyroidism when in the womb?

A

Cretinism

553
Q

What antagonizes calcitonin?

A

Parathyroid hormone

554
Q

Where is aldosterone produced?

A

Zona Glomerulosa

555
Q

Humoral Trigger

A

Blood is being monitored. When level of substance is too low, it stimulates release of hormone.

556
Q

Neuronal Trigger

A

A neuron directly stimulates gland to cause secretion of hormone.

557
Q

Hormonal Trigger

A

Endocrine gland releases a hormone that stimulates another endocrinegland to release its hormone.

558
Q

Humoral triggers Examples are

A 
Parathyroid
Insulin, 
Glucagon
Aldosterone
Hormone
559
Q

ACS AVOID

A

tachycardia, systolic hypertension, sympathetic nervous system stimulation, arterial hypoxemia, and hypotension (c/in 20% of the normal awake patient)

560
Q

SAD-P

A

Syndrome Adrenal

Disease Pituitary

561
Q

Valvular associated with PVC

A

MVP

562
Q

P mitrale is associated with

A

Mitral stenosis

563
Q

High Peak pressure

A

May be needed to deliver TV of bronchospasm

564
Q

Fiberoptic bronchoscopy

• Principal contraindication to pleural biopsy is

A

coagulopathy

565
Q

Maintenance volatile for CABG , gas and MAC

A

Iso, Sevo or des, titrated to 0.5 MAC

Avoid nitrous oxide

566
Q

Fentanyl and bypass

A

May be given throughout the case
50 -100mcg if good EF
<50 if bad EF

567
Q

CABG induction agent if CO is less than 35%

A

Etomidate 0.2-0.3mg/kg

568
Q

CABG induction agent if CO is MORE than 35%

A

Sodium thiopental 2-4mg/kg

569
Q

Induction meds

A

Succ , give roc defasciculating dose

Midazolam

570
Q

COPd and volume

A

RV gets larger closing capacity

571
Q

Add peep

A

For negative pulmonary edema

572
Q

OPCAB can be used

A

To Perform multi-vessel bypass
To Carry out redo CABG
In patients with Aortic disease when cannulation of the aorta poses significant embolic risk

573
Q

OPCABG is best for patients where the side effects of cardiopulmonary bypass are

A

especially undesirable

574
Q

OPCABG The major difficulties for this surgery include

A

hemodynamic alterations with cardiac manipulation and tilting and intraoperative myocardial ischemia.

575
Q

Off pump better for

ASLVR

A
  • hemodynamically stable patients with coronary arteries that can be stabilized on the anterior wall of the heart
    Promoted in patients at increased risk for stroke, severe lung disease, severe vascular disease, and renal dysfunction (SLVR)
576
Q

Bad for regurgitation

A

Hypercarbia

577
Q

Status asthmaticus give

A

8% sevo
Decrease TV
Lidocaine
PPV

578
Q

• EKG and MVP change

A

PVCs, repolarization abnormalities, and prolonged QT interval.

579
Q

S/sx of MVP:

A 
Palpitation
Anxiety 
Dyspnea
Atypical chest pain.
Fatigue,
Orthostatic symptoms
580
Q

Regurgitant valve wanted hemodynamics

A

AB-DA-IPNIC

581
Q

Stenotic valves wanted hemodynamics

A

MS-AT-IA-NIP-NIC-minpU

582
Q

Holodiastolic descrecendo murmur

A

Mitral stenosis

SRNA3CoExisting (16 decks)

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