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Anesthesia subspecialty > CCM > Flashcards

CCM Flashcards

1
Q

What pressor of choice in sever acidemia (sever sepsis/septic shock)

A

Vasopressin

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2
Q

TRALI rxn features?

A
  • wide A-a gradient
  • non cardio plum edema
  • leukopenia (due to sequestration in lung)
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3
Q

If SVC line pulled upwards where would it land (which vein branch)?

A

Brachiocephalic

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4
Q

Shortest period of anticoagulant in PCI type?

A

PTCA (2 wks) > bate metal stent ( 1m ) > drug eluting stent ( 1y )

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5
Q

Ratio of compression ventilation in BLS?

A

30:2

Only newborns 3:1

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6
Q

Anthrax presents like viral flu but after spores are inhaled they get transported by macrophages to …. and presents with ….

A

Mediastinal LNs

Widened mediastinum in viral like flu sx (anthrax)

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7
Q

DOC for VT/VF refractory to defibrillation

A

Amiodarone

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8
Q

What is the indication for activated protein C?

A

Sepsis with APACHE score>25

It inhibits factor 5 and 8 which results into reduction in inflammation and microthrombi, it also blocks the production of TNF

SE is hemorrhage

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9
Q

Criteria for Brain death ?

A

1) Two physician evaluation.
2) no other causes that mimic brain death.
3) coma with absent brainstem reflexes.
4) lack of respiratory drive by apnea testing.

Confirmatory testing is only needed under the age of 1

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10
Q

Confirmatory testing for brain death may be required in …. and what would be the most sensitive test?

A

in situations where clinical evaluation is compromised (severe facial trauma, pre-existing neurologic derangements prior to the incident) or where apnea testing is contraindicated such as significant hemodynamic instability, metabolic acidosis, or high levels of ventilatory support.

Cerebral angiography

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11
Q

Some patients with hemophilia A eventually develop antibodies against factor VIII. They manifests as continues bleeding refractory to cryoprecipitate infusion and do not respond well to exogenous human factor VIII infusion. what blood product considered?

A

Anti-factor VIII antibodies (involves porcine factor VIII, recombinant factor VIIa, or recombinant factor IIa).

Activated preparation of factors II and VII are used because human factor VIII is unavailable, even after it is infused, secondary to antibody binding. These two factors (IIa and VIIa) circumvent the dysfunctional step in the coagulation cascade. VIIa acts through the extrinsic pathway, VIII is a part of the intrinsic pathway, and IIa is downstream of the union of the two pathways.

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12
Q

who are the patients prefered to have Peritoneal dialysis over hemodialysis?

A

Peritoneal dialysis is the preferred dialysis modality for patients who are intolerant of the hemodynamic changes induced by hemodialysis.

This may include patients with a history of unstable angina, severe aortic stenosis, or heart failure with severely reduced ejection fraction.

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13
Q

SVR formula?

A

SVR = ( [MAP-CVP] ÷ CO) x 80

MAP = SBP + (2xDBP) / 3
CVP = RAP
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14
Q

PVR formula?

A

PVR = ( [MPAP – PAOP] ÷ CO) x 80

MPAP = mean pulmonary arterial pressure (mm Hg)
PAOP = pulmonary artery occlusion pressure or pulmonary capillary wedge pressure (mm Hg)
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15
Q

Will increasing FiO2 in ARDS improves oxygenation in ARDS?

A

No, Oxygen therapy is of limited value with large intrapulmonary shunts due to limitation of gas exchange and requires alternative therapies to improve V/Q matching.

1) PEEP helps improve FRC and maintain patency of available alveolar units for gas exchange.
2) ECMO bypasses the lungs and provides mechanical oxygenation but requires invasive line placement and anticoagulation.
3) Inhaled nitric oxide improves V/Q matching by increasing blood flow to only ventilated alveolar units without reversing hypoxic pulmonary vasoconstriction, which may occur with other pulmonary vasodilators such as nitroglycerin or nitroprusside.
4) Inverse ratio ventilation reverses the time spent in inspiration and expiration to favor more time spent in inspiration (when gas exchange occurs).

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16
Q

For patients with HIT, when do you start warfarin?

A

1) stop heparin
2) start direct thrombin inhibitor (because risk of thrombosis remains high for 2-4 weeks after initiating treatment of heparin)
3) warfarin started after plt count normalize (warfarin induces skin necrosis is higher risk in people with HIT who have low plt)

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17
Q

Indications for stress ulcer ppx

A

Any 1 one of following

  • coagulopathy
  • intubated > 48 hours
  • GI bleed or ulcer in last 12 months
  • Head trauma, spinal cord injury or major burn

2 or more of following

  • Glucocorticoid therapy
  • > 1 wk ICU stay
  • occult GI bleed > 6 days
  • sepsis
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18
Q

How dose HypoCalcemia induced hyperventilation in coronary artery stenosis may lead to MI? and what other neurological symptoms may develop from hyperventilation?

A

In patients with subcritical coronary artery stenosis, the vasospasm induced by hypocarbia may be sufficient to provoke myocardial injury.

Neurologic symptoms occur because hypocapnia causes reduced cerebral blood flow. Symptoms of dizziness, weakness, confusion, and agitation are common. Syncope or seizure may be provoked by hyperventilation. Paresthesias occur more commonly in the upper extremity and are usually bilateral. Perioral numbness is very common.

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19
Q

Propofol infusion syndrome is a rare complication of … and risk factors are …

A

high-dose (> 4-5 mg/kg/hr or > 65-80 mcg/kg/min), long-term (> 24 hours) propofol administration. It has been described more commonly in children, though adult patients are also at risk.

Additional risk factors, especially for adults, include concurrent catecholamine or corticosteroid administration, concurrent acute neurologic or inflammatory disease, and severe infection or sepsis. Lipid metabolism disorders may also increase the risk of PRIS, especially in pediatric populations.

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20
Q

Propofol infusion syndrome is a rare complication of … and risk factors are …

A

high-dose (> 4-5 mg/kg/hr or > 65-80 mcg/kg/min), long-term (> 24 hours) propofol administration. It has been described more commonly in children, though adult patients are also at risk.

Additional risk factors, especially for adults, include concurrent catecholamine or corticosteroid administration, concurrent acute neurologic or inflammatory disease, and severe infection or sepsis. Lipid metabolism disorders may also increase the risk of PRIS, especially in pediatric populations.

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21
Q

The pathophysiology of Propofol infusion syndrome

relates to

A

propofol’s ability to impair cellular free fatty acid utilization and mitochondrial activity leading to inadequate aerobic metabolism and increased reliance on anaerobic metabolism. Cardiac and skeletal muscle are particularly susceptible leading to muscle damage or necrosis that can cause cardiac failure and rhabdomyolysis. Additional downstream effects include lactic acidosis, hyperkalemia, and renal failure.

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22
Q

The signs of Propofol infusion syndrome

include …

A

Metabolic lactic acidosis, cardiac failure, renal failure, rhabdomyolysis, hyperkalemia, hypertriglyceridemia, hepatomegaly, and pancreatitis.

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23
Q

Why left internal jugular catheter placement is associated with increased malposition?

A

The smaller caliber vein of the left internal jugular takes a more tortuous path to the right atrium, which involves several sharp bends. This tortuous path is the reason that left internal jugular catheter placement is associated with increased malposition.

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24
Q

Which associated with more successful line placement when compared left vs rt IJ line placement?

A

Successful placement of a right-sided central line occurs about 6 times more often than on the left. One study demonstrated a 3% incidence of malposition with right-sided central lines using a landmark approach versus a 19% incidence on the left.

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25
Q

What major risk can develop after embolization-induced carotid artery cannulation? Why right-sided carotid massage preferred over left side?

A

Although uncommon, carotid artery cannulation can lead to embolization. Carotid embolization on the left poses a greater risk as the left cerebral hemisphere is dominant in the majority of the population. This is also one of the reasons why right-sided carotid massage is preferred over left-sided massage. Another reason is that some investigations have found a greater cardioinhibitory effect on the right side.

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26
Q

Why placement of a left-sided central line is associated with increased complications?

A

There is an increased incidence of arterial puncture because the left internal jugular vein is often smaller and overlays the internal carotid artery more often than the right. Additionally, the more tortuous course increases the incidence of malposition.

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27
Q

Ease of placement for a pulmonary artery catheter from easiest to most difficult is:

A

right internal jugular > left subclavian > left internal jugular > right subclavian.

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28
Q

The treatment of choice for methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency?

A

Ascorbic acid.

Methylene blue provides an electron receptor for the reduction of methemoglobin using NADPH produced from the hexose phosphate pathway. In a patient with G6PD deficiency the hexose phosphate pathway is dysfunctional and free radicals develop, which causes red blood cell lysis. Therefore, methylene blue should be avoided in patients with G6PD deficiency.

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29
Q

Cisplatin, Carboplatin associated with …

A

acoustic nerve damage, nephrotoxicity

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30
Q

Vincristine associated with …

A

peripheral neuropathy, SIADH

(Acute neuropathies include paralytic ileus, urinary retention, and acute nerve pain).

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31
Q

Bleomycin, Busulfan associated with …

A

pulmonary fibrosis

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32
Q

Doxorubicin, Trastuzumab associated with …

A

cardiotoxicity

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33
Q

myelosuppression toxicity associated with what chemo?

A

5-FU, 6-MP, methotrexate

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34
Q

Acute respiratory alkalosis should demonstrate a pH

A

increase of 0.10 and a HCO3- decrease of 2 mEq/L per acute 10 mm Hg decrease in PaCO2.

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35
Q

If respiratory alkalosis becomes chronic, pH nearly normalizes and HCO3- …

A

decreases 5 to 6 mEq/L per 10 mm Hg sustained decrease in PaCO2.

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36
Q

Acute respiratory acidosis should demonstrate a pH decrease of …

A

0.05 and a HCO3- increase of 1 mEq/L per acute 10 mm Hg increase in PaCO2.

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37
Q

A patient with a chronic respiratory acidosis should have a nearly normal pH since HCO3- concentrations …

A

increase 4-5 mEq/L per 10 mm Hg sustained increase in PaCO2.

38
Q

The four anatomical sites recommended for IO access are: …

Which is most preferred?

A

sternum, proximal tibia, distal tibia, and proximal humerus.

The proximal tibia (1-2 cm below and slightly medial to the tibial tuberosity) is considered by most to be the preferred site since it has the highest first-attempt success rate due to a large flat target area with thin overlying tissue and easily identifiable landmarks

39
Q

Why AHA recommends IO access over central line in ACLS guideline?

A

Major complications from IO access occur in less than 1% of insertions. During code situations, the AHA recommends IO access over central access due to a faster insertion time, higher first-attempt success rate, and lower infection incidence.

40
Q

Recommendations for the prevention of central line infections include …

A
  • The use of ultrasound guidance
  • skin preparation with chlorhexidine and alcohol
  • avoidance of femoral vein site
  • Aseptic technique with sterile barrier precautions
  • daily chlorhexidine skin washing
  • use of antimicrobial-impregnated catheters.

Most importantly, central venous catheters should be removed as soon as they are no longer needed, though scheduled removal and replacement of necessary catheters has not been shown to be effective.

41
Q

Why the incidence of arterial puncture is higher in left sided central line placement then right sided?

A

The left internal jugular vein is often about one-half the size of the right internal jugular vein. In a study on optimal head position for central line placement, it was found that head rotation greater than 30 degrees resulted in a higher incidence of overlap between the artery and vein.

42
Q

What is the reason that left internal jugular catheter placement is associated with increased malposition?

A

The smaller caliber vein of the left internal jugular takes a more tortuous path to the right atrium, which involves several sharp bends. This tortuous path is the reason that left internal jugular catheter placement is associated with increased malposition.

43
Q

What screening test is the best for C.diff?

A

Persistent diarrhea and leukocytosis are sensitive clinical markers of Clostridium difficile infection.

A C. difficile bacterial antigen EIA can rapidly detect the presence of the bacteria, although asymptomatic carriers will also be positive. Follow-up to a positive antigen EIA is typically done with the gold standard C. difficile cell culture cytotoxin assay. The latter is highly sensitive and specific for C. difficile infection but does not provide results quickly (1-2 days)

A C. difficile toxin A/B EIA has moderately high sensitivity and specificity, produces results quickly, and may be used as a solitary test (20 min-2 hrs)

44
Q

Clinical symptoms of C.diff include …

A

Persistent diarrhea, lower abdominal discomfort, fever, and leukocytosis.

Among these, persistent diarrhea and leukocytosis are the most highly sensitive clinical indicators for infection.

Persistent diarrhea is defined as three or more loose stools per day for at least two days or 10-15 episodes that are nocturnal or associated with fever.

Note, however, that fever it not typically seen with C. difficile infection.

Pseudomembranous colitis on endoscopy or direct visualization is pathognomonic.

Severe complications of C. difficile infections include toxic megacolon, sepsis, and death.

45
Q

What increases/decreases Strong Ion Differences (SID)?

A

Disturbances that increase the SID increase the blood pH (alkalosis) while disorders that decrease the SID lower the plasma pH (acidosis). So, low pH or SID is associated with acidosis and high pH or SID is associated with alkalosis.

Increased SID:

  • Dehydration (contraction alkalosis) due to increased Na+
  • Chloride loss (e.g. aggressive NG suctioning with loss of HCl)

Decreased SID:

  • Free water excess (dilutional acidosis) due to decreased Na+
  • Aggressive administration of Normal Saline (NS) as the SID of Normal Saline is 0 (Na+ = 154mEq/L and Cl- = 154mEq/L → SID = 154 – 154 = 0)
  • Severe diarrhea due to loss of K+ and Na+
  • An increase in unmeasured anions such as lactate (e.g. lactic acidosis) or ketoacids (e.g. diabetic ketoacidosis)
46
Q

What are the benefits of early enteral feeding?

A

Enteral nutrition is touted to be the preferred method of nutrition support in critically ill patients and studies have suggested that the earlier this is performed the better. Prior theories about decreased infection due to maintenance of gut integrity with resultant decrease in bacterial translocation has never been proven in humans. Though this prior theory has not been proven, there are other significant benefits to enteral feeding including improved gut flora and blood flow, lower risk of overfeeding compared to parenteral nutrition, no need for vascular access and its associated complications such as line infection and pneumothorax, stimulation of gall bladder and biliary secretion to prevent cholestasis and fatty liver, and decreased cost compared to parenteral nutrition

47
Q

Complications of enteral feeding?

A
  • Most result from the delivery system and from the interruptions in feeding which causes inadequate nutrient delivery.
  • Sinusitis is seen with larger tubes and prolonged periods of use and can be a cause of fever and leukocytosis.
  • Increased gastric residuals and regurgitation is also a common concern as gastroparesis is often seen in critically ill patients and the feeding tube itself can impair the GE junction function.
  • Post-pyloric feeding tubes have not been proven to decrease the risk of pulmonary aspiration.
  • Other considerations include metabolic changes such as hypoglycemia when tube feeds are stopped but insulin therapy continues and refeeding syndrome (hypokalemia, hypophosphatemia, hypomagnesemia, metabolic acidosis). Thus, in patients at high risk feeding should be initiated slowly over 7-10 days and labs monitored frequently.
  • A very common complication also seen with enteral nutrition is diarrhea which can be multifactorial including feed composition, contamination, and too rapid administration. Composition of feeds can also be important especially in specific medical conditions such as renal failure (excessive urea that cannot be cleared), fluid overload (CHF), and hepatic encephelopathy (cirrhotic patients).

Summary: lack of delivery of adequate calories due to frequent interruptions, sinusitis, high gastric residuals, diarrhea, regurgitation and aspiration, metabolic derangements, difficult ventilator weaning, and refeeding syndrome

48
Q

Sepsis is defined by life-threatening organ dysfunction caused by a dysregulated host response to infection. This can be clinically represented by

A

a Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score 2 points or more.

SOFA is designed to represent the following systems: respiratory, coagulation, hepatic, cardiovascular, central nervous system, and renal.

GCS <15 (1 point)
RR > 22 (1 point)
SBP < or = 100 (1 point)

As of 2017, Sepsis-3 uses the Quick SOFA (qSOFA) score to predict mortality. A point value of 2 or above indicates high risk.

49
Q

Arterial blood gas analysis directly measures …

A

pH, PaCO2, and PaO2.

Other parameters such as base excess (or deficit), bicarbonate, and SaO2 are calculated or derived from the directly-measured parameters.

50
Q

Complications of TPN?

A

1) Hyperglycemia is more prevalent when compared to enteral feeding.
2) Volume overload can occur, especially in patients with significant cardiovascular disease who cannot process the volume associated with TPN or those with altered renal function.
3) Likely the biggest risk to the patient is the associated complications from the intravenous access that is required to deliver the TPN. TPN is typically delivered via central venous access, which puts the patient at risk for central line infections and thrombosis. Although it can be delivered peripherally for short periods of time, thrombophlebitis is common in peripheral intravenous access. Also, specialized formulations are required for peripheral administration to reduce fluid osmolarity

51
Q

Why glucose & po4 levels should be checked in patients receiving TPN before surgery?

A

Glucose: Several reports of hyperosmolar, nonketotic, hyperglycemia have been reported in patients on TPN therapy who failed to regain consciousness following anesthesia and surgery.

Po4: Hypophosphatemia can occur in patients receiving TPN and this may affect the patient’s muscle strength. Checking phosphate levels in a patient receiving TPN who appears weak in the perioperative period may be prudent. Administration of phosphate in hypophosphatemia may result in profound changes in muscle strength. In addition, a reduction of 2,3-diphosphoglyceric acid (DPG) level may occur with the hypophosphatemia, therefore a leftward shift of the oxygen-hemoglobin dissociation curve may occur.

52
Q

Guidelines for TPN maintenance in the intraoperative period are tough to find, but most authors recommends …

A

administering TPN as a closed system during the procedure, avoiding addition of stopcocks to the administration line. If there is an emergency and the intravenous line providing TPN has to be used, it’s important that proper cleaning of infusion ports occur and significant bolus administration should not be given with the TPN. It is probably best to discontinue the TPN for the period of time the central line needs to be used to avoid problems. Do not instead switch the central TPN to a peripheral line. When used for TPN, multi-lumen catheters and multiple purpose single lumen catheters have been shown to cause higher infection rates.

53
Q

Guidelines for TPN maintenance in the intraoperative period are tough to find, but most authors recommends …

A

administering TPN as a closed system during the procedure, avoiding addition of stopcocks to the administration line. If there is an emergency and the intravenous line providing TPN has to be used, it’s important that proper cleaning of infusion ports occur and significant bolus administration should not be given with the TPN. It is probably best to discontinue the TPN for the period of time the central line needs to be used to avoid problems. Do not instead switch the central TPN to a peripheral line. When used for TPN, multi-lumen catheters and multiple purpose single lumen catheters have been shown to cause higher infection rates.

Blood should not be withdrawn from the same line as TPN as it may result in erroneous values. Additionally, medications should not be administered through the TPN intravenous line because some incompatibilities are known. Packed red blood cells should not be given with TPN because dextrose hemolyzed blood; although different lumens in the same catheter would be a safer option versus Y-site or piggyback connecting. Again, the TPN should be discontinued to allow for transfusion to proceed if needed. It is important to account for volume of the TPN solution in the intraoperative record, especially for longer cases and in patients who need careful attention to total volume infused (e.g. renal failure and congestive heart failure patients).

54
Q

What is the reason that TPN can not be administered peripherally?

A

TPN that was meant for central administration should not be switched to a peripheral intravenous site because peripheral veins cannot tolerate osmolarity greater than 750 mOsm/L. The peripheral route is mainly used for short-term feeding when central access is not available thus; TPN should not be switched for routine use of a central line. Further, specialized formulations with lower osmolarity are used for peripheral administration. If supplementary central access is needed, consideration for insertion of an additional central line should occur or replacement of the current line with one that includes more lumens.

55
Q

Why blood should not be administered through the same line as TPN using Y-site or piggyback connections?

A

Packed red blood cells should not be administered through the same intravenous line as TPN because dextrose causes hemolysis of red blood cells.

56
Q

How hyperglycemia induced by stress and will insulin be high or low in stress state?

A

The stress response to critical illness such as sepsis triggers the hypothalamic-pituitary-adrenal (HPA) axis to release cortisol, which promotes hyperglycemia. Meanwhile, pro-inflammatory factors inhibit insulin release from the pancreas. Insulin itself decreases the body’s inflammatory response while hyperglycemia potentiates it.

57
Q

The manifestation of Pericardial tamponade on the central venous pressure waveform … where in Constrictive pericarditis …

A

exaggerated X-descent and attenuated Y-descent

exaggerated X and Y-descent on CVP tracing

58
Q

Hemodynamic goals for cardiac tamponade are best described as keeping the patient …

A

fast (tachycardia), full (hypervolemia), and tight (increased SVR). Some sources describe the goals as “fast, full, and strong” where strong relates to contractility. Either way, cardiac output becomes mostly heart rate dependent so measures that reduce heart rate should be avoided.

59
Q

The most common cause of adrenal insufficiency in patients with critical illness in the intensive care unit?

A

Subnormal production of corticosteroids in the absences of structural defects in the hypothalamic-pituitary-adrenal axis is termed functional adrenal insufficiency.

60
Q

what Vent setting avoided in ARDS?

A

Plateau pressures greater than 30 cm H2O, tidal volumes greater than 6 mL/kg, and FiO2 greater than 0.5 should generally be avoided.

Tidal volume is calculated by IBW, with 6 mL/kg being preferred over 12 mL/kg:

  • M: IBW = 50 kg + 2.3 kg for each inch over 5 feet
  • F: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet
61
Q

Agents effective against MRSA like vancomycin, daptomycin, and linezolid are only effective against Gram-positive organisms. what other agents effective against MRSA and Gram Negatives?

A

Ceftaroline, tigecycline, and TMP-SMX have the broadest spectrum of activity effecting both Gram positives and some Gram negatives

62
Q

Antibiotics options for hospital-associated MRSA include:

A
  • Ceftaroline
  • Daptomycin
  • Linezolid
  • Quinupristin/dalfopristin
  • Teicoplanin
  • Tigecycline
  • Vancomycin
63
Q

Which type of nutrition has the lowest respiratory quotient (RQ) may be beneficial in changing patient’s diet to facilitate ventilator weaning?

A

A lower RQ would decrease CO2 production and may improve the chances of successful ventilator weaning. Respiratory quotient refers to the amount of CO2 produced per unit of O2 consumed to a specific energy substrate. Generally the number 0.8 is used for the Q due to a relatively high mix of carbohydrates and proteins in the diet. Lipids have the lowest Q at 0.7 and thus will result in a decrease in CO2 production compared with carbohydrates (Q of 1) and proteins (Q of 0.8).

64
Q

What is “Sedation Vacation”?

A

Once intubated for respiratory failure, it is the standard of care to give patients a daily awakening trial (“sedation vacation”) and an SBT. Patients who are able to breathe spontaneously with minimal or no ventilator support for at least 30 minutes are usually considered candidates for extubation, presuming there are no other contra-indications to extubation. Longer SBT times (>120 min) or multiple SBTs in a single day do not seem to offer a further advantage in predicting who will fail extubation but may contribute to patient fatigue.

For patients who fail an initial SBT due to respiratory distress, apnea, or other causes, a weaning strategy should be chosen. Progressive decrease in pressure support ventilation, where the support for patient triggered breaths is slowly weaned, is the most common mode of ventilator weaning, especially when combined with daily SBTs to assess readiness to extubate. Patients with significant obesity or smaller ET tubes may derive additional benefit from SBTs with pressure support to help overcome resistance generated from the ET tube.

65
Q

Percutaneous tracheostomy is typically avoided in pediatric patients. Percutaneous tracheostomy can be safely performed in the presence of:

A
  • Obesity
    • Neutropenia
    • History of sternotomy
    • Spinal cord injury
    • Repeat tracheostomy
66
Q

There are a few absolute contraindications for percutaneous tracheostomy:

A
  • Active infection at the site of tracheostomy
  • Uncontrolled bleeding disorder
  • Unstable cardiopulmonary status (shock, extremely poor ventilatory status)
  • Patient unable to stay still
  • Abnormal anatomy of the tracheolaryngeal structures
67
Q

A possible complication of tracheostomy is a tracheoesophageal fistula, which will present with

A

an air leak.

68
Q

There are four indications for a tracheostomy:

A

1) Emergency airway access
2) Airway access for continuing mechanical ventilation
3) Functional or mechanical upper airway obstruction
4) Decreased/incompetent clearance of tracheobronchial secretions

69
Q

Compared to an open surgical approach, percutaneous tracheostomy has some advantages.

A
  • Avoids deep neck dissection
    • Can be performed by non-surgeons
    • Can be performed at bedside (lowers costs/delays)
    • Lower incidence of stoma infection
    • Lower incidence of significant bleeding
70
Q

The RASS is an …

A

agitation sedation score. If the patient has any score other than 0 than the patient is positive for an altered mental status.

RASS zero is defined as calm, alert, and appropriate.

71
Q

The CAM-ICU screen is a …

A

Quick screening tool which is used to assess for delirium. It uses acuteness or fluctuation in course along with inattention for the initial part of the screen. Additionally, the patient must have either an altered level of consciousness or disorganized thinking to test positive for delirium.

72
Q

The qSOFA criteria are scored from 0-3 with one point for each of the following:

A

altered mental status (GCS < 15), respiratory rate ≥ 22, and systolic blood pressure ≤ 100 mm Hg.

73
Q

Hyperalimentation (TPN) is commonly associated with …

A

hypophosphatemia, hypo or hyperglycemia, and acute liver injury. Patients on total parenteral nutrition (TPN) require vitamin K supplementation and often have an elevated prothrombin time.

74
Q

The risk factors for a patient being at risk for MDR (Multi-Drug Resistance) organisms is as follows …

A
  • In a hospital more than 5 days at the time of diagnosis
  • Have history of prior antibiotics use
  • Have recent hospitalization within 90 days
  • Are admitted from a nursing home, long-term care facility, or dialysis center
75
Q

Electrolytes abnormalities results from hyperventilation …

A

Respiratory alkalosis, such as from hyperventilation, can cause electrolyte abnormalities such as hypocalcemia, hypokalemia, and hypophosphatemia. Hypocalcemia is caused by increased calcium binding to negatively charged plasma proteins as the proteins release hydrogen ions to restore physiologic pH

76
Q

Sepsis and septic shock are medical emergencies and should be rapidly and aggressively managed as soon as a diagnosis is made. The Surviving Sepsis Campaign Guidelines are …

A

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

77
Q

Dose sepsis cause increase or decrease mixed venous oxygen saturation levels?

A

Sepsis usually causes a decrease in SvO2, but can also cause an increase due to high flow state and/or poor oxygen utilization.

78
Q

Mixed venous oxygen saturation levels are INCREASED in the following settings:

A
  • Increasing the hemoglobin concentration via blood transfusions
  • Increased SaO2
  • Decreased VO2 (e.g. cyanide toxicity, sepsis, carbon monoxide poisoning, methemoglobinemia, hypothermia)
  • Increased CO (e.g. sepsis)

A left to right intracardiac shunt, in addition to increasing cardiac output, also shifts oxygenated blood from the left side of the heart to mix with deoxygenated blood on the right side, thereby falsely elevating the SvO2.

79
Q

Mixed venous oxygen saturation levels are DECREASE in the following settings:

A
  • Increased oxygen consumption (e.g. hyperthermia, shivering, or pain)
  • Decreased cardiac output (e.g. myocardial infarction or hypovolemia)
  • Decreased hemoglobin concentration
  • Decreased arterial oxygen saturation
80
Q

The static compliance of the respiratory system indicates the “stiffness” of the respiratory system, which includes the lungs and chest wall

A

CS = VT ÷ (PPL – PEEP)

Where: CS is static compliance, VT is tidal volume, and PPL is plateau pressure.

81
Q

Dynamic pulmonary compliance calculation?

Dynamic respiratory system compliance, which is also a reflection of respiratory system resistance, can be measured at any point during inspiration when there is airflow.

A

DC = VT ÷ (Peak – PEEP)

82
Q

Normal values of following

PVR
SVR
CO
VCO2
VO2
A 
1200 dynes/sec/cm5
200 dynes/sec/cm5
5 L/min
200 ml/min
250 ml/min

(Note: when VO2 is 250 and VCO2 200, RQ is 0.8)

83
Q

Dysoxia?

A

It is impaired oxygen extraction by tissue, buzzword for sepsis where Satmv worsening/decreasing due to inadequate delivery of O2 and reaches the point where Venus O2 decreases due to the decreasing in delivery of O2 (DO2)

84
Q

Interpretation of low Satmv?

A

If delivery of O2 is ok (DO2)

Then check;

PaO2 -> if low (increase FiO2, or PEEP)

Hb -> transfuse if low

CO -> IVF/inotrope if low

If no further optimization of DO2 then think about decreasing VO2, decreasing Temp, nutrition, or paralyze which all are bad options

85
Q

Normal CVP tracing summary:

A

a wave: (a)trial contraction, absent in atrial fibrillation
c wave: (c)usp, TV bulging into RA during RV isovolumetric contraction
x descent: TV descends into RV with ventricular ejection and atrial rela(x)ation
v wave: (v)enous return to and systolic filling of the RA
y descent: atrial empt(y)ing into RV through open TV

86
Q

Septic shock metabolic effect manifested by …

A

Increased cellular respiration, protein catabolism, and metabolic acidosis with a compensatory respiratory alkalosis.

87
Q

Organisms involved in early-onset (48-72 hours) adult ventilator-associated pneumonia (VAP) are …

A

methicillin-sensitive Staphylococcus aureus (MSSA), Haemophilus influenzae, Streptococcus pneumoniae (Pneumococcus), as well as Proteus, Klebsiella, and Enterobacter species.

They does not typically affect morbidity and mortality, unlike late-onset VAP.

88
Q

Late-onset VAP is associated with a fairly high mortality rate and is caused by more virulent organisms such as

A

methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species.

89
Q

Why placement of a left-sided central line is associated with increased complications? what are they?

A

There is an increased incidence of arterial puncture because the left internal jugular vein is often smaller and overlays the internal carotid artery more often than the right. Additionally, the more tortuous course increases the incidence of malposition.

90
Q

Acidosis is associated with numerous abnormalities including:

A

1) Reduced cardiac contractility, decreased SVR, and, QT abnormalities.
2) Catecholamines bind to receptors with significantly less efficacy at lower pH than at a normal pH.
3) There is also an increased likelihood of arrhythmias with severe acidosis.

91
Q

Formula to calculate HCO3- deficit and bolus dose?

A

Sodium bicarbonate (mEq) = 0.2 * patient weight (kg) * base deficit

Bolus formula:
Initial sodium bicarbonate (mEq) = [0.3 * patient weight (kg) * (24 – patient HCO3 mEq/L)]/2

92
Q

What to make sure before giving bicarbonate?

A

Sodium bicarbonate should not be administered to a patient with respiratory depression or respiratory failure unless the patient is mechanically-ventilated. Sodium bicarbonate will be converted to CO2 and if a respiratory compensation cannot occur, respiratory acidosis will worsen the acidosis.

Anesthesia subspecialty (9 decks)

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