APP 1 final Flashcards
1
Q
TEG R Time
A
- latency until clot formation begins as defined by an amplitude of 2 mm- Normal 3-9 mins
2
Q
TEG K Time
A
time from the end of R until the clot reaches 20mm – reflects speed of initial clot formation (Normal .5 to 3 mins)
3
Q
Normal R Time-TEG
A
3-9 mins
4
Q
Normal K-Time-TEG
A
.5-3 mins
5
Q
α - alpha angle - TEG
A
the angle tangent to the curve at K
6
Q
MA - maximum amplitude
A
reflects total clot strength
7
Q
Lysis time (LY30)
A
% lysis after 30 min - reflects the fibrinolysis stage of clot development
8
Q
TEG- Increased R Time
A
FFP
9
Q
TEG- Decreased alpha angle
A
Cryo
10
Q
TEG- Decreased MA
A
Platelets/ DDAVP
11
Q
Fibrinolysis
A
TXA or aminocaproic acid
12
Q
TEG- Platelet Blockers
A
MA Decreased
13
Q
TEG- Fibrinolysis
A
MA Decreased
LY30 Markedly increased
14
Q
TEG- Hypercoagulable state
A
*α angle increased
*MA increased
15
Q
TEG- Early DIC
A
*α angle increased
*MA increased
LY 30 increased
16
Q
TEG- Late DIC
A
R Prolonged
*α angle increased
*MA increased
17
Q
Normal Platelet count
A
150-450k
18
Q
Thrombocytopenia Goals for Neuraxial, Major surgery, Central Line placement
A
Neuraxial- 70k
Major Surgery- 50K
Central Line 20k
19
Q
PCC (Prothrombin Complex Concentrates)/ KCentra
A
Contains the 4 vitamin K dependent clotting factors
II, VII, IX, X
20
Q
Vitamin-K Dependent Factors
A
II, VII, IX, X
21
Q
Indications for PCC
A
Hemophilia
Immediate reversal of Vitamin K antagonists (Warfarin)
22
Q
PCC Vs Vitamin K for reversal of warfarin
A
Compared to vitamin K, PCC is faster and requires less redosing (IV vitamin K corrects INR over 12-24 hours
23
Q
PCC vs FFP For reversal of Warfarin
A
Compared to FFP, reversal with PCC is faster (no thawing) and has less infection risk
24
Q
Desmopressin
A
synthetic analog for the endogenous antidiuretic hormone, vasopressin
acts at the V2 receptor found in the nephron and within endothelial cells
causes the release of FVIII and vWF from within vascular endothelial cells, thereby improving platelet function
25
Clinical use for desmopressin
treatment of bleeding in vWD and mild hemophilia A
26
TXA blocs
Plasminogen
27
Stimulates erythropoiesis
Erythropoietin
28
Delayed Hemolytic Transfusion Reaction
alloantibodies in the recipient to minor RBC antigens (Rh, Kell, Kidd, Duffy)
29
Delayed hemolytic transfusion rxn diagnosis
low haptoglobin, positive direct Coombs, anemia
30
TRIM
Transient depression of the immune system following transfusion of blood products
31
Alloimmunization
Induction of immune response to allogenic antigen exposure
Occurs in pregnancy, transfusions
Non-ABO alloantigens (Rh, Kell, Kidd, Duffy) on surface of donor RBC leads to antibody generation (IgG) in recipient
Cell destruction (DHTR) does not occur until 2nd exposure
32
TRALI
Acute onset dyspnea within 6 hours of transfusion
Low pressure pulmonary edema due to neutrophils leaky capillaries
Antibodies in donor plasma (HLAs, HNAs)
33
TRALI Diagnostic Criteria
Diagnostic Criteria:
Acute bilateral infiltrates (non-cardiogenic pulmonary edema)
Hypoxemia (PaO2/FiO2 < 300 or O2 sat< 90% on RA)
No evidence of LA hypertension
34
Transfusion-associated GVHD can be prevented with
Gamma irradiation (damages donor WBC DNA)
35
Transfusion- associated GVHD
Donor lymphocytes engraft in the recipient and attack host cells as foreign
36
Post-transfusion purpura Treatment
IVIG
Plasmapheresis
37
Define- Post-Transfusion Purpura
Severe thrombocytopenia (<10,000)
5-10 days post transfusion
38
Acute respiratory distress within 6 hours of transfusion
Increased CVP
Increased BNP
Signs of volume overload
Radiographic evidence of bilateral acute pulmonary edema
TACO Diagnostic criteria
39
TACO Pathophysiology
high-pressure pulmonary edema
Not immune modulated
Not associated with increased capillary permeability
40
Leading cause of transfusion-associated fatalities
TACO
41
TACO Treatment
Diuresis
Afterload reduction
42
Wrist drop indicates an injury to which nerve?
Radial
43
Hand clawing indicates an injury to which nerve?
Ulnar
44
Ape sign of the hand indicates an injury to which nerve?
Median
45
Lumbar plexus begins as the anterior fibers of which spinal nerves?
L1, L2, L3, L4
46
Most common brachial plexus injury
Ulnar neuropathy
47
Erb's palsy
Upper brachial plexus injury
C5-6
Stretching during vaginal delivery
Waiter's tip
48
Femoral nerve cord contributions from the Lumbar Plexus
L2-4
49
Sciatic nerve cord contributions from the Sacral plexus
L4-S3
50
Saphenous nerve originates from what nerve? Is the saphenous nerve sensory or motor?
Femoral nerve
Sensory only
51
Lateral cutaneous nerve cord contributions and sensory/motor?
L2-3
Sensory only
52
Obturator nerve originates from?
Sensory/Motor
L2-4
Motor: Thigh adduction
Sensory- Medial surface of the thigh
53
Which nerve is responsible for all motor function below the knee
Sciatic nerve
54
What nerve is responsible for plantar flexion and foot inversion?
Tibial Nerve
55
What nerve is responsible for ankle dorsiflexion and foot eversion
Common peroneal nerve
56
Sural nerve Motor/Sensory
Sensory only- Lateral surface of the foot
57
Lower extremity nerve injuries most likely to have an associated motor dysfunction
Common fibular/peroneal
Sciatic
Femoral
58
Foot drop is associated with
Common peroneal (fibular) nerve injury
59
Hyperflexion of hip and extension of knee
Can occur in lithotomy if pt shifts toward caudal end of table to increase exposure to perineum
Sciatic neuropathy
60
weakness of quadriceps (Hip flexion)
Femoral neuropathy
61
Sensory loss of medial thigh
Obturator neuropathy
62
Lateral Cutaneous neuropathy
Leads to meralgia parasthesia
Hyperflexion of the hip onto the abdomen increases pressure within the inguinal ligament and can compress these sensory branches
associated with pregnancy
63
Complication associated with beach chair positioning
VAE
64
Complication associated with prone positioning
Ischemic Optic neuropathy (ION)
65
1cm rise = what change in MAP?
1cm rise= 0.75 mmHg drop in MAP
66
ADult lethal volume of air
200-300 mL or 3-5mL
67
increasing pulmonary vascular resistance and eventual CV collapse
Slow air leak
68
Air lock in the RV will lead to
Immediate CV Collapse
69
Most sensitive monitor to VAE
TEE
70
Most common cause of post-op vision loss
Ischemic optic neuropathy
Impaired bloodflow to optic nerve
71
Cardiac surgery is associated with what type of vision loss?
Anterior ION
72
Spine surgery is associated with what type of vision loss?
Posterior ION
73
Most common ophthalmological complication of general anesthesia for non-ocular surgery
Corneal abrasion
74
TBW=
ICF+ ECF
75
ICF
2/3 TBW or 40% total body weight
76
ECF
1/3 TBW or 20% total body weight
77
Interstitial fluid volume
3/4 of ECF or 15% Total body weight
78
Plasma volume
1/4 ECF or 5% Total body weight
79
Fluid replacement=
Maintenance+ Deficit+ Insensible losses+Surgical losses/Blood loss
80
NS contains
154 Na, 154 Cl , 5.7 pH, 308 mOsm/L
* The Cl content is significantly higher than plasma
81
NS can cause what metabolic derangement?
hyperchloremic metabolic acidosis
82
Plasmalyte contains
140 Na, 98 Cl, 5 K, 3 Mg, 27 Acetate, 23 Gluconate, 7.4 pH, 295 mOsm
83
Why must plasmalyte be used with caution in renal insufficiency?
may result in Mg, K, and Na retention
84
LR contains
130 Na, 109 Cl, 4 K, 3 Ca, 28 lactate, 6.4 pH, 273 mOsm/L
85
Why is LR contraindicated in blood transfusions?
Calcium binds to the citrate anticoagulant in blood products. Causes blood clots from chelation
86
What is the clinical use for hypertonic saline?
Reduce cerebral edema and ICP
87
Theoretical concern for Hypertonic saline?
Central pontine myelinolysis
88
Is albumin safe for use in patients with TBI
NO
89
Contraindications to hetastarch use
Avoid in pts with sepsis as it may significantly increase risk of renal dysfunction
90
Parkland formula
4 mL of LR per Kg per % TBSA burn in initial 24hr
91
How is the parkland formula used and administered?
½ of calculated fluid given in the first 8 h post-burn, remainder given over next 16 h (e.g., 70 Kg
man with 60% TBSA burn needs: 4 x 70 x 60 = 16,800 mL; give 8,400 mL of LR during 0-8 h after burn, 8,400 mL during 8-24 h
92
How is cardiac output affected post-burn (immediate)
reduced immediately post-burn
Decreased circulatory volume+ direct myocardial depression
93
How is cardiac output affected post-burn (3-5 days)
hypermetabolic state -> increased CO (2-3 x normal, decreased SVR)
94
Rule of 9s for adults
9% for each arm, 18% for each leg, 9% for head, 18% for torso (front), 18% for torso (back)
95
K+ > 5.5 mEq/L
Hyperkalemia
96
peaked T waves ->prolonged PR interval & QRS duration ->loss of P waves -> widening of QRS complex -> sine waves (merged QRS and T waves) -> V fib/ asystole
Symptoms of hyperkalemia
97
K+ < 3.5 mEq/L
Hypokalemia
98
fatigue, muscle cramps, progressive weakness leading to paralysis; increased risk of
arrhythmias; can enhance digitalis toxicity; cause hepatic encephalopathy
U waves, ventricular ectopy, +/- Prolonged QT
Symptoms of hypokalemia
99
Normal pH
7.35-45
100
Normal PCO2
38-42
101
Normal PO2
75-100
102
Normal HCO3
22-26
103
if the pH is acidic <7.35 and PCO2 >40, what is the metabolic derangement?
Respiratory acidosis
104
If the ph is acidic <7.35 and pco2 is <40, what is the metabolic derangement
Metabolic acidosis
105
ph alkaline >7.45 and PCO2 <40
Respiratory alkalosis
106
pH alkaline >7.45 and PCO2 >40
Metabolic alkalosis
107
gain of H+ or loss of HCO3- ; low pH; low PaCO2 (compensatory); low
HCO3
Metabolic Acidosis
108
Gain of HCO3- or loss of H+; high pH; high PaCO2 (compensatory); high
HCO3-
Metabolic alkalosis
109
hypoventilation; low pH; high PaCO2; high HCO3- (compensatory)
Respiratory Acidosis
110
hyperventilation; high pH; low PaCO2; low HCO3- (compensatory)
Respiratory Alkalosis
111
What are the chemoreceptors that are H+ sensitive?
Carotid body in carotid bifurcation in neck and brainstem
112
Metabolic acidosis excites the chemoreceptors and initiates what?
A prompt increase in ventilation and a decrease in PaCO2
113
Metabolic alkalosis silences the chemoreceptors and produces what?
* A prompt decrease in ventilation and increase in arterial PaCO2
* Though patients will not decrease ventilation to apnea
114
What formula is used to determine if respiratory compensation is adequate?
Winter’s formula
* PCO2 = (1.5 x [HCO3-]) + 8 +/- 2
115
How to use winter's formula
PCO2 = (1.5 x [HCO3-]) + 8 +/- 2
* This calculates the expected CO2 given the HCO3- measured
* If the two values are roughly equal there is compensation
* If measured PCO2 is higher than calculated there is concurrent respiratory acidosis
* If measured PCO2 is lower than calculated there is concurrent respiratory alkalosis
116
Na+ - (Cl- + HCO3-)
Anion Gap equation
117
PCO2 = (1.5 x [HCO3-]) + 8 +/- 2
Winter's formula
118
Normal anion gap
<11 mEq/L
119
Adjusted anion gap
measured anion gap + 2.5 x (4 - albumin)
120
This is calculated if anion gap metabolic acidosis is present
Delta Gap
121
(actual AG – 12) + HCO3-
Delta gap = (actual AG – 12) + HCO3-
Adjusted HCO3 - should be 24 (+/- 6) {18 – 30}
if delta gap > 30 additional metabolic alkalosis
* If delta gap < 18 additional non-gap metabolic acidosis
* If delta gap 18– 30 no additional metabolic disorders
122
If delta gap > 30
additional metabolic alkalosis
123
If delta gap < 18
additional non-gap metabolic acidosis
124
If delta gap 18– 30
no additional metabolic disorders
125
MUDPILERS
Methanol, Uremia, DKA/Alcoholic KA, Paraldehyde, Isoniazid, Lactic acidosis, EtOH/Ethylene glycol,
Rhabdo/Renal failure, Salicylates
126
CUTE DIMPLES
Cyanide, Uremia, Toluene, Ethanol, DKA, Isoniazid, Methanol, Propylene glycol, Lactic acidosis, Ethylene
glycol, Salicylates
127
HARDUPS
Hyperalimentation, Acetazolamide, Renal tubular Acidosis, Diarrhea, Uretero-pelvic shunt, Post-
hypocapnea, Spironolactone
128
CUTE DIMPLES/ MUDPILES associated with
Anion Gap Metabolic Acidosis
129
HARDUPS is associated with
Non-Anion GAP Metabolic AcidosisCC
130
CLEVER PD
Contraction, Licorice, Endo (Conn’s, Cushings, Bartter’s), Vomiting, Excess alkali, Refeeding
alkalosis, Post-hypercapnia (high PCO2), Diuretics and chronic diarrhea
131
CLEVER PD is associated with
Metabolic Alkalosis
132
hypokalemia/ hypochloremia is associated with what metabolic derangement?
Metabolic alkalosis
133
hyperchloremia is associated with
Normal anion gap acidosis
134
Acute Respiratory acidosis
decrease in pH = 0.08 x (PaCO2 – 40)/10
10:1
For every rise of 10 in the pCO2, the HCO3 will rise by 1
135
Chronic respispiratory acidosis
decrease in pH = 0.03 x (PaCO2 – 40)/10
10:3
For every increase of 10 in PCO2, the HCO3 will rise by 3
136
Acute Respiratory Alkalosis
increase in pH = 0.08 x (40 – PaCO2)/10
10:2
For every fall of 10 in PCO2, the HCO3 will fall by 2
137
Chronic respiratory alkalosis
increase in pH = 0.03 x (40 – PaCO2)/10
10:4
For every fall of 10 in PCO2, the HCO3 will fall by 4
138
Approx what percentage of the US is obese?
42%
139
Which US State has the highest percentage of obesity? AL, AR, TX, WV
WV
140
A patient with a BMI of 46 falls into which category of obesity?
Morbid obesity/ Class 3
141
Body composition
TBW= FW+ LBW
142
What is the ideal body weight for a 5ft female who weighs 100 kg
45.5 kg + 2.3 kg x height (inches-60)
add 20% of IBW to account for extra lean mass in obesity
143
Lean body weight (LBW)
80% of TBW in Males
75% of TBW in Females
144
IBW calculation
Males: 50 kg + 2.3 kg x (height in inches – 60)
Females: 45.5 kg + 2.3 kg x (height in inches – 60)
145
BMI Calculation
Body mass index (BMI) = weight(kg)/height(m^2)
146
Central distribution of fat
Android
147
Peripheral distribution of fat
Gynecoid
148
40F with morbid obesity on ozempic presents to pre-op clinic for optimization prior to surgery . When should her last dose of ozemic occur?
Hold on day of surgery
149
All patients at increased risk of aspiration should do what prior to surgery?
clear liquid diet for 24 hrs prior to surgery
150
Obesity effects on Cardiovascular system
Increased CO
Increased LV Wall thickness
increased proinflammatory and prothrombic mediators
151
Obesity+ HTN->
Dilation-> Hypertrophy-> Biventricular heart failure
152
OBesity effects on hematologic conditions
Increased:
Fibrinogen
Factor VII
Factor VIII
vWF
PAI-1
Hypofibrinolysis
HYPERCOAGULABILITY
153
What respiratory parameter significantly decreases in obesity?
FRC- Functional residual capacity
154
the most sensitive indicator of the effect of obesity on pulmonary function
ERV- Expiratory Reserve Volume
155
STOP-BANG
Sleep Apnea sceening
Snoring
Tiredness
Observed Apnea
P-Elevated PRessure
BMI >35
Age >50
Neck >16in
Gender-Male
156
Apnea-Hypopnea index score of 13 indicates what category of OSA
Mild
157
AHI 5-15
Mild
158
AHI 16-30
Moderate
159
AHI >30
Severe
160
Obesity Hypoventilation Syndrome
Pickwickian
PHTN-> Cor Pulmonale
BMI >30
PACO2 >45
Absence of unknown cause of hypoventilation
Reliance on hypoxic drive for ventilation
161
An otherwise healthy 18yo female with BMI 42 presents for carpal tunnel release. What pre-op NPO guidelines should be recommended?
Standard NPO Guidelines
162
Obesity effects on gastric volume
Increased residual gastric volume (fasting >25 ml)
163
Which weight should be used to dose SUx in obesity?
TBW
164
Which weight should be sued to dose Roc in obesity?
Corrected IBW
Add 20% of calculated IBW to account for extra lean mass in obesity
165
which weight should be used to dose sugammadex in obesity?
Neostigmine?
TBW
TBW
166
Which weight should be used to calculate induction dose of propofol in obesity?
LBW
167
What weight should be used to calculate maintenance dose of propofol in obesity?
TBW
168
What weight should be used to calculate the dose for fentanyl in obesity?
LBW- TTE
169
What weight should be used to calculate dosing for Precedex/Dexmedetomidine?
TBW
170
Of the following, which is the biggest predictor of difficult BMV?
Mallampati IV
Neck circumference >40
Edentulous
Short TM Distance
Neck circumference ≥40cm is the single biggest predictor of difficult mask ventilation AND difficult intubation!
171
What is the appropriate TV for a 60yo male who is 5ft tall and weighs 130kg
IBW 6-8 mL/kg
172
Abdominal weight effects on CO
abdominal weight -> compress vena cava -> decrease preload -> reflex tachycardia -> decreased CO
173
An ortho bro is finishing up fixing a bone and wants to inject 1%Lido plain, but he forgot how to calculate the max dose. Your patient is a 55yo Male who weighs 130 kg and is 5ft tall. The max volume he can safely inject is?
Male, 5 ft tall: IBW 50 kg
Lidocaine 1% max dose: 5 mg/kg IBW
Lidocaine 1% = 10 mg/ml
50 kg x 5 mg/kg = 250 mg
250 mg / 10 mg/ml = 25 ml
174
Which of the following is NOT a cardiovascular change associated with
the aging process?
A. Conduction system fibrosis
B. Decreased baroreceptor reflex
C. Decreased response to ß-receptor stimulation
D. Increased vascular compliance
E. Left ventricular hypertrophy and reduced compliance
D. Increased vascular compliance
175
In healthy patients, which of the following is unlikely to
change significantly between the ages of 40 and 70?
A. Albumin
B. Creatinine
C. Hemoglobin
D. Insulin
. Creatinine
176
Which of the following cardiovascular changes is seen in the
geriatric population?
A. Increased beta adrenergic sensitivity
B. Increased cardiac inotropy
C. Increased large artery compliance
D. Increased myocardial wall stiffness
. Increased myocardial wall stiffness
177
Which of the following is NOT a physiologic change found
in the geriatric population?
A. Decreased hepatic metabolism of medications
B. Increased sensitivity to most anesthetic agents
C. Increased minimum alveolar concentration requirement
D. Reduced vascular compliance
Increased minimum alveolar concentration requirement
178
Which of the following statements regarding geriatric pulmonary
changes is TRUE?
A. Residual volume decreases
B. Closing capacity increases
C. Functional residual capacity decreases
D. Total lung capacity increases
Closing capacity increases
179
Morphine metabolite
Active metabolite, morphine-6-glucuronide, has analgesic
properties and is renally excreted
* M3G is other metabolite
* not clinically relevant unless patient has renal failure
180
Which opioid can cause histamine release
Morphine/ Meperidine
181
Which opioid should be avoided in use with MAOIs?
Meperidine
182
Tolerance
a state of adaptation in
which exposure to a drug induces
changes that result in a diminution of
one or more of the drug's effects over
time
183
NMDA Agonists may alleviate pain by
inhibition of central sensitization
184
An NMDA antagonist administered in
the perioperative period as an adjunct
analgesic may be opioid sparing and
may improve postoperative analgesia by
decreasing central sensitization
185
NSAIDS are contraindicated in
CAD
Renal Disease
potentially inhibits bone healing
186
