AP 2 Test 3 Flashcards
1
Q
Glomerular filtration pressure is about __% of mean arterial pressure
A
60
2
Q
What is the major function of the proximal tubule?
A
Sodium reabsorption
3
Q
What part of the nephron is the site of aldosterone mediated Na+ reabsorption?
A
Distal tubule
4
Q
How does aldosterone affect Na/K ATPase in the collecting duct?
A
It enhances the activity which increases the number of open K+ and Na+ channels to favor reabsorption into the plasma
5
Q
What part of the nephron is the principle site of antidiuretic hormone?
A
Medullary portion of collecting tubule
6
Q
What physiologic changes causes the kidneys to release renin?
A
1) Sympathetic stimulation
2) Hypotension
3) Decreased sodium delivery
7
Q
Renal failure symptoms aren’t detected until less than __% of functioning nephrons remain
A
40
8
Q
What is creatinine?
A
A byproduct of muscle metabolism that is fairly constant and a good indicator of renal health
9
Q
What are normal creatinine levels in men?
A
0.8-1.3
10
Q
What are normal creatinine levels in women?
A
0.6-1
11
Q
How do you calculate creatinine clearance?
A
[(140-age) x lean body weight] / (72 x plasma creatinine)
12
Q
What is normal creatinine clearance values?
A
100-200
13
Q
Creatinine clearance below __ indicats renal failure
A
25
14
Q
Creatinine clearance below __ indicates end stage renal failure
A
10
15
Q
How are creatinine levels related to glomerular filtration rate?
A
Inversely proportional
16
Q
What physiologic state can affect BUN levels?
A
Hypovolemia
17
Q
What is the normal range for BUN?
A
10-20
18
Q
BUN:Creatinine ratios greater than ____ are seen in volume depletion and edematous disorders
A
15:1
19
Q
Urine pH above 7 in the presence of systemic acidosis indicates what?
A
Renal tubular acidosis
20
Q
Protein excretion greater than ___ is significant when screening for proteinurea
A
150
21
Q
What causes acute glomerular nephritis?
A
An antibody-antigen reaction
22
Q
Acute glomerular nephritis usually occurs after infection from which bacteria?
A
Beta streptococci
23
Q
What is Polycystic Kidney Disease?
A
An autosomal genetic disease that causes cysts on the kidneys
24
Q
What conditions are associated with Polycystic Kidney Disease?
A
Aortic aneurysms, brain aneurysms, HTN, chronic renal disease
25
How does renal artery stenosis lead to hypertension?
The afferent arterioles read a decreased blood pressure due to the stenotic renal artery and release renin which increases BP
26
What causes diabetic renal neuropathy?
Glucose increases past the kidneys capacity to reabsorb. This causes more water to be excreted and the sodium in the urine becomes diluted which triggers macula densa cells to secrete renin and decrease blood flow to the kidney.
27
What is hepatorenal syndrome?
Rapid deterioration in renal function secondary to liver failure
28
Which surgeries have the highest incidence of patients with acute kidney injury?
Cardiac
29
What is azotemia?
The rapid deterioration in renal function that results in retention of nitrogenous waste products in the blood
30
What causes pre-renal azotemia?
Decrease in renal perfusion due to hypotension or hypovolemia
31
How can you treat pre and post renal failure to avoid renal azotemia?
Preoperative volume loading
32
How does most perioperative AKI occur?
Renal ischemia due to hypotension or hypovolemia
33
How does volume loading avoid AKI?
It suppresses renin and increases ANP release
34
Optimizing what 3 physiologic parameters reduces AKI and mortality by over 50%?
1) MAP
2) Preload
3) Cardiac output
35
MAP below __ mmHg is associated with AKI
60
36
There is a graded increase in AKI for pre-op Hbg less than __
12
37
Oliguria is defined as having a urine output less than ___ cc/day
400
38
What are the treatments available for improving renal perfusion?
- Treat hypovolemia
- Treat/raise MAP
- Pressors
- Dopaminergic dilators such as dopamine or fenoldapam
39
What fluid doubles the incidence of AKI when compared to LR?
Normal saline
40
How do most diuretics increase urinary output?
By decreasing reabsorption of Na/K and water
41
How do osmotic diuretics increase urine output?
Their presence in the proximal tubule limits passive water reabsorption
42
What is the dose for Mannitol (osmotic diuretic)?
0.25-1g/kg
43
How should you administer Mannitol? Why?
Give over 20 minutes b/c if its given too quickly it can increase blood osmolarity and draw fluid into the bloodstream, causing increase in intravascular volume and possibly initiating cardiac failure in susceptible patients
44
How do carbonic anhydrase inhibitors increase urine output?
They interfere with Na+ reabsorption and H+ secretion in the proximal tubules
45
What is the dose of Diamox (CA inhibitor) to increase urine output?
250-500mg
46
How do loop diuretics work to increase urine output?
Inhibit Na+ and K+ reabsorption in the thick ascending loop of henle
47
What is the dose of Lasix?
10-100mg
48
What is the dose of Bumetetanide/Bumex?
0.5-1mg
49
What can be caused by chronic usage of loop diuretics?
Hearing loss
50
How do diuretics work at the distal tubule?
Inhibit sodium reabsorption by competing for the Cl- site on the Na/Cl carrier protein
51
What is the dose of Diuril (distal tubule diuretic)?
500mg
52
How do aldosterone antagonists work?
Cause the excretion of Na+ and H2O follows, and keeps K+
53
What aldosterone antagonist is used to prevent oliguria?
Spironolactone
54
How do non-competitive K+ sparing diuretics work?
Inhibit Na+ reabsorption and K+ secretion by decreasing number of open Na+ channels
55
What is an example of a K+ sparing diuretic used to prevent oliguria?
Triamterene
56
What are the metabolic manifestations of renal failure?
- High K+, Mg2+, uric acid
| - Low phosphate, Ca2+, albumin
57
What are the hematological manifestations of renal failure?
- Anemia
| - Decrease white cell and platelet function
58
Why is there an increased cardiac output in chronic renal failure patients?
It increases to offset decrease in O2 carrying capacity and the increase in preload
59
What are the results of increased angiotensin levels in chronic renal failure patients?
Arterial hypertension --> increased SVR --> left ventricular hypertrophy --> congestive heart failure
60
What are the pulmonary manifestations of renal failure?
- Increased minute ventilation due to metabolic acidosis
| - Pulmonary edema
61
What are the endocrine manifestations of renal failure?
Abnormal glucose tolerance secondary to peripheral resistance to insulin
62
What are the GI manifestations of renal failure?
- Anorexia
- N/V
- Delayed gastric emptying
- Hepatitis
63
What is the mainstay of treatment for chronic renal failure?
Dialysis or transplant
64
What is dialysis?
The process of removing solute such as toxins, electrolytes, and water from the body
65
What drugs are considered nephrotoxins and should be avoided when renal function is compromised?
- Antibiotics
- Anesthetic agents (methoxyflurane and enflurane)
- NSAIDs
- Contrast media
- Immunosuppressive agents
66
What is myoglobinuria?
Severe muscle breakdown that causes myoglobin to be filtered by the kidneys which clogs the system
67
What causes myoglobinuria?
- Severe muscle wasting
- Malignant hyperthermia
- Transfusion rxn
- Anaphylactic rxn
68
What treatments are available for myoglobinuria?
- Keep urine flowing
- Fluids
- Diuretics (mannitol)
- Alkanalize urine with sodium bicarb
69
What is the concern if renal patients were just dialyzed before surgery?
Anticoagulants might still be on board
70
What lab values should be assessed preoperatively for patients with compromised renal function?
- Recent electrolytes especially K+
- Recent CBC
- Blood glucose level
71
We should not use succinylcholine in renal patients unless the pre-op K+ level is less than __
5.0
72
What are the EKG manifestations of hyperkalemia?
- Peaked T waves
- Very flat ST segment
- Long QRS
73
What are the quick treatments for hyperkalemia?
- Calcium chloride
- Sodium bicarb
- Glucose and insulin
- Hyperventilation
74
When managing renal patients, we should exercise judicious use of what drug classes?
- Narcotics
- Benzos
- Relaxants
75
How should fluids be managed for renal patients?
- Very judicious use
- Use phenylephrine for low BP instead of fluid loading
- Fluids with no potassium such as normal saline
- Glucose free fluids
76
Rapid respirations might not always mean pain in renal patients - what else could be causing it?
Metabolic acidosis compensation or pulmonary edema
77
What basic parameters should be assessed postoperatively in patients with renal failure?
- Oxygen saturation
- Electrolytes and hb/hct
- Fluid balance
- Blood sugar
78
On average, assume __ ml/min of irrigation fluid is absorbed during TURP and TURB procedures
20
79
What are the deleterious affects of dilution with irrigation during TURP/TURB procedures?
CV collapse, heart failure, hypotension, pulmonary edema, hyponatremia, cerebral edema, anemia, hyperglycemia, hyperammonemia
80
Clinical symptoms of deleterious effects of irrigant absorption from TURB/TURPs is classified as....
TURP syndrome
81
What are the early signs of TURP syndrome in awake patients?
Restlessness, headache, N/V, confusion/slurred speech, tachypnea
82
What are the later signs of TURP syndrome?
Seizure, tachycardia and HTN followed by bradycardia and hypotension followed by CV collapse
83
What lab value confirms TURP syndrome?
STAT serum Na+ less than 120
84
What are the treatments available for TURP syndrome?
- Loop diuretics
- Restrict fluids
- Hypertonic saline for the low Na+
- Benzos for seizures
85
What are other issues (aside from TURP syndrome) associated with TURP/TURB procedures?
- Hypothermia
- Bladder perforation
- Coagulopathy
- Septicemia
86
What is a good choice of anesthesia for TURP/TURB procedures?
Spinal/epidural for good pain relief and allows you to monitor mentation
87
What can ECG changes can be seen during lithotripsy procedures due to shock waves?
Dysrhythmias on R waves
88
What type of anesthesia is usually necessary for percutaneous nephrolithotomy tube placement?
General
89
What are the anesthetic considerations for prostatectomies and cystectomies?
- Significant blood loss
- A line
- Good IV access
- May need indigo carmen or methylene blue
90
What is the more popular anesthetic method for prostatectomies/cystectomies?
General anesthesia
91
What are anesthetic considerations for nephrectomies?
- Potential for extensive blood loss
| - Reflex renal vasoconstriction can occur at non-effected kidney and can cause post op renal failure, consider mannitol
92
What drugs should be considered prior to clamping the iliac vessels during renal transplants?
- Heparin
- Calcium channel blocker into graft to prevent reperfusion injury
- Mannitol
93
How does the autonomic nervous system correct hypertensive states?
- Decrease HR
- Vasodilation
- Increase vagal tone
- Decrease sympathetic tone
94
How does the autonomic nervous system correct hypotensive states?
- Increase HR
- Vasoconstriction
- Increase contractility
- Decrease vagal tone
- Increase sympathetic tone
95
What activates the RAA system?
Hypotension and decreased sympathetic tone
96
What is the ultimate result of RAA system activation?
- Increased vasopressin levels
| - Increased angiotensin II
97
What occurs during the initiation of the RAA system?
Macula densa cells sense low fluid or low sodium concentration and prompt the juxtaglomerular cells to secrete renin into the blood
98
What happens after renin from the kidney and angiotensinogen from the liver is released into the blood?
Renin converts angiotensinogen to angiotensin I
99
What happens once angiotensinogen is converted to angiotensin I?
ACE from the pulmonary blood converts angiotensin I to angiotensin II
100
What happens once angiotensin I is converted to angiotensin II?
Angiotensin II stimulates vasoconstriction and aldosterone secretion from the adrenal cortex
101
How does aldosterone affect blood volume?
Aldosterone stimulates Na+ uptake and water reabsorption, thus increasing blood volume and arterial blood pressure
102
What are common causes of secondary hypertension?
- Renal disease
- Endocrine disorders
- Renal artery stenosis
- Medications
- Neurologic disorders
103
What is the neurologic manifestation of unmanaged hypertension?
Ischemic stroke
104
What are the cardiovascular manifestations of unmanaged hypertension?
Aneurysms, LVH, angina, heart failure, arrhythmias
105
What are the renal manifestations of unmanaged hypertension?
- Sodium retention
- Hyperuricemia
- Diminished GFR
106
What is a hypertensive emergency?
Severe HTN with evidence of acute end organ damage i.e. stroke, encephalopathy, LV failure, MI, renal failure
107
What is hypertensive urgency?
High blood pressure without signs of acute end organ damage
108
What is the likely etiology of a hypertensive emergency?
A very acute increase in SVR leading to acute increase in BP
109
Blood pressure should be lowered by about __% in the first few hours following an acute hypertensive emergency
20
110
What factors do the JNC-8 guidelines for hypertension depend on?
The patient's age and co-morbid conditions
111
Hypertensive patients with chronic kidney disease can be managed with what drug classes?
- ACE inhibitors
| - ARBs
112
African American hypertensive patients without chronic kidney disease can be treated with what drug classes?
- Thiazide diuretics
| - Calcium channel blockers
113
Non-african american hypertensive patients without chronic kidney disease can be treated with what drug classes?
- Thiazide diuretics
- Calcium channel blockers
- Ace inhibitors
- ARBs
114
What lifestyle modifications can be made to treat hypertension?
- Weight loss
- Reduce salt intake
- Alcohol/tobacco cessation
115
How do thiazide diuretics (hydrochlorothiazide) work to treat HTN?
Reduces sodium reabsorption in DCT which causes water loss and decreased BP
116
How do loop diuretics such as Furosemide and Torsemide work to treat HTN?
- Inhibits sodium and chloride reabsorption in loop of henle to cause water loss
- Increase prostaglandin levels
117
How do ACE inhibitors such as Lisinopril work to treat HTN?
Blocks the conversion of angiotensin I to angiotensin II to cause vasodilation, smooth muscle relaxation, natriuresis, and decreased vasopressin release
118
How do angiotensin receptor blockers such as Losartan and Valsaratan work to treat HTN?
Blocks the activation of the angiotensin II receptor which causes vasodilation, smooth muscle relaxation, natriuresis, and decreased vasopressin release
119
How do calcium channel blockers such as Amlodipine and Nicardipine work to treat BP?
Block calcium channels thus decreasing Ca2+ levels and causing vasodilation, negative inotropy, negative chronotropy, and reduced aldosterone production
120
You should avoid using calcium channel blockers in patients with what co-morbid condition?
Heart failure
121
When are calcium channel blockers commonly used to treat HTN?
For otherwise fairly normal functioning patients who don't respond to diuretics or ACE inhibitors
122
Where are B1 receptors primarily located?
Heart and kidneys
123
Where are B2 receptors primarily located?
Muscle
124
Where are B3 receptors primarily located?
Adipose tissues
125
How do beta blockers such as metoprolol and carvedilol work to treat HTN?
Negative chronotropy, negative inotropy, anti-arrhythmic effect, reduced aldosterone, smooth muscle relaxation
126
What is a true aneurysm?
Aneurysm encompassing all 3 layers of the aorta
127
What is a pseudo-aneurysm?
Aneurysm of just the bottom layer of the aorta
128
What are common etiologies of aortic aneurysms?
HTN, artherosclerosis, collagen vascular disease, bicuspid aortic valve, syphilis, hyperlipidemia, mycotic, inflammatory
129
What is an aortic dissection?
An intimal tear creating a false lumen for blood to enter
130
What is a Type A aortic dissection?
Dissection involving either the ascending aorta or both ascending and descending
131
What is a Type B aortic dissection?
Dissection involving just descending aorta
132
What are common etiologies of aortic dissections?
HTN, collagen vascular disease, biscuspid valve, inflammatory, trauma, heart surgery complication
133
What is carotid artery stenosis?
Narrowing of the carotid arteries primarily due to atherosclerotic disease
134
Which carotids are primarily affected by carotid artery stenosis?
Internals
135
Carotid artery stenosis greater than __% indicates intervention
70
136
What are common risk factors for carotid artery stenosis?
HTN, hyperlipidemia, DM, PAD, tobacco
137
What is Raynaud's phenomenon? In what gender is it most common?
Vasoconstriction in extremities during periods of cold or stress. Most common in females.
138
What is a venous thromboembolism?
A deep vein thrombosis plus pulmonary embolism that primarily occurs in lower extremities
139
Total hepatic blood flow accounts for __% of cardiac output
25
140
Hepatic blood flow has ___ (high/low) flow, ____ (high/low) resistance
High flow, low resistance
141
Most patients with liver disease have ___ SVR (hi/lo), ____ cardiac output (hi/lo), and ___ arterial pressure (hi/lo).
low SVR, high cardiac output, low arterial pressure
142
Splanchnic volume has a major role in the body's response to what perioperative condition?
Hypovolemia
143
What nerves have neural control of liver blood flow?
Vagus and splanchic
144
Sympathetic stimulation _______ (increase/decreases) blood flow
Decreases
145
How does epinephrine affect liver blood flow?
Initial vasoconstriction via alpha receptors, then dilation via beta receptors
146
How does glucagon affect liver blood flow?
Long lasting arterial vasodilation
147
How does angiotensin II affect liver blood flow?
Profound vasoconstriction
148
How does vasopressin affect liver blood flow?
Marked splanchnic vasoconstriction
149
What components of anesthesia will decrease total hepatic blood flow?
- All anesthetics that decrease cardiac output
- Controlled ventilation
- Regional anesthesia
- Controlled hypotension with sodium nitroprusside
150
What type of surgery decreases hepatic blood flow up to 60%?
Upper abdominal surgeries
151
What key protein that maintains intravascular oncotic pressure is produced by the liver?
Albumin
152
What is the normal range of albumin levels?
3.5-6
153
All coagulation factors except which 3 are produced by the liver?
3, 4, and 8
154
A deficiency in which coagulation factors is a good indication of hepatic dysfunction?
Vitamin K dependent factors
155
Which clotting test is a good indicator of acute hepatic dysfunction?
PT
156
Removal of what toxic metabolite is impaired in both acute and chronic liver disease?
Ammonia
157
How are glucose levels affect in patients with impaired liver function?
Blood glucose can rise several fold
158
The majority of cholesterol synthesized by the liver is converted to what?
Bile salts
159
What is jaundice?
The yellow-green tint of body tissue due to bilirubin accumulation in extracellular fluids
160
Skin discoloration is usually visible when plasma bilirubin reaches __ times normal values
3
161
Why does bilirubin accumulation occur
- Increased breakdown of hemoglobin (indirect bilirubin)
| - Obstruction of bile duct (direct bilirubin)
162
Which form of bilirubin (conjugated or unconjugated) travels to the liver bound to albumin?
Unconjugated
163
What is the normal daily production of bilirubin?
300mg
164
How do narcotics affect common bile duct pressure?
Increase common bile duct pressure
165
Which narcotic increases common bile duct pressure the most? The least?
Fentanyl - the most
Morphine - middle
Demerol - the least
166
What drugs can attenuate the increase in common bile duct pressure caused by narcotics?
NTG, naloxone, atropin, glucagon
167
What occurs during phase I of drug biotransformation in the liver?
Oxidation w/ cytochrome P-450
168
What occurs during phase II of drug biotransformation in the liver?
Conjugation to water soluble for excretion
169
What factors affect drug metabolism in the liver?
- Blood flow, protein binding, intrinsic hepatic clearance
- Enzyme inducing compounds
- Self-induced drugs like ketamine and diazepam
170
What lab value is increased when bile ducts are blocked?
Alkaline phosphatase (ALP)
171
What lab test is the best for detecting hepatitis?
Alanine transaminase (ALT)
172
What lab test is a more sensitive marker for cholestatic damage?
Gamma-glutamyl transpeptidase (GGTP)
173
What enzyme level used to evaluate liver function is found in the liver, heart, and muscle?
Aspartate transaminase (AST)
174
What is the normal range for ALT levels?
5-40
175
What is the normal range for ALP levels?
13-39
176
What other tests are useful in assessing liver function?
- PT
- Total proteins
- Albumin
- Bilirubin
- Platelets
- Ammonia
177
How are serum albumin levels changed in patients with chronic liver disease such as cirrhosis?
Decreased
178
What is bilirubin?
The breakdown product of heme that is cleared from the blood by the liver
179
If direct bilirubin levels are normal, what are the etiologies of impaired liver function?
- Hemolysis
- Hepatitis
- Cirrhosis
180
If direct bilirubin levels are elevated, what is the issue? What should be suspected?
The liver is unable to secrete the bilirubin.
- Gallstones
- Cancer
181
What is the normal range for total bilirubin?
0.2-1.5
182
What is the normal range for direct/conjugated bilirubin?
0-0.3
183
What is the normal range for indirect/unconjugated bilirubin?
0.2-0.8
184
How is Hep A transmitted?
Fecal/oral route. Contaminated shell fish common
185
How does Hep A manifest?
Fever, jaundice, painfully enlarged liver
186
How is Hep B transmitted?
Blood transfusion, needle stick, sexual contact, across the placenta
187
How is Hep C transmitted?
Blood transfusion, needle stick, sexual contact, across the placenta
188
What is Hep D?
A co-infection acquired with hep B
189
How is Hep E transmitted?
Fecal/oral route due to contaminated water or poor hygiene
190
What are the top causes of acute liver failure?
- Viral hepatitis
- Drugs (acetaminophen, amiodarone, volatile anesthetics)
- Toxins
- Vascular events (ischemia)
191
Which hepatitis is an occupational risk for anesthesia care providers?
Hep B
192
What should be assessed during preop of a patient with hepatitis?
- Assess coagulation and treat with fresh frozen plasma if needed
- Glucose levels
193
What respiratory state should be avoided in patients with hepatitis?
Hypercarbia
194
Which drug classes have a prolonged affect in patients with hepatic dysfunction?
- Benzodiazepines
- Opioids
- Non-depolarizing muscle relaxants
195
Which opioids have prolonged effects in patients with hepatic dysfunction?
Morphine and alfentanil
196
Which muscle relaxants are a better choice for patients with hepatic dysfunction?
Cis and atracurium
197
What is cirrhosis?
Chronic disease of the liver characterized by distortion of the normal hepatic structure or scaring caused by cellular destruction
198
In what patients is cirrhosis most commonly seen?
- Patients with chronic viral hepatitis
| - Alcholics
199
What is cholelithiasis?
Formation of stones in the gallbladder caused by cholesterol crystal precipitation
200
What is cholecystitis?
Inflammation of the gallbladder caused by a gallstone in the cystic duct
201
What may be considered for induction with patients presenting for cholecystectomy?
RSI b/c they may present with a recent history of N/V
202
The use of which drug class may prevent flow of contrast dye during a cholangiogram?
Opioids
203
An elevation in unconjugated bilirubin can lead to what condition?
Kernicterus, characterized by seizures and brain damage
204
1 unit of PRBCs contains approximately how much bilirubin?
250mg
205
What IV access/monitoring should be considered for a hepatic resection?
- Large bore IV
- A line
- CVC
206
How should post op pain be managed for a hepatic resection?
Epidural
207
How should you manage the patients fluid status during the hepatic resection phase?
Keep them relatively hypovolemic to minimize EBL
208
How many units of T&C blood should be available during a hepatic resection?
6
209
What is the normal range for portal vein pressures?
6-12cmH2O
210
What is portal hypertension?
Sustained elevation of portal vein pressure causing an increased resistance to blood flow in the liver
211
What are collateral channels (varices)?
Channels caused by the overload of the portal circuit in an attempt to flow around the hepatic obstruction
212
What causes prehepatic portal htn?
Thrombosis
213
What causes intrahepatic portal htn?
Cirrhosis
214
What causes posthepatic portal htn?
Budd-chiari syndrome, right heart failure, pericarditis
215
What is the clinical manifestation of severe portal hypertension?
Bleeding of varicies, particularly from the esophagus
216
What is ascites?
Accumulation of serous fluid in the peritoneal cavity
217
Ascites can be a manifestation of what other conditions?
- Cirrhosis
- Portal htn
- Increased lymph, Na+ retention
- Impaired h2o excretion
- Hypoalbuminemia
- Decreased colloid osmotic pressure
218
Patients with ascites often present with what condition?
Arterial hypoxemia
219
What are the common PaO2 values in patients with ascites?
60-70mmHg
220
What is the most likely cause of the arterial hypoxemia seen in patients with ascites?
Right to left intrapulmonary shunting as a result of pulmonary htn, cigarettes, or COPD
221
What is the common medical management of ascites?
Aldosterone antagonists such as Spironolactone
222
How should fluids be managed during ascites fluid removal?
Administer IV fluids, usually colloids, to prevent hypotension. No more than 1 L drained per day.
223
What is the mainstay treatment of coagulopathy in patients with advanced hepatic failure?
FFP
224
What is the greatest fear of massive blood loss in the coagulopathic liver patients?
Fibrinolysis
225
How does hepatic encephalopathy (hepatic coma) manifest?
1. Mental confusion
2. Asterixis (flapping motion of hands)
3. Fetor hepaticus (fruity breath)
226
What are the anesthetic questions we should ask when presented with patients with advanced liver diseases?
```
1 - Stage of disease?
2 - Coagulopathy?
3 - Ascites?
4 - Renal compromise?
5 - Anesthetic drug issues with hepatic dysfunction?
6 - Anticipated blood loss?
```
227
The posterior pituitary secretes
A. TSH
B. Prolactin
C. Vasopressin
D. Growth hormone
C. Vasopressin
228
Which lobe of the pituitary gland produces hormones? Which hormones does it produce?
Anterior - ACTH, TSH, GH, FSH, LH
229
Which hormones are secreted by the posterior pituitary?
ADH and oxytocin
230
What are the principle hormones secreted by the thyroid?
Thyroxine (T4)
| Triiodothyronine (T3)
231
Which hormone secreted by the thyroid is more potent and less protein bound?
T3
232
Graves Disease is an autoimmune disease causing
A) Hypothyroidism
B) Hyperthyroidism
B. Hyperthyroidism
233
What is the pathophysiology of hyperthyroidism?
Hyperfunction of the thyroid gland with excessive secretion of T3 or T4
234
What are common causes of hyperthyroidism?
- Graves disease
- TSH secreting tumors
- Iatrogenic
- Thyroiditis
235
What are the symptoms of hyperthyroidism?
- Weight loss
- Fatigue
- Arrhythmias (a fib, SVTs, widened pulse P)
- Anxiety
- Exopthalmos
236
What are the common treatments for hyperthyroidism?
- Antithyroids
- Beta blockers
- Thyroidecetomy
237
What can be administered to patients with hyperthyroidism pre-op to decrease hormone release?
Steroids
238
What beta blocker is good intra-op for patients with hyperthyroidism?
Esmolol
239
What intra-op drugs should be avoided in patients with hyperthyroidism?
Drugs that cause SNS stimulation
- Ketamine
- Pancuronium
- Meperidine
- Atropine
240
What exaggerated response can occur during induction of patients with hyperthyroidism?
Exaggerated hypotensive response
241
What are the major post op concerns in patients with hyperthyroidism?
- Unilateral RLN injury (manifests as hoarseness)
- Bilateral RLN injury (stridor)
- Hypocalcemia 1-3 days after surgery (parathyroid removal)
242
How does hyperthyroidism change MAC requirements?
No change
243
What is a thyrotoxic crisis (thyroid storm)?
A life threatening exacerbation of hyperthyroidism that can be caused by trauma, infection, surgery, or illness
244
When do thyroid storms most often appear?
6-18 hours after operation
245
What are the symptoms of thyroid storm?
Abrupt anxiety, fever, tachycardia, CV instability
246
What is the treatment of a thyroid storm?
- Cooled crystalloids
- Esmolol infusion (50-300mcg/kg/min)
- Dexamethasone (2mg every 6 hours)
- Cortisol (100-200mg)
247
What other condition does a thyroid storm mimic?
Malignant hyperthermia
248
How can you decipher a thyroid storm from MH?
A thyroid storm doesn't cause muscle rigidity, elevated creatinine kinase, or acidosis
249
What drug can be given PO to inhibit conversion of T4 to T3 during a thyroid storm?
Propylthiouracil
250
What is the pathophysiology of primary hypothyroidism?
Dysfunction or destruction of thyroid tissue
251
What is the most common kind of hypothyroidism?
Hashimoto's thyroiditis
252
Patients with primary hypothyroidism have __ (hi/lo) TSH levels but ___ (hi/lo) T3 and T4 levels
High TSH, low T3/T4
253
What causes secondary hypothyroidism?
HPA axis dysfunction iatrogenically (thyroidectomy, antithyroid meds, radioactive iodine) or due to myxedema coma
254
What is myxedema coma? In which patients is it most common?
Loss of deep tendon reflexes with severe hypothermia, hypoventilation, hyponatremia, hypoxia, hypotension, delirium. Most common in elderly women with long history of hypothyroidism.
255
What are the symptoms of hypothyroidism?
- Lethargy
- Weight gain
- Cold intolerance
- Hypoactive reflexes
256
What is the treatment for hypothyroidism?
PO T4 (L-thyroxine aka Synthroid)
257
What are intra-op considerations for patients with hypothyroidism?
- Can have severe hypotension and increased sensitivity to agents
- Diminished cardiac output
- Blunted baroreceptor reflexes
- Impaired pulmonary function
258
What anesthetic approach is best in patients with hypothyroidism?
Regional
259
If you must do a general anesthetic in patients with hypothyroidism, what induction med should be used?
Ketamine
260
What are post-op concerns for patients with hypothyroidism?
- Resedation
- Hypothermia
- Hypoventilation
261
Parathyroid hormone increases the levels of serum:
A. albumin
B. calcium
C. potassum
D. sodium
B. calcium
262
What serum electrolyte is decreased by parathyroid hormone?
Phosphate
263
What percentage of calcium in the blood is protein bound?
40%
264
How many parathyroid glands are there?
4
265
What are the common causes of primary hyperparathyroidism?
- Adenoma
- Carcinoma
- Hyperplasia
266
What are the common causes of secondary hyperparathyroidism?
Compensatory increase in PTH secretion due to hypocalcemia caused by renal disease or GI malabsorption
267
What are the symptoms of hyperparathyroidism?
- Renal stones
- HTN
- Constipation
- Fatigue
268
What are the medical treatments for hyperparathyroidism?
- Saline
| - Loop diuretics
269
What are the periop anesthetic considerations for patients with hyperparathyroidism?
- Adequate hydration
- Maintenance of urine output
- Possible hypotension during induction
- Altered response to muscle relaxants
270
What are the EKG manifestations of hypercalcemia due to hyperparathyroidism?
- Prolonged PR interval
| - Short QT interval
271
What is hypoparathyroidism?
Decreased PTH or resistance to PTH that causes decreased calcium - almost always iatrogenic
272
What is pseudohypoparathyroidism?
A congenital condition where the patient has normal PTH but kidneys don't response
273
What are the symptoms of acute hypoparathyroidism after surgery?
- Paresthesias
- Neuromuscular irritability
- Restlessness
274
What are the symptoms of chronic hypoparathyroidism?
EKG changes, lethargy, cataracts
275
What is a positive Chvostek sign when screening for hypoparathyroidism?
Facial muscle twitching with manual tapping at angle of mandible
276
What is a positive Trousseau sign when screening for hypoparathyroidism?
Carpopedal spasm after 3 minutes of tourniquet ischemia
277
What is the treatment for hypoparathyroidism?
- Calcium infusion
- PO calcium
- Vitamin D
278
How should respiration be managed perioperatively in patients with hypoparathyroidism?
Don't hyperventilate so you can avoid alkalosis
279
The Thymus is a specialized gland of the _________ system:
A) cardiovascular
B) Neurological
C) renal
D) Immune
D. immune
280
What does the thymus do?
Differentiates developing lymphocytes into mature T cells of the adaptive immune system
281
What is the pathophysiology of DiGeorge Syndrome (congenital thymic hypoplasia)?
Hypoplasia or aplasia of the parathyroid and thymus
282
What are the symptoms caused by DiGeorge Syndrome?
- Hypocalcemia
- Increased infections
- Congenital cardiac defects
283
What symptom of DiGeorge Syndrome indicates a difficult DL?
Micrognathia
284
What are periop considerations for patients with DiGeorge Syndrome?
- Avoid hyperventilation bc it could exacerbate hypocalcemia
| - Unpredictable NMB
285
Cushing’s Disease is an excess of which hormone?
A) ACTH
B) Cortisol
C) Aldosterone
D) GH
B. Cortisol
286
What is released from the adrenal cortex?
- Glucocorticoids (cortisol)
- Anti insulin
- Minerocorticoids (aldosterone)
- Androgens
287
What is the net effect of aldosterone?
Increased extracellular fluid volume caused by fluid retention, decreased plasma potassium, metabolic alkalosis
288
What imbalance can occur with high circulating levels of anti-insulin?
Hyperglycemia
289
What endocrine disorder is assessed with the Chvostek and Trousseau tests?
Hypoparathyroidism
290
What is the only important disease process associated with the adrenal medulla?
Pheochromocytoma
291
What neurotransmitters are released from the adrenal medulla?
Catecholamines (NE, E, DA)
292
What is Cushing's Syndrome?
ACTH stimulates excessive cortisol secretions from the adrenal cortex
293
What are the symptoms of Cushing's syndrome?
Obesity, HTN, glucose intolerance, osteoporosis, muscle weakness
294
What are the treatments for Cushing's syndrome?
- Radiotherapy
| - Transsphenoidal resection if microadenoma is the cause
295
What are the preop considerations of a patient with Cushing's syndrome?
- Consider BP
- Check for electrolyte imbalances
- Check blood sugar
- May be hypervolemia
- May be hypokalemic
- Muscle weakness may indicate sensitivity to NMB
296
What are the intraop considerations for a patient with Cushing's syndrome?
- Careful positioning due to osteoporosis
| - Obesity
297
What are the physiologic effects of excess cortisol that must be considered while managing a patient with Cushing's syndrome?
- Systemic HTN
- Muscle weakness
- Osteoporosis
- Obesity
- Poor wound healing
- Susceptible to infections
298
What post op considerations are important for a patient with Cushing's syndrome?
- Poor wound healing
| - Infection prone
299
If Conn Syndrome involves oversecretion of Aldosterone, you would expect a patient with it to have:
A) Hypokalemic Metabolic Acidosis
B) Hyperkalemic Metabolic Alkalosis
C) Hypokalemic Metabolic Alkalosis
D) Hyperkalemic Metabolic Acidosis
C) Hypokalemic Metabolic Alkalosis
300
What is the cause of primary hyperaldosteronism (Conn syndrome)?
Excess secretion of aldosterone usually from a tumor, hyperplasia, or adrenal carcinoma
301
What are the symptoms of Conn syndrome?
Often asymptomatic but may see
- headache
- muscle cramps
- metabolic alkalosis
- hypokalemia
302
What are the treatments for Conn syndrome?
- Supplemental potassium
| - Competitive aldosterone antagonist (Spironolactone)
303
What are periop considerations of a patient with Conn syndrome?
- Correction of hypokalemia
- Treatment of systemic HTN
- Don't hyperventilate
304
What is the cause of primary adrenocorticoid deficiency (Addison's disease)?
An autoimmune disease that causes
- Decreased release of glucocorticoids and mineralocorticoids
- Absence of cortisol and aldosterone
305
What causes secondary adrenocorticoid deficiency?
Can be caused from iatrogenic use of synthetic steriods. Causes...
- decreased ACTH from pituitary
- No cortisol
- Normal aldosterone
306
What symptoms of adrenocorticoid deficiency are caused by the absence of cortisol?
- Weakness
- Fatigue
- Hypoglycemia
- Hypotension
- Weight loss
307
What symptoms of adrenocorticoid deficiency are caused by the absence of aldosterone?
- Hyponatremia
- Hypovolemia
- Hyperkalemia
- Metabolic acidosis
- Hyperpigmentation of skin
308
What is Addisonian crisis? How is it triggered
Severe hypotension leading to a coma that can be triggered in steroid-dependent patients who do not receive increased doses during periods of stress
309
What are the treatments for adrenocorticoid defiency?
Replace steroids with hydrocortisone
310
What are the periop considerations for patients with adrenocorticoid deficiency?
- Be aware of addisonian crisis
- Beware of steroid withdrawal and redose steriods
- Infection prone
- Assess if pressors and fluids are working to treat hypotension
311
What induction drug should be avoided in patients with adrenocorticoid deficiency?
Etomidate
312
What are the causes of hypoaldosteronism?
- Congenital deficiency of aldosterone synthase
- Hyporeninemia
- unilateral adrenalectomy
313
When is hypoaldosteronism suspected?
-When the patient has hyperkalemia but no renal insufficiency
314
What metabolic condition could be due to hypoaldosteronism?
Hyperchloremic metabolic acidosis
315
What is the treatment for hypoaldosteronism?
Fludrocortisone
316
What are the periop considerations for patients with hypoaldosteronism?
- Patients may have heart block due to hyperkalemia and orthostatic hypotension
- Consider volume status
317
What is the pathophysiology of pheochromocytoma?
Tumor of the adrenal medulla causes an oversecretion of epi, norepi, and dopamine
318
What are the symptoms of pheochromocytoma?
Sudden onset of malignant hypertension, tachycardia, arrhythmias, headache, perspiration
319
```
Acromegaly is associated with an oversecretion of which hormone?
A) ACTH
B) TSH
C) GH
D) ADH
```
C) Growth Hormone
320
What is the most common cause of acromegaly?
Adenoma in the pituitary gland
321
What symptoms of acromegaly can make airway management difficult?
- Enlarged tongue and epiglottis
- Elongated mandible
- Narrowed glottic opening
322
What sized OETT may be best for an acromegalic patient?
A smaller OETT because of the increased incidence of subglottic stenosis
323
What test should be performed before placing an a-line on an acromegalic patient?
Allen's test
324
What is the pathophysiology of diabetes insipidus?
Deficiency or resistance to vasopressin causing poor reabsorption of water by the kidneys
325
What are the symptoms of diabetes insipidus?
- Extreme thirst (polydypsia)
| - Dilute urine
326
What are the periop considerations for patients with diabetes insipidus?
Watch for electrolyte imbalances like high Na+ and low K+/Mg2+
327
What is diabetes mellitus?
Chronic disease caused by abnormal glucose metabolism that results in long-term morbidity
328
What organ is the primary source of endogenous glucose?
Liver
329
What is a normal Hemoglobin A1C?
A) Less than 6%
B) Less than 8 %
C) Less than 10%
D) Less than 15%
A. Less than 6%
330
What is the function of beta cells in the pancreas?
Secrete insulin when blood glucose levels are high
331
What is the function of alpha cells in the pancreas?
Secrete glucagon when blood glucose levels are low
332
What is the function of delta cells in the pancreas?
Secrete somatostatin upon food ingestion and inhibits insulin, glucagon, growth hormone, etc to extend the time over which food nutrients are put into the blood
333
What is the sympathetic innervation supplying the pancreas?
T5-T10, causes insulin inhibition and glucagon stimulation
334
What is the parasympathetic innervation supplying the pancreas?
Innervation via the vagus to cause insulin release
335
What is the function of insulin?
- Triggers glucose transport into the cells for usage by the cells
- Stimulates protein and lipid synthesis
336
Is insulin required for brain utilization of glucose?
No
337
What is the function of glucagon?
- Increases glucose output from the liver
- Stimulates glycogenolysis
- Stimulates gluconeogenesis
- Inhibits glycolysis
338
What causes diabetes mellitus?
Decreased secretion of insulin from beta cells or increased resistance of receptors to insulin caused by either heredity or obesity
339
What is Type I DM?
- Immune related destruction of beta cells
| - Insulin dependent
340
What is Type II DM?
Insulin resistance, have normal to high plasma insulin levels but inappropriate for level of glucose
341
What is gestational diabetes?
Glucose intolerance that first develops during pregnancy
342
What is the classic triad of symptoms of diabetes melitus?
1) Polyurea
2) Polydypsia
3) Polyphagia (constant appetite)
343
What are the acute complications associated with diabetes mellitus?
- Diabetic ketoacidosis
- Hyperosmolar coma
- Hypoglycemia
344
What are the long term complications associated with diabetes mellitus?
- HTN
- CAD
- MI
- CHF
- Vascular disease
- Neuropathy
345
Patients with DM have a __ times greater risk of an MI perioperatively
20
346
What preop testing should be done to avoid a periop MI in patients with DM?
EKG
347
What symptoms of DM could indicate a difficult DL?
Stiff joint syndrome causes atlanto-occipital joint stiffness and possible TMJ stiffness
348
Diabetic Ketoacidosis (DKA) is more common in patients with Type 2 Diabetes.
A) True
B) False
B) False
349
What is the cause of diabetic ketoacidosis?
Decreased insulin activity causes the metabolism of free fatty acids and the accumulation of organic acid by products
350
What is often the first manifestation of type I DM in adolescents?
Infection
351
What are the clinical signs of diabetic ketoacidosis?
- Kussmal breathing
- Dehydration
- N/V
- BS 320-330
- Polyuria
- Ketones in urine
- Fatigue
- Altered mental status
352
What is the treatment of diabetic ketoacidosis?
- Correct hypovolemia with normal saline
- Correct hyperglycemia with insulin
- Correct electrolyte deficiencies
353
What is a hyperosmolar nonketotic coma?
When hyperglycemia diuresis results in dehydrations and hyperosmolality
354
What are the symptoms of hyperosmolar nonketotic coma?
- Glucose over 600
- No acidosis or ketones
- Thirst
- Confusion
355
What is the treatment for hyperosmolar nonketotic coma?
- Hypotonic saline
| - Low dose insulin
356
What causes hypoglycemia?
Excessive insulin relative to carbohydrate intake
357
Which type of diabetes does hypoglycemia most often occur?
Type I
358
Hypoglycemia is defined as a blood glucose less than __ mg/dL
50
359
What are the symptoms of hypoglycemia?
- Catecholamine discharge causing agitation, diaphoresis, tachycardia
- Mental status changes
360
Which type of diabetes is managed with regular insulin therapy?
Type I
361
What is the only insulin that can be given IV?
Regular insulin
362
How soon before surgery should metformin be discontinued?
24 hours
363
Which insulin drug has a rapid onset?
Novalin
364
Which insulin drug is intermediate?
Humalin
365
Which drugs given to diabetics stimulates insulin secretion?
Sulfonylureas like tolazamide and tolbutamide
366
Which drugs given to diabetics inhibit gluconeogenesis?
Biguanidines
367
What biguanide is considered first line therapy in obese type II patients who dont respond to diet and exercise?
Metformin (glucophage)
368
What are the four major classes of oral hypoglycemic agents? What are their MOAs?
1) Secretagogues (sulfonylureas) - increase insulin availability
2) Biguanides (Metformin) - suppress glucose release
3) Glitazones - improve insulin sensitivity
4) Alpha glucosidase inhibitors (Acarbose) - delay GI glucose absorption
369
Hemoglobin 1Ac levels greater than __% indicate poor glycemic control
10
370
Patients with hypoglycemia may have drug interactions with which classes?
- Steroids
- Catecholamines
- Beta blockers
371
What are the risks during induction of hypoglycemic patients?
- Dramatic drop in BP
| - Gastric aspiration risk
372
How can you assess for autonomic neuropathy of the parasympathetic nervous system in hypoglycemic patients?
Valsalva maneuver or watch for sinus arrhythmia
373
What is normal heart rate variability during voluntary deep breathing?
Greater than 10 beats per minute
374
When should you treat high glucose levels intraoperatively?
Greater than 150
375
How do you calculate the number of insulin units to give patients with high glucose intraop?
(Blood sugar-100)/40
376
Insulin administration will decrease what serum electrolyte?
K+
377
How often should you check blood glucose when administering insulin intraop?
Every hour
378
What is the starting infusion rate for insulin?
0.1 units/kg/hour
379
How much does 1 unit of insulin lower blood sugar?
25-30 mg/dL
380
Carcinoid syndrome is caused by tumors in the GI tract that release massive amounts of what substances?
- Serotonin
| - Histamine
381
What are the symptoms of carcinoid syndrome?
- Flushing
- Diarrhea
- Hypotension
382
What are the anesthetic considerations for patients with carcinoid syndrome?
- A line
- Zofran
- Octreotide
383
What drugs commonly given by anesthetists can cause a carcinoid crisis?
- Succinylcholine
- Atracurium
- Epi
- Norepi
384
What are the 6 significant risk factors for a postoperative cardiac event?
1) High risk surgery
2) Ischemic heart disease
3) Creatinine over 2.0
4) History of TIA or CVA
5) Type I Diabetes
6) History of CHF
385
Patients having __ or more risk factors are considered at an elevated risk for a postop cardiac event
2
386
What are the indications for a pre-op 12 lead ECG?
- CAD
- PAD
- Arrhythmias
- Cerebrovascular disease
387
What pre-op test gives us a good assessment of left ventricular function?
Echo
388
A pre-op echo is reasonable for patients with what symptoms and medical histories?
- Dyspnea of unknown origin
- CHF with worsening dyspnea
- Previous LV dysfunction
389
ECG exercise testing requires the ability to exercise enough to get the heart rate up to __% of age predicted maximum
75%
390
What is the dipyridamole-thallium stress test?
Assess for at risk areas by redistributing myocardial perfusion
391
What is the range of positive predictive values for ischemic events with the dipyridamole-thallium stress test?
4-20%
392
What is the dobutamine stress echo?
Assess for new regional wall motion abnormalities with increased heart rate
393
What 3 components make up the preoperative cardiac assessment according to ACC/AHA guidelines?
1) Clinical predictors
2) Functional capacity
3) Surgical risk
394
What are considered "active cardiac conditions" according to ACC/AHA guidelines?
1) Recent MI
2) Decompensated heart failure
3) Significant arrhythmias
4) Severe valvular disease
395
What are considered high risk surgeries according to ACC/AHA guidelines?
1) Emergencies
2) Aortic and major vascular surgeries
3) Prolonged surgeries with large fluid shifts/loss
396
What are considered intermediate risk surgeries according to ACC/AHA guidelines?
1) Carotid endarterectomy
2) Head/neck surgeries
3) Intraperitoneal/intrathoracic
4) Orthopedic
5) Prostate
397
What are considered low risk surgeries according to ACC/AHA guidelines?
1) Endoscopic procedures
2) Superficial procedures
3) Cataracts
4) Breast
5) Ambulatory
398
What activities are considered 1 MET?
- Eat, dress, walk around house
| - Walk 1 or 2 blocks on ground level
399
What activities are considered 4 MET?
- Climb 1 flight of stairs
- Walk on level ground at 4mph
- Heavy house work
- Golf
- Dance
400
What activities are considered 10 MET?
- Swim
- Run
- Aerobic exercise
401
When is CABG indicated according to ACC/AHA guidelines?
- Stable angina and L main stenosis
- Stable angina and 3-vessel CAD
- Stable angina and 2-vessel CAD with LAD stenosis and EF less than 50%
402
Use of beta blockers in patients with CAD has shown an increased risk of what periop events?
Bradycardia and stroke
403
Which beta blocker has been associated with an increased risk of stroke?
Metoprolol
404
Patients with __ or more RCRI risk factors may need to begin beta blockers before surgery
3
405
Why are ACE inhibitors usually held on the morning of surgery?
To prevent intraop hypotension
406
What AAR monitoring is necessary for all aortic cases?
- ASA standard monitoring
- Large IV access
- A line
407
What AAR monitoring is necessary for patients with good LV function?
Central venous line
408
What AAR monitoring is necessary for patients with poor LV function?
- PA catheter
| - TEE
409
What are the renal affects caused by infrarenal aortic cross clamping?
- Reduction in renal blood flow
| - Reduced GFR
410
What should be monitored during and after clamping of infrarenal aorta to assess renal function?
Urine output
411
What diuretics should be considered during an infrarenal aortic cross-clamping?
Mannitol and furosemide
412
What are the hemodynamic changes during clamping of the aorta?
Increase in catecholamines leading to venoconstriction which causes increased preload, afterload, and contractility
413
What are the hemodynamic changes after the unclamping of the aorta?
- Decrease myocardial contractility
- Central hypovolemia
- Decrease venous return
- Decrease cardiac output
- Hypotension
414
Neuraxial anesthesia with abdominal aortic surgeries for post op pain relief has been found to decrease what postop incidence?
MI
415
What IV access should be obtained for an infrarenal aortic endostent graft surgery?
- Large IV access
| - A-line
416
What anesthetic techniques can be used for an infrarenal aortic endostent graft surgery?
- Local
- Regional
- General
417
What are the symptoms of anterior cord ischemia?
Loss of motor function, pain, and temperature sensation
418
What are the symptoms of posterior cord ischemia?
Loss of proprioception and fine touch
419
What are the hemodynamic changes associated with clamping of the thoracic aorta?
- Shift of blood volume to the brain
- Increased ICP
- Decrease spinal cord perfusion
420
What airway device should be used for an open thoracic aneurysm repair?
Double lumen ETT
421
A spinal drain is used during an open thoracic aneurysm repair to keep CSF pressure less than __ mmHg
10
422
What drugs should be administered during an open thoracic aneurysm repair for spinal cord protection?
Steroids
423
Carotid endarterectomies are more prevalent for patients with which risk factors?
- Angina
- HTN 180/110
- CHF
- A fib
- Over 75 y/o
- Diabetes
- Renal insufficiency
424
What are the standard monitoring used in carotid endarterectomies?
- Standard ASA
- 5 lead ECG
- A line
425
Patients that had an rSO2 decrease by more than __% presented with neurological symptoms
30
426
What are the advantages of regional anesthesia for a carotid endarterectomy?
- Can keep patient awake to monitor cerebral function
- Less hemodynamic variation
- No postop sedation to confuse evaluation
427
What are the advantages of general anesthesia for a carotid endarterectomy?
- No patient movement
- Control of airway
- Can control CO2
- Can provide HTN during clamping
428
What physiologic states can increase cerebral protection during carotid endarterectomies?
1) HTN
2) Hemodilution
3) Hypothermia
4) Normoglycemia
5) Normocarbia
429
What anesthetic drugs can increase cerebral protection during carotid endarterectomies?
1) Barbituates
2) Volatile agents
3) Propofol
430
What are the symptoms of hyperperfusion syndrome?
- Ipsilateral headache
- Seizures
- Focal neurologic signs
431
What factors increase the risk of hyperperfusion syndrome?
- Severe ICA stenosis
- HTN
- Contralateral ICA stenosis
432
How should perfusion pressure be maintained before and during aortic crossclamping?
Maintain high pressures
433
After aortic surgeries there should be close monitoring post-op for what issues?
1) Hypotension
2) Neck hematoma
3) Hyperperfusion syndrome
