Anesthesia 2nd year Flashcards Preview

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Flashcards in Anesthesia 2nd year Deck (157):
1

To determine the etiology of hypoxemia, calculate the?

A-a gradient to narrow thedifferential diagnosis

2

When other causes have been ruled out, persistent and refractory hypotension in trauma or other critically ill patients may be caused by (2)

hypocalcemia
hypomagnesemia

3

Speed of onset of volatile anesthetics is increased by (4)

Increasing the
1. Concentration
2. Fresh gas flow
3. Alveolar ventilation
4.Using non-lipid soluble agents

4

Termination of effect of intravenous anesthetics is by ________________ , not biotransformation and breakdown.

Redistribution

5

* Lipid solubility, pKa, and protein binding of the local anesthetics determine their _______, _________, and _____________, respectively

1. Potency
2. Onset
3. Duration

6

When compressed, some gases condense into a liquid such as (2) and some do not such as (2)

1. N2O and CO2
2. O2 and N2

7

Most commonly used anesthesia circuit?
What are its components (6)?

1. Semiclosed circuit using a circle system

1. inspiratory limb
2. expiratory limb
3. unidirectional valves
4. CO2 absorber
5. Gas reservoir bag
6. Pop-off valve on the expiratory limb

8

Every patient ventilated with an ascending bellows anesthesia ventilator receives approximately ___ cm H2O of positive end-expiratory pressure (PEEP) because of the weight of the bellows.

2.5 to 3 cm H2O

9

The first step in the care of the hypoxic patient fighting the ventilator is to?

Ventilate the patient manually with 100% oxygen

10

Risk factors for auto-PEEP include (4)

1. High minute ventilation
2. Small endotracheal tube
3. Chronic obstructive pulmonary disease
4. Asthma

11

Below a hemoglobin saturation of ____, a small decrease in saturation corresponds to a large drop in PaO2.

90%

12

Except for visualization with bronchoscopy, _____ is the best method of verifying
endotracheal tube location.

CO2 detection

13

If a patient’s ______ is excellent, even in the presence of ischemic heart disease, the chances are good that the patient will be able to tolerate the stresses of surgery.

Exercise capacity

14

The necessary criteria for acute lung injury/acute respiratory distress syndrome (ALI/ARDS) include: (5)

(1) Acute onset
(2) PaO2/FiO2 ratio of 300 for ALI
(3) PaO2/FiO2 ratio of 200 for ARDS
(4) Chest radiograph with diffuse infiltrates
(5) Pulmonary capillary wedge pressure of 18 mm Hg

15

Mechanical ventilation settings for patients with ARDS or ALI include tidal volume of at _____ of ideal body weight while limiting plateau pressures to ______ cm H2O. FiO2 should be adjusted to maintain
oxygen saturations between __________.

6 to 8 ml/kg
<30 cm H20
88% and 92%

16

Measures to acutely decrease intracranial pressure (ICP) include (4)

1. elevation of the head of the bed
2. hyperventilation (PaCO2 25 to 30 mm Hg)
3. diuresis (mannitol and/or furosemide)
4. minimized intravenous fluid

17

Malignant hyperthermia (MH) is an inherited disorder that presents in the perioperative period after exposure to inhalational agents and/or succinylcholine.
The disease may be fatal if the diagnosis is delayed and dantrolene is not administered. The sine qua non of
MH is an unexplained rise in __________, with a simultaneous increase in ___________, in the setting of an unexplained, ___________.

Rise in end-tidal carbon dioxide
Increase in minute ventilation
Unexplained tachycardia

18

In patients with ___________ spinal anesthesia should be used with caution and only in situations in which the benefits of spinal anesthesia over general anesthesia are clear.

Multiple sclerosis

19

The inability to touch the palmar aspects of the index fingers when palms touch (the ____sign) can indicate a difficult oral intubation in patients with diabetes.

Prayer sign

20

The initial goal of burn resuscitation is to correct ________.

Hypovolemia

21

Abrupt oxygen desaturation while transporting an intubated pediatric patient is probably the result of ___________?

Main stem intubation

22

Infants may be difficult to intubate because they have a more anterior larynx, relatively large tongues, and a floppy epiglottis.
The narrowest part of the larynx is below the vocal
cords at the _______

Cricoid cartilage

23

Best first step in treating a pulmonary hypertensive event?

Hyperventilation with 100% oxygen

24

If a child with tetralogy of Fallot has a hypercyanotic spell during induction of anesthesia, _____________, can reverse the right-to-left shunt
while pharmacologic treatments are being prepared.

Gentle external compression of the abdominal aorta

25

Read
In preeclampsia hypertension should be treated, but blood pressure should NOT be normalized.

Spinal anesthesia may be preferable to general anesthesia when the preeclamptic patient does not have an existing epidural catheter or there is insufficient time because of nonreassuring fetal heart rate tracing.

Read
If a patient is pacemaker dependent, the interference by electrocautery may be interpreted by the device as intrinsic cardiac activity, leading to profound inhibition of pacing and possible asystole. Devices should be programmed to the asynchronous mode before
surgery.

26

______ blood is the universal donor for packed red blood cells; for plasma it is ______.

O-negative blood
AB positive

27

Always reassess optimal positioning of any lung-isolation device after repositioning the patient. A malpositioned tube is suggested by (2)

1. acute increases in ventilatory pressures
2. decreases in oxygen saturation

28

Methods to improve oxygenation during one-lung ventilation include (5)

1. increasing FiO2
2. adding PEEP to the dependent lung
3. adding continuous positive airway pressure to the
nondependent lung
4. adjusting tidal volumes
5. clamping the blood supply to the nonventilated lung

29

If PaCO2 significantly increases after 30 minutes of pneumoperitoneum, search for another
cause of hypercapnia such as

1. capnothorax
2. subcutaneous PaCO2
3. CO2 embolism
4. endobronchial intubation

30

_____________________ should be considered the drug of choice for the induction of anesthesia for
electroconvulsive therapy (ECT).

Methohexital

31

What kind of pain is usually less responsive to opioids than pain originating from nociceptors?

Neuropathic pain

32

Indirect-acting sympthomimetics (e.g., ephedrine) depend on ___________release to be effective.

Norepinephrine

33

Preganglionic sympathetic neurons originate from the _________ of the thoracolumbar spinal cord. These myelinated fibers exit via the _______ and synapse with postganglionic fibers in ____________, ____________, or a ________. Preganglionic neurons may ascend or descend the sympathetic chain before synapsing. Preganglionic neurons stimulate nicotinic cholinergic postganglionic neurons by releasing ______. Postganglionic adrenergic neurons synapse
at targeted end-organs and release __________

Intermediolateral columns
Ventral root of the spinal nerve
Paravertebral sympathetic ganglia, unpaired
prevertebral ganglia, or a terminal ganglion.
Acetylcholine
Norepinephrine

34

What are the 3 postganglionic receptors of the sympathetic nervous system? (3)

What is the preganglionic receptor of the sympathetic nervous system? (1)

a1, a2, B2

a2

35

Dopamine receptors are post or preganglionic?

Postganglionic

36

Preganglionic parasympathetic neurons originate from cranial nerves (4) and sacral segments ____.

III, VII, IX, and X (1973)
2-4

37

Are hydroxy-substituted phenylethylamines and stimulate adrenergic nerve endings.

Catecholamines

38

3 naturally occurring catecholamines

Norepinephrine, epinephrine, and dopamine

39

2 synthetic catecholamines

Dobutamine and isoproterenol

40

Synthesis of dopamine, norepinephrine, and epinephrine:

The amino acid _______ is actively transported into the adrenergic presynaptic nerve terminal cytoplasm, where it is converted to _____by two enzymatic reactions: (2)

Dopamine is transported into storage vesicles, where it is hydroxylated by ___________ to norepinephrine.

Epinephrine is synthesized in the ________ from norepinephrine through methylation by _______.

Tyrosine
Dopamine

1. Hydroxylation of tyrosine by tyrosine hydroxylase to dopamine
2. Decarboxylation of dopamine by aromatic L-amino acid decarboxylase.

Dopamine b-hydroxylase

Adrenal medulla
Phenylethanolamine N-methyltransferase

41

How is norepinephrine metabolized?
Norepinephrine is removed from the synaptic junction by ______ into the presynaptic nerve terminal and __________.

Reuptake
Metabolic breakdown

42

The enzyme ____________ metabolizes norepinephrine within the neuronal cytoplasm.

Both ______ and _____ metabolize the neurotransmitter at extraneuronal sites.

The important metabolites are (3)

Monoamine oxidase (MAO)

MAO and catecholamine O–methyltransferase (COMT)

1. 3-methoxy-4-hydroxymandelic acid
2. metanephrine
3. Normetanephrine.

43

The cholinergic neurotransmitter acetylcholine (ACh) is synthesized within presynaptic neuronal
_______by esterification of _____ and ____by the enzyme _______; it is stored in synaptic vesicles until release.

After release, ACh is principally metabolized by acetylcholinesterase, a membrane-bound enzyme located in the synaptic junction. Acetylcholinesterase is also located in other nonneuronal tissues such as _____.

Mitochondria
Acetyl coenzyme A
Choline
Choline acetyltransferase
Erythrocytes

44

Phenylephrine stimulates primarily ____ receptors, resulting in increased systemic vascular resistance and blood pressure.

A1

45

Ephedrine produces norepinephrine release, stimulating mostly ___ and ___ receptors; the effects resemble those of epinephrine although they are less intense.

A1 and B1

46

What beta blocker has an a-blocking property?

Labetalol

47

Closing capacity increases with age and is equal to FRC in the supine individual at approximately ___ years and in the upright individual at approximately ___ years.

44
66

48

What represents the amount of base (or acid) needed to titrate a serum pH back to normal at 37 C while the PaCO2 is held constant at 40 mm Hg.

BD (or base excess)

49

Compartment model (%):
Solids?
Fluids?
ICF?
ECF?
ISF (interstitial)?
BV (blood vol)?

Solids 43%
Fluids: 57%

ICF: 35%
ISF: 15%
BV: 7%

50

What hormone body water and tonicity regulated?
Half life?

AHD
20 mins

51

Hypothalamic osmoreceptors have an osmotic threshold of about ____ mOsm/kg. Above this level ADH release is stimulated.

289

52

Hypothalamic thirst center neurons regulate conscious desire for water and are activated by an increase in plasma sodium of ___ mEq/L, an increase in plasma osmolality of ___ mOsm/L, and loss of potassium from
thirst center neurons and angiotensin II.

2
4

53

ADH, or vasopressin, is synthesized in the _____ and ______ nuclei of the hypothalamus.

supraoptic
paraventricular

54

Where is angiotensinogen produced?

liver

55

What is the normal range for serum osmolality?

285 and 305 mOsm/L

56

The most common cause of postoperative hyponatremia is (2)?

SIADH
Water retention

57

Generally elective surgery should be delayed if serum sodium levels exceed mEq/L?

150

58

Hyperkalemia >__ mEq/L should be corrected before elective procedures. Usually ____ is the treatment.

6
Dialysis

59

Changes in stored blood that reduce post-transfusion viability are known as?

Storage lesions

60

Mild hypothermia (34 to 36 C) increases blood loss by ___ % and increases the relative risk for transfusion by ____ %.

16%
22%

61

Erythropoietin stimulates erythrocyte production in ___ to ___ days

5 to 7

62

When a clot is formed, plasminogen is incorporated and then converted to plasmin by tissue plasminogen activator (tPA) and fragments of factor ____.

XII

63

It is a potent vasodilator that inhibits platelet activation and helps confine primary hemostasis to the injured area.

Prostacyclin (PGI2)

64

Antithrombin III complexes with and deactivates
circulating coagulation factors (except factor ____).

VIIa

65

Protein C inactivates factors (2)

Va and VIIIa

66

In von Willebrand’s disease there is a decrease of both factor ___ antigen and factor VIII:vWF.

VIII & VIII:vWF

67

Coagulation is initiated primarily by contact of factor ___ with extravascular tissue.

VII

68

The most common intraoperative bleeding diathesis is ?

Dilutional thrombocytopenia

69

_____ is a dynamic test of clotting and can be as useful as all other clotting tests combined.

Thromboelastography

70

The extrinsic pathway is affected first by vitamin K
deficiency because the factor with the shortest half-life is factor ____, found only in the extrinsic pathway.

VII

71

What is a polyanionic mucopolysaccharide that accelerates the interaction between antithrombin III and the activated forms of factors II, X, XI, XII, and XIII, effectively neutralizing each?

Heparin

72

What is the phospholipid surface in the
1. Intrinsic pathway?
2. Extrinsic pathway?

1. Platelet phospholipid
2. Tissue thromboplastin

73

What does the partial thromboplastin time measure?

Intrinsic and common pathways except factor XIII

74

What does the prothrombin time measure?

Extrinsic and common pathways

75

Cryoprecipitate contents (4)

1. VIII
2. XIII
3. vWF
4. fibrinogen

76

What nerve blocks are useful when awake intubation is planned?

Glossopharyngeal nerve
Superior laryngeal nerv

77

Is most accurate for determining FRC in patients with obstructive airway disease.

Plethysmography

78

What law states that the volume of gas in a closed space varies inversely with the pressure to which it is subjected.

Boyle’s law

79

Measures the rate of uptake of the nonphysiologic gas carbon monoxide (CO).

Diffusing capacity for the single-breath diffusion capacity (DLCO)

80

Upper abdominal procedures result in a decrease in FRC within _________; FRC gradually returns to normal by _______.

10 to 16 hours
7 to 10 days

81

The potency of anesthetic gases is compared using?

Minimal alveolar concentration (MAC)

82

What is the term for the concentration required to block autonomic reflexes to nociceptive stimuli?
What is its value?

MAC-BAR
1.7-2

83

What is the term for the concentration required to block appropriate voluntary reflexes and measure perceptive awareness?
What is its value?

MAC-awake
0.3 to 0.5 MAC

84

The highest MACs are found in what age group of patients?

Infants at 6 to 12 months of age

85

For every Celsius degree drop in body temperature, MAC decreases approximately how many percentage? (range)

2-5%

86

Describes the distribution of a given agent at equilibrium between two substances at the same temperature, pressure, and volume

Partition coefficient

87

Ultimately is the principal factor in determining onset of action of volatile anesthetics?

Alveolar concentration

88

What theory observed that observed that an increasing
oil-to-gas partition coefficient correlated with anesthetic potency.

Meyer-Overton lipid solubility theory

89

______ and _______ found that an amphophilic solvent (octanol) correlated better with potency than lipophilicity and concluded that the anesthetic site must contain both polar and nonpolar sites.

Franks and Lieb

90

When nitrous oxide is discontinued abruptly, its rapid diffusion from the blood to the alveolus decreases the oxygen tension in the lung, leading to a brief period of
decreased oxygen concentration known as?

Diffusion hypoxia

91

Read
Speed of onset of volatile anesthetics is increased by increasing the delivered concentration of anesthetic, increasing the fresh gas flow, increasing alveolar ventilation, and using nonlipid-soluble anesthetics.

Read
MAC is decreased by old age or prematurity, hyponatremia, hypothermia, opioids, barbiturates, a2-blockers, calcium channel blockers, acute alcohol intoxication, and pregnancy.

MAC is increased by hyperthermia, chronic alcoholism, and CNS stimulants (e.g., cocaine).

92

Degradation of _____ and _______by desiccated absorbents may lead to CO production and poisoning.

* Desflurane
Sevoflurane

93

Toxicity to this volatile anesthetic toxicity is a rare but real threat in abusers, patients with vitamin B12 deficiencies, and possibly unborn fetuses because of impaired methionine synthesis and results in neurologic sequelae.

Nitrous oxide

94

Which anesthetic agent is most associated with cardiac dysrhythmias?

Halothane

95

Fluoride-associated renal dysfunction has been linked to the use of what volatile anesthetic?

Methoxyflurane

96

What volatile anesthetic administered to pregnant rats in concentrations greater than 50% for over 24 hours has been shown to increase skeletal abnormalities?

Nitrous oxide

97

Is a mu-, k-, and s-receptor antagonist that will reverse the effects of agonist drugs.

Naloxone
The peak effect occurs within 1 to 2 minutes
Duration 30 to 60 minutes
Incremental doses of 0.5 to 1 mcg/kg should be used initially

98

As a k-receptor agonist, this drug may be used to suppress postoperative shivering. Notably is contraindicated for use in patients taking monoamine oxidase inhibitors because the combination may lead to serotonin toxicity, hyperthermia, and death.

Meperidine

99

Neuraxial opioids bind to receptors in ________ of the spinal cord.

Rexed lamina II (substantia gelatinosa) in the dorsal horn

Activation of m-receptors appears to reduce visceral and somatic pain via g-aminobutyric acid–mediated descending pain pathways. Activation of k-receptors appears to reduce visceral pain via inhibition of
substance P.

100

IV anesthetic with an imidazole derivative the induction properties of which result from Gammaamino-butyric acid (GABA) receptor modulation. It is noted for its hemodynamic stability.

Etomidate

101

What happens when you inject sodium thiopental intra-arterially?

Intra-arterial STP is likely to cause significant discomfort, vasospasm, and possibly thrombus formation. Leave the catheter in place and inject dilute papaverine, procaine, or lidocaine through the catheter to inhibit smooth muscle vasospasm. If this does not re-establish perfusion, consider brachial plexus block or a-blockade. Also administer heparin to prevent
thrombus formation.

102

The GABA receptor complex is composed of two a-subunits and two b-subunits. Where does the benzodiazepine bind to?

a-subunit

103

The GABA receptor complex is composed of two a-subunits and two b-subunits. Where does the benzodiazepine bind to?

a-subunit

104

Prolonged exposure of the receptors to SCH results in persistent open receptor channel and ionic fluxes through the ion pore, known as __________. Normal depolarization/repolarization is not possible until SCH is metabolized.

phase II or desensitization blockade

105

How do mature and immature acetylcholine receptors differ?

Mature contains e-receptor
Immature contains y-receptor

106

Where is pseudocholinesterase produced?

Pseudocholinesterase is produced in the liver and circulates in the plasma.

107

Example of aminosteroid relaxants?

"curonium"
pancuronium, vecuronium, pipecuronium, and rocuronium

108

Relaxant with biliary excretion (2)

Vecuronium and rocuronium

109

Relaxant with Hoffman elimination (1)

Atracurium

110

Relaxant metabolized by pseudocholinesterase.

Mivacurium

111

Relaxant with tachycardic side effect

Pancuronium

112

Discuss important characteristics of a nerve stimulator. (3)

1. Single twitch at 0,1 Hz
2. TOF of 2 Hz
3. Tetanic stimulation at 50 Hz
Black electrode (-) depolarize
Red electrode (+) hyperpolarize

113

Which nerves can be chosen for stimulation?

Ulnar nerve

114

Discuss the appropriate time to reverse neuromuscular blockade based on nerve stimulation.

Neuromuscular blockade can be reversed when there is at least one twitch with TOF stimulation

115

How are local anesthetics metabolized?
1. Esters
2. Amides

1. hydrolysis by pseudocholinesterases (plasma)
2. enzymatic biotransformation (liver)

116

What determines local anesthetic potency?

The higher the solubility, the greater the potency.

117

Why are epinephrine and phenylephrine often added to local anesthetics? What cautions are advisable regarding the use of these drugs?

These drugs cause local tissue vasoconstriction, limiting uptake of the local anesthetic into the vasculature and thus prolonging its effects and reducing its toxic potential.

118

______ acts primarily on the arterial vasculature whereas _____ has its most prominent effect on venous capacitance vessels

Sodium nitroprusside
Nitroglycerin

119

Is a new third-generation CCB that is considered an ultrashort-acting arteriolar vasodilator.

Clevidipine

120

Is a pyridazinone-dinitrite and a member of a new class of pharmacologic agents, the “calcium sensitizers.” This drug acts to increase contractility without elevating intramyocardial calcium levels. This is achieved by stabilizing troponin C in an active form, thus providing inotropic support in similar fashion to other agents but with much lower intracellular calcium requirements.

Levosimendan

121

What is the only acetylcholinesterase inhibitor that crosses the blood-brain barrier and can be used to treat the central anticholinergic syndrome?

Physostigmine

122

Bronchociliary function improves within ___ to ____ of smoking cessation, and sputum volume decreases to normal levels within about _______.

1 to 2 days
2 weeks

123

A patient may be instructed to stop warfarin __ days before surgery

4

124

However, at room temperature N2O condenses into a
liquid at ___ psi.

747

125

N2O cylinder tank contains about ___ liters.

1600 L

126

Wall gas pressures are typically about ____ psig

55

127

Tank pressure is generally regulated by the first-stage regulator to ___ psig.

45

128

N2O condenses into a liquid at _____ psi

747

129

E-cylinders of N2O contain the equivalent of about ___ L of gas when full, whereas E-cylinders of O2 and air hold only about 600 L.

1600

130

What leads are most helpful when looking for a bundle-branch block?

V1, V6, 1 and 2 (wide QRS > 120 sec

131

A condition which there is an ST-segment depression that occurs in patients with an ST-elevation MI.

Reciprocal change

Not all patients with ST-elevation MI have reciprocal change, but when it is seen, it generally confirms the diagnosis of acute MI

132

Most pulse oximeters use wavelengths of ____ nm (red) and ___ nm (infrared).

660
940

133

Refers to the variation in ICP in accordance with intracranial volume.

Intracranial elastance or compliance

134

CBF increasing/decreasing ___ to ___ ml/100g/min with a 1-mm Hg change in PaCO2.

1 to 2

135

2 preferred intravenous induction agents because they reduce both CBF and CMRO2 in increased ICP.

2 drugs to be avoided

Thiopental and propofol

Ketamine and etomidate should be avoided because ketamine increases CBF and ICP and the propylene glycol formulation of etomidate may induce neurologic deficits in at-risk tissue.

136

Range of CPP to maintain in traumatic brain injury?
MAP?

60-80 mmHg
>90%

137

Myopathy characterized by an uncontrolled increase in skeletal muscle metabolism after exposure to a triggering agent.

Malignant hyperthermia

138

The earliest symptom is of MH is?

Unexplained tachycardia

139

Dantrolene management in MH

Administer dantrolene, 2 mg/kg; repeat every 5 minutes to a total dosage of 10 mg/kg if needed.
Dantrolene sodium inhibits calcium release via RyR1 antagonism.

The solution is prepared by mixing 20 mg of dantrolene with 3 g of mannitol in 60 ml of sterile water.

140

The gold standard for diagnosis of MH?

Caffeine-halothane contracture test (CHCT)

141

Is defined as jaw muscle tightness with limb muscle flaccidity following a dose of succinylcholine.

Masseter muscle rigidity (MMR)

142

A condition which presents with present with
generalized fatigue and weakness that worsens with repetitive muscular use and improves with rest.

Myasthenia gravis

143

This is an immune-mediated disease of the neuromuscular junction that frequently arises in the setting of malignancy, often small-cell carcinoma of the lung. As opposed to MG, weakness improves with motor activity, although frequently the improvement is transient.

Lambert-Eaton myasthenic syndrome

144

Acute idiopathic polyneuritis or __________ is currently the most frequent cause of generalized paralysis and usually presents with sudden onset of weakness or paralysis, typically in the legs, that spreads to the trunk, arms, and bulbar muscles over several days.

Guillain-Barre´ syndrome

145

Drugs avoided in Guillain-Barre´ syndrome (2)

Succinylcholine and pancuronium

146

The leading cause of death in chronic users of alcohol is?

Cardiac dysfunction

147

Which nutritional deficiencies are seen in chronic alcohol users?

thiamine & folic acid

148

Best inhalational agent for maintaining hepatic blood flow.

Isoflurane

149

The American Diabetes Association (ADA) 2008 Clinical Practice Recommendations recommend an A1C goal for nonpregnant adults in general of?

<7% (6% or lower is the nondiabetic A1C range)

150

Approximately ___ mcg of T3 and __ mcg of T4 are produced daily.

8
90

151

The most common cause of hypothyroidism is _____ of thyroid tissue in the treatment of hyperthyroidism, most commonly Graves’ disease.

Surgical or radioiodine ablation

152

This in large doses not only blocks hormone
production, but it also decreases the VASCULARITY and SIZE of the thyroid gland,

Iodine

153

Normally approximately __ to __ mg of cortisol per day is produced.

20 to 30

154

Also referred to as acute adrenocortical insufficiency, an ________ is caused by a relative lack of cortisol or other glucocorticoid in relation to a physiologic stress such as
surgery. It is a shock state characterized by refractory hypotension, hypovolemia, and
electrolyte disturbances.

Addisonian crisis

155

Neurogenic shock is noted in trauma affecting what vertebral level

T6

156

2 MC complication of burn injury

1. Pneumonia 2. Respiratory failure

157

Rule of nines

Head and neck 9% UPPER EXT 9% each chest ant & post 9% each ABDOMEN 9% Lower back 9% LOWER EXT 18% Perineum 1%