ITE CA2 General 4

Question 1

most common periop anaphylactic causes in kids and adults

Answer 1

In adults, neuromuscular blocking agents are the most likely agents to induce an anaphylactic reaction in the perioperative period. In children, latex is the most likely causative agent.

Question 2

Anaphylaxis is mediated by

Answer 2

Anaphylaxis is an IgE-mediated type 1 hypersensitivity reaction.

Question 3

signs and symptoms of anaphylaxis

Answer 3

Signs and symptoms include bronchospasm and upper airway edema, urticaria, changes in capillary permeability and inotropy, and vasodilation.

Question 4

what is carboxyhemoglobin

Answer 4

Carbon monoxide forms a tight bond with hemoglobin producing carboxyhemoglobin

Question 5

Methemoglobin left or right shift of oxygen dissociation curve

Answer 5

left

Question 6

hypophosphatemia left or right shift of oxygen dissociation curve

Answer 6

left

Question 7

anesthesia information management systems (AIMS)

Answer 7

AIMS are a form of the electronic health record which allows automatic collection, storage, and presentation of patient data during the perioperative period.

Question 8

limitations or problems with anesthesia information management systems

Answer 8

There are several limitations for the use of AIMS. Implementation of AIMS can be expensive and time-consuming. The cost can range from $4000 to $9000 per operating room with an additional cost for the servers and maintenance. AIMS can help with billing and charge capture which may help offset some of the costs. Another major problem is vertical integration. Information may not transfer from one phase of care to the next, for instance from the preoperative, intraoperative, and postoperative periods. There also may be difficulty with communication between different systems, for instance the patient monitor may not communicate with the ventilator and the AIMS creating data capture problems. The initial time and effort to implement and train staff on the AIMS can be significant with many roadblocks.

Question 9

prob with asynchronous pacing

Answer 9

An R-on-T phenomenon occurs when a cardiac depolarization (R-wave) is initiated during a period of myocyte repolarization (T-wave) and can precipitate polymorphic ventricular tachycardia. Causes of R-on-T Phenomena include asynchronous cardiac pacing, long QT syndrome, or frequent PVC’s.

Question 10

Inverted T waves differential

Answer 10

Inverted T waves can result from bundle branch blocks, myocardial ischemia/infarction, left ventricular hypertrophy, pulmonary embolism, and elevated intracranial pressure. They can also be a normal finding in children.

Question 11

Lung abscesses usually occur due to

Answer 11

Lung abscesses usually occur due to primary infections, namely aspiration pneumonia, and are commonly caused by anaerobic bacteria. Broad-spectrum antibiotics are first-line treatment and lung isolation should be utilized if surgical intervention is necessary.

Question 12

Lung abscesses organisms

Answer 12

Lung abscesses are most commonly a result of primary lung infections, such as aspiration pneumonia, leading to further necrosis and abscess formation. Organisms that are commonly implicated include anaerobes (Bacteroides, Peptostreptococcus), as well as some aerobes (Staphylococcus, Klebsiella, and Pseudomonas).

Question 13

Things that affect billing and payment

Answer 13

The total billable charge for an anesthetic is generally represented by: (BU + TU + Modifying Factors) x Anesthesia Conversion Factor. Modifying factors include QCU, physical status modifier, and specialized monitoring.

Many insurance providers allow for additional units (QCUs) to be billed for four unique clinical situations.

1) Extremes of age (patients < 1 year or >70 years)
2) Use of (deliberate) total body hypothermia
3) Use of controlled hypotension
4) Anesthesia complicated by emergency conditions

The intraoperative administration of drugs, IV fluids, blood products, etc. are considered an integral part of the global general anesthetic service and do not increase or decrease reimbursements for an anesthetic.

Question 14

Transillumination

Answer 14

Transillumination involves placement of a lighted stylet into the trachea until a glow is visualized at the cricoid cartilage, with subsequent passage of an endotracheal tube. It is useful in cases of increased airway secretions and blood but should be avoided in morbidly obese patients and cases of airway anatomy distortion.

Question 15

A patient experiencing acute respiratory alkalosis should demonstrate a pH increase of ___ and a HCO3- decrease of ___ mEq/L per acute 10 mm Hg decrease in PaCO2.

Answer 15

A patient experiencing acute respiratory alkalosis should demonstrate a pH increase of 0.10 and a HCO3- decrease of 2 mEq/L per acute 10 mm Hg decrease in PaCO2.

Question 16

A patient experiencing acute respiratory acidosis should demonstrate a pH decrease of ____ and an HCO3- increase of ____ mEq/L per acute 10 mm Hg increase in PaCO2.

Answer 16

A patient experiencing acute respiratory acidosis should demonstrate a pH decrease of 0.05 and an HCO3- increase of 1.0 mEq/L per acute 10 mm Hg increase in PaCO2.

Question 17

If the respiratory acidosis becomes chronic, pH nearly normalizes, and HCO3- concentrations increase __ mEq/L per 10 mm Hg sustained increase in PaCO2.

Answer 17

If the respiratory acidosis becomes chronic, pH nearly normalizes, and HCO3- concentrations increase 4-5 mEq/L per 10 mm Hg sustained increase in PaCO2.

Question 18

If a respiratory alkalosis becomes chronic, pH nearly normalizes and HCO3- decreases ___ per 10 mm Hg sustained decrease in PaCO2.

Answer 18

If a respiratory alkalosis becomes chronic, pH nearly normalizes and HCO3- decreases 5-6 mEq/L per 10 mm Hg sustained decrease in PaCO2.

Question 19

Plasma albumin has a half-life of

Answer 19

Plasma albumin has a half-life of nearly 3 weeks.

Question 20

5′-nucleotidase is a marker of cholestasis

Answer 20

5′-nucleotidase is a marker of cholestasis, along with γ-Glutamyl transpeptidase and alkaline phosphatase. However, alkaline phosphatase lacks specificity for hepatobiliary disease and may be derived from bone or other sources.

Question 21

Brachial artery catheterization potential complications

Answer 21

Brachial artery catheterization is low risk and can be used for long-term monitoring. Potential complications include thrombosis, infection, and median nerve injury.

Nerve injury is a concern when puncturing the upper extremity arteries. The brachial artery is in close proximity to the median nerve (just medial to the artery), and can potentially injure the nerve during catheterization. The axillary artery runs through the axillary sheath, which contains the median, ulnar, and radial nerves. Bleeding during the puncture of the axillary artery can cause a hematoma to form within the sheath. This can result in nerve compression leading to serious neurological deficits.

Question 22

The axillary sheath contains

Answer 22

TrueLearn Insight : The axillary sheath contains the median, ulnar, and radial nerves. The musculocutaneous nerve is located outside of the axillary sheath.

Question 23

absolute contraindication to shock wave lithotripsy.

Answer 23

pregnancy, bleeding disorders, and anticoagulation therapy

Question 24

relative contraindications to shock wave lithotripsy

Answer 24

Relative contraindications include large aortic or renal aneurysms, untreated urinary tract infection (UTI), ureteral obstruction distal to the calculus, implanted pacemaker/defibrillator, and morbid obesity.

Question 25

crystal vs colloid for resuscitation

Answer 25

Both crystalloids and colloids have been used for resuscitation. There have been many different studies evaluating the efficacy of each therapy. The SAFE and ALBIOS studies suggest no difference in mortality between the two when used for resuscitation.

Question 26

Induced hypothermia following cardiac arrest
reasoning
guidelines

Answer 26

Induced hypothermia following cardiac arrest can reduce ischemic injury and improve neurologic outcomes. It is accomplished by various cooling methods for a duration of 12-24 hours post-resuscitation with a goal temperature of 32 °C to 36 °C. Rewarming should occur slowly to avoid major complications.

Question 27

Most deaths associated with the use of induced hypothermia occur ___

Answer 27

Most deaths associated with the use of induced hypothermia occur during the rewarming phase due to too rapid rewarming.

Question 28

pupillary light reflex under GA

Answer 28

intact

Question 29

PO2 of room air

Answer 29

room air PO2 of about 159 mmHg

Question 30

delay in ABG causes what

Answer 30

Delays in analysis and exposure of a sample to room air are the two most common sources of error in blood gas analysis. A delay will result in decreased PaO2, pH, and base excess values and an increase in PaCO2. Entrainment of room air will tend to cause the PaO2 value of the sample to approach the PO2 of room air (159 mmHg at sea level) and result in a decreased measured PaCO2.

Question 31

active vs passive humidification

Answer 31

An advantage of active humidifiers is more effective humidification of air. However, no clinical benefit has been demonstrated compared to passive heat and mouisture exchangers HMEs, which are widely used due to their simplicity, low labor costs, and the option to filter bacterial components. Nevertheless, disadvantages of HMEs exist and include increased airway resistance leading to disastrous airway obstruction, circuit disconnection, less efficient humidification, and increased dead space

Question 32

ASA second standard require end tidal CO2 monitoring for MAC cases?

Answer 32

The advisory states, “during moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment.”

The second standard states that patient oxygenation, ventilation, circulation, and temperature shall be continually evaluated

Question 33

Define levels of sedation by patient responsiveness

Answer 33

Minimal sedation - Normal response to verbal stimulation
Moderate sedation - Purposeful response to verbal or tactile stimulation
Deep sedation - Purposeful response following repeated or painful stimulation
GA - Unarguable even with painful stimulus

Question 34

Define levels of sedation by airway

Answer 34

minimal sedation - Unaffected
moderate - No intervention required
deep - Intervention may be required
GA - Intervention often required

Question 35

Define levels of sedation by spontaneous ventilation

Answer 35

minimal - Unaffected
moderate - Adequate
deep - May be inadequate
GA - Frequently inadequate

Question 36

Define levels of sedation by cardiovascular function

Answer 36

minimal - Unaffected
moderate - Usually maintained
deep - Usually maintained
GA - May be impaired

Question 37

aldrete score and how many you need to leave PACU

Answer 37

need 9 points

Activity
Able to move four extremities on command: 2
Able to move two extremities on command: 1
Able to move 0 extremities on command: 0

Breathing:
Able to breathe deeply and cough freely: 2
Dyspnea: 1
Apnea: 0

Circulation:
Systemic blood pressure ≠ 20% of the preanesthetic level: 2
Systemic blood pressure is 20% to 49% of the preanesthetic level: 1
Systemic blood pressure ≠ 50% of the preanesthetic level: 0

Consciousness:
Fully awake: 2
Arousable: 1
Not responding: 0

Oxygen Saturation (Pulse Oximetry):
92% while breathing room air: 2
Needs supplemental oxygen to maintain saturation >90%: 1
90% even with supplemental oxygen: 0

Question 38

burn resuscitation

Answer 38

The primary therapy for major burns in adults is crystalloid administration. Several commonly accepted formulas (e.g. Parkland, modified Brooke, and rule of tens) are available and call for initial infusion rates based on patient weight and/or the size of the burn (% TBSA) which are then regularly titrated based on clinical response. Fluid boluses and the use of glucose-containing crystalloids should generally be avoided. Albumin administration during the first 24 hours after injury, and especially during the first 8-12 hours, may worsen edema.

Question 39

Risk factors for a difficult intubation can be found below:

Answer 39

Risk factors for a difficult intubation can be found below:
Long upper incisors
Prominent overbite
Poor voluntary prognath
Less than 3 cm inter-incisor distance
Mallampati class III or IV airway
Highly arched or very narrow palate
Stiff or indurated mandibular space
Less than 3 fingerbreadths thyromental distance
Short neck
Thick neck (>17 inches)
Limited flexion or extension of neck

Question 40

less than __cm inter-incisor distance for risk diff intubation

Answer 40

3

Question 41

less than __ fingerbreadths thyromental distance for diff intubation risk
cm

Answer 41

3

6.5cm

Question 42

greater than __ inches neck risk factor for diff intubation

Answer 42

17

Question 43

Ludwig angina

Answer 43

Ludwig angina is an infection involving the floor of the mouth, resulting in severe upper airway swelling above the level of the vocal cords

Question 44

pacemaker and MRI

Answer 44

Cardiovascular Implantable Electronic Devices (CIEDs) are generally considered a contraindication to magnetic resonance imaging (MRI) scanning. However, newer devices are MRI conditional and full body MRI can be performed safely under a specific MR environment. Additional consideration should occur for pacemaker patients who are not pacemaker dependent and will be exposed to a magnet, as this could lead to R-on-T phenomenon.

Question 45

Regarding magnet effects of CIEDs

Answer 45

Regarding magnet effects of CIEDs, an ICD will have tachyarrhythmia therapy (e.g. defibrillation) turned off when exposed to a magnet. The pacemaker function of an ICD will not be affected. On the other hand, for pacemakers that are exposed to a magnet, they will default to VOO mode. For patients who are not pacemaker dependent, meaning their intrinsic heart rate is higher than the pacemaker backup rate, this can lead to R-on-T phenomenon and thus cardiac arrest.

Question 46

flail chest management

Answer 46

Flail chest is a serious traumatic thoracic injury in which three or more adjacent ribs are broken in more than one place, which can result in paradoxical chest wall motion. Mortality can be high due to respiratory complications and the presence of additional serious injuries due to the significant amount of force needed to result in flail chest. The mainstays of treatment include aggressive pulmonary hygiene and adequate analgesia, with thoracic epidural analgesia being effective. Surgical intervention is not routinely performed unless the patient has additional underlying injuries or does not respond to conservative management.

Question 47

Vascular rings

Answer 47

Vascular rings are due to the failure of embryonic structures to regress. They may cause symptoms such as wheezing, dysphagia, cyanosis, apnea, aspiration, and stridor. They may be complete rings that encircle the trachea or esophagus, or they may be incomplete but cause significant compression. The side of the aorta is defined by its position relative to the trachea. It is not uncommon for vascular rings to occur in the context of right-sided aortic arches, and compression may occur due to a left ligamentum arteriosum. Double aortic arches may also be seen, which compress the trachea that lies between each aortic arch.

Question 48

Mirror branching

Answer 48

Mirror branching consists of a right-sided aortic arch that gives rise to a left brachiocephalic artery, which then gives rise to a left subclavian artery and left carotid artery.

Question 49

Inability to extend the neck and create a sternomental distance ≥ ___cm is associated with difficult intubation.

Answer 49

Inability to extend the neck and create a sternomental distance ≥ 12.5 cm is associated with difficult intubation.

Question 50

suicide facts

Answer 50

Physicians are twice as likely to die by suicide than the general population and currently have the highest suicide rate of any profession in the United States. Nearly one physician dies by suicide every day (300-400 per year). Among physician specialties, anesthesiologists (especially males) are more than twice as likely to die by suicide than any other specialty.

Resident physicians are similarly impacted. Suicide is the second leading cause of death in all resident physicians (cancer is first). However, it is the number one cause of death in male residents.

Question 51

phase 1 vs phase 2 of heat loss

Answer 51

Following induction of general anesthesia, there is a large shift of body heat from the core to the peripheral tissues, a process known as redistribution. During the first hour of anesthesia, redistribution is responsible for a drop in core body temperature between 1-2 degrees Celsius and is labeled phase I of hypothermia. Following this phase, heat is lost to the environment itself, during phase II of hypothermia. In the operating room environment, this can include radiation (loss of heat to the colder surrounding air), conduction (loss of heat to the colder contacted surfaces such as the operating room table), convection (loss of heat due to circulating colder air), and evaporation (loss of heat due to evaporation for example from large open wounds).

Question 52

Severe abrupt hypoxia under one-lung ventilation

Answer 52

Severe abrupt hypoxia under one-lung ventilation requires a return to two-lung ventilation, at least temporarily. After confirming double-lumen tube position, assuring 100% O2 is being delivered, and maintaining normal cardiac output, the modern answer for hypoxemia under one-lung ventilation is to apply PEEP to the dependent lung, at least in patients without significant COPD. CPAP, on the other hand, is relatively contraindicated in video-assisted thoracoscopic surgery and would warrant a discussion with the surgeon before employing.

Question 53

BP for controlled hypotension

Answer 53

Controlled hypotension is defined as a mean arterial pressure of 50 mmHg to 65 mmHg or 30% below baseline.

Question 54

maximum inspiratory pressure threshold

Answer 54

No single test can predict the success or failure of a wean from ventilatory support. A maximum inspiratory pressure of > -20 cmH2O (i.e. -20 to 0 cmH2O) is a fairly sensitive predictor of wean failure, but a value of < -20 cmH2O is not necessarily predictive of a successful wean. All bedside tests should be taken in aggregate with a patient’s overall clinical status in order to determine their adequacy for a ventilatory wean.

Question 55

RSBI
and how to calc
and threshold

Answer 55

The rapid shallow breathing index (RSBI) is another bedside measurement that may have both negative and positive predictive value in predicting failure or success at weaning. It is calculated when the patient is on no ventilatory support (0 cmH2O pressure support, 0 cmH2O PEEP) by dividing the patient’s unsupported respiratory rate by their tidal volumes in liters. This generates units of ‘breaths/min/L’. In general, conventional teaching is that an RSBI of < 105 breaths/min/L is reassuring, though the true number may be lower than this. Some studies have proposed an RSBI of 80 as a cutoff. However, regardless of the cutoff, this factor alone is, again, not independently predictive of a successful wean.

Question 56

PaO2 to FiO2
how to calc
threshold

Answer 56

PaO2 to FiO2, unlike the previous two measurements, is a measure of oxygenation capacity and not ventilatory capacity. It is calculated by dividing the measured PaO2 by the decimal value of the FiO2. Values in a normal human are greater than 400, and values of less than 200 are indicative of a diminished capacity for oxygen diffusion and may be predictive of a failure to wean.

Question 57

Airway leak pressure threshold

Answer 57

While this is a controversial topic, a leak pressure of less than 12-15 cmH2O is generally thought to be reassuring that a patent airway exists.

Question 58

what receptor subunit does acetylcholine bind

Answer 58

Acetylcholine binds to the alpha-1 subunit of the postjunctional nicotinic acetylcholine receptor at the neuromuscular junction.

Question 59

PCA opioid

Answer 59

Opioid PCAs provide superior pain control to traditional nurse administered “as needed” IV opioid dosing regimens, though they may also increase the patient’s total opioid exposure during the hospitalization. No data exist to show that PCA use decreases the cost of an admission, time to hospital discharge, or the incidence of opioid-induced side effects.

Question 60

what to do with home diuretics pre-op

Answer 60

stop them

Question 61

pre-op anemia

Answer 61

Preoperative anemia is common and can be optimized, in many scenarios, prior to surgery. The first step involves a diagnosis of the exact cause, and this requires further studies in addition to the hemoglobin level. Normal studies should prompt consideration for a colonoscopy. Most often, anemia is due to iron deficiency and treatment requires supplementation of iron, either oral or parenteral. Erythropoiesis-stimulating agents such as erythropoietin may be part of the treatment algorithm to improve red blood cell production. This must occur at least two weeks from surgery to allow the bone marrow to be stimulated.

Question 62

POCD risk factors

Answer 62

No anesthetic best practice currently exists to prevent POCD. Age greater than 65 years old has been independently shown to predict the development of POCD. No other risk factors for POCD have been definitively identified. No difference in POCD has been seen with a regional versus general anesthetic technique, nor is there any single anesthetic drug that has been identified as either causative or protective.

Question 63

what does trendelenburg do to cardiac index

Answer 63

increase

Question 64

Sepsis initial management

Answer 64

Broad-spectrum antibiotics should be initiated within the first hour. Sepsis-induced hypoperfusion should be treated with at least 30 mL/kg of intravenous crystalloid within the first three hours. For patients with septic shock, vasopressor therapy should be used in combination with volume resuscitation to target an initial MAP of 65 mm Hg.

Question 65

Cardiogenic shock presents with

Answer 65

Cardiogenic shock presents with a decreased CI and an increased CVP, PCWP, and SVR.

Question 66

Distributive shock presents with

Answer 66

The vasodilation associated with distributive shock results in a low SVR. The CI is increased in order to compensate for the low SVR, thus maintaining perfusion to the vital organs. CVP and PCWP will remain the same or decrease.

Question 67

Types of distributive shock

Answer 67

septic, anaphylactic, neurogenic, adrenal crisis

Question 68

hypovolemic shock presents with

Answer 68

The decreased preload will result in a decreased CI, PCWP, and CVP. SVR will be elevated in order to compensate for the low CI.

Question 69

obstructive shock presents with

Answer 69

Obstructive shock is due to an obstruction to cardiac output, most likely due to pericardial tamponade, pulmonary embolism, or a tension pneumothorax. Since cardiac output is obstructed, the patient will present with a low cardiac output. PCWP and CVP will be elevated due to pump failure. SVR will also be increased in order to maintain perfusion to the vital organs.

Question 70

Septic shock results in a complex pathophysiologic process involving

Answer 70

Septic shock results in a complex pathophysiologic process involving cytokine release, complement activation, endothelial activation, induction of TF expression, and depression of cell-mediated immunity. This process emphasizes the link between the inflammatory response and clotting cascade, both of which can result in organ hypoperfusion.

Question 71

does mallampati predict difficult mask ventilation

Answer 71

yes, class 3 or 4 ass’d with diff mask vent

Question 72

The most common cause for claims made in the ASA Closed Claims Project database for death or brain damage is _____

Answer 72

The most common cause for claims made in the ASA Closed Claims Project database for death or brain damage is non-respiratory events.

Question 73

_____ is the best perioperative test to predict acute kidney injury in the setting of suprarenal aortic cross-clamping for repair of a ruptured abdominal aortic aneurysm.

Answer 73

Creatinine clearance is the best perioperative test to predict acute kidney injury in the setting of suprarenal aortic cross-clamping for repair of a ruptured abdominal aortic aneurysm.

Question 74

CV physiology in aging

Answer 74

Resting systolic function is not altered by aging, but
exercise-induced increases in cardiac output, stroke volume, and heart rate are reduced.
increase in circulating catecholamines with a corresponding
desensitization of the β-receptor.
Diastolic dysfunction results in a reduction and delay in left ventricular relaxation and therefore reduced passive filling during early diastole.
increased reliance on atrial kick for adequate cardiac output.

Question 75

Risk factors for awareness under anesthesia include:

Answer 75

Risk factors for awareness under anesthesia include: substance abuse (opioids, benzodiazepines, cocaine), history of awareness, history of difficult intubation or anticipated difficult intubation, chronic pain patients using high doses of opioids, cesarean delivery, trauma and emergency surgery, use of neuromuscular blockade, total intravenous anesthesia, and limited hemodynamic reserve.

Question 76

MELD:

Child-Pugh:

Answer 76

MELD: “I Crush Beer Daily” - INR, Creatinine, Bilirubin, Dialysis
Child-Pugh: “Pour Another Beer At Eleven” - PT/INR, Ascites, Bilirubin, Albumin, Encephalopathy