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Anesthesiology Advanced TL > Critical Care > Flashcards

Critical Care Flashcards

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1
Q

How does clostridium botulinum toxin work?

A

Cleaves SNARE proteins which prevents the release of ACh from storage vesicles in the NMJ, resulting in significant muscle weakness or flaccid paralysis

ACh = Acetylcholine; NMJ = Neuromuscular Junction

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2
Q

What is the last step in clinical assessment of brain death?

A

Apnea testing

Confirmatory testing is optional for death determination in adults

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3
Q

What is the clinical criteria for brain death?

A

Must be a known cause with evidence of acute, catastrophic, irreversible brain injury; reversible conditions must be excluded. The patient must have:
* Temperature > 36C
* No chance of drug intoxication, neuromuscular blockade, or shock
* Does not respond to commands
* No spontaneous movements
* Nonreactive pupils
* No oculocephalic reflex
* No corneal reflexes
* No gag reflex
* No spontaneous ventilation

These criteria ensure accurate diagnosis of brain death.

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4
Q

What is septic shock?

A

A type of distributive shock defined as sepsis with hypotension despite adequate fluid resuscitation, characterized by:
* Decreased effective circulating volume
* Increased vasodilation and tissue permeability
* Requires elevation in plasma lactic acid levels > 2
* Requirement for vasopressors to maintain MAP > 65
* Hypotension, high cardiac output, low systemic vascular resistance, decreased tissue perfusion

MAP = Mean Arterial Pressure

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5
Q

What is phosgene?

A

A chemical warfare agent that can lead to significant pulmonary damage with no specific antidote; treatment is supportive care

Phosgene exposure can cause severe morbidity and mortality.

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6
Q

When should clinical examination not be used for brain death?

A

Confirmatory tests should not replace clinical examination but only when clinical criteria cannot be applied, such as:
* Presence of heavy sedation or muscle paralysis
* Cranial nerves cannot be properly examined
* Apnea test cannot be completed
* Shortened observation period

Confirmatory tests include cerebral angiography, transcranial Doppler, MRI angiography, CT angiography, radionuclide brain imaging, and electroencephalography.

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7
Q

What does the EKG look like on tricyclic antidepressant (TCA) overdose?

A

Hallmark is prolonged QRS interval; other findings include:
* PR and QT interval prolongation
* Block within His-Purkinje system
* Intraventricular conduction delays

EKG changes result from inhibition of sodium influx and potassium efflux during repolarization.

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8
Q

What is the acute discontinuation of TPN associated with?

A

Hypoglycemia

The significant carbohydrate load in TPN causes the pancreas to secrete excess insulin, leading to hypoglycemia upon abrupt cessation.

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9
Q

What are the diagnostic criteria for ARDS?

A

Includes:
* Hypoxemia (PaO2/FiO2 < 300)
* Acute onset within 7 days of known clinical insult
* Bilateral opacities on chest imaging
* Pulmonary edema not explained by another cause

ARDS = Acute Respiratory Distress Syndrome.

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10
Q

What is the respiratory quotient (RQ)?

A

Volume of CO2 released over the volume of O2 consumed during respiration or when a substance is metabolized (RQ = VCO2/VO2)

RQ provides insight into metabolic processes.

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11
Q

Which organisms are most likely to cause early-onset adult ventilator-associated pneumonia?

A

Antibiotic sensitive flora include:
* Methicillin-sensitive Staphylococcus aureus
* Haemophilus influenzae
* Streptococcus pneumoniae
* Proteus, Klebsiella, and Enterobacter

Early-onset pneumonia does not typically affect morbidity and mortality.

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12
Q

What is the most important electrolyte to monitor following the diagnosis of brain death?

A

Sodium; Na < 155 is a goal for organ procurement after brain death

Up to 80% of patients experience diabetes insipidus post-brain death.

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13
Q

What are the 10 major donor management goals (DMGs)?

A
  • MAP 60-120 mmHg
  • CVP 4-12
  • Final Na < 155 or 135-160
  • Pressors < 1 ideal or low dose
  • PaO2/FiO2 ratio > 300
  • pH on ABG 7.25-7.5
  • Glucose < 150
  • Urine Output 0.5-3
  • LV EF (%) > 50
  • Hgb > 10

DMGs are crucial for effective organ procurement.

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14
Q

What are the risk factors for multi-drug resistant pathogens causing ventilator-associated pneumonia?

A

Risk factors include:
* 5 or more days of hospitalization at pneumonia onset
* Prior intravenous antibiotic use within 90 days
* Septic shock at occurrence
* ARDS or acute renal replacement therapy prior to onset

Patients with these risk factors need empirical treatment with two anti-pseudomonal antibiotics and MRSA coverage.

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15
Q

What are the indications for various antibiotics?

A

Indications include:
* Serratia marcesens – aminoglycosides (gentamicin, amikacin, tobramycin)
* MRSA – vancomycin
* Gram positive skin flora – first generation cephalosporins

Appropriate antibiotic selection is essential for effective treatment.

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16
Q

Which blood products carry the highest risk of transfusion-related acute lung injury (TRALI)?

A

FFP (fresh frozen plasma); platelets are second

TRALI is a serious complication associated with transfusion.

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17
Q

What is the mechanism of action of clostridium botulinum?

A

Causes a flaccid neuroparalysis by preventing fusion and release of vesicles containing acetylcholine at the neuromuscular junction

Understanding the MOA is crucial for treatment strategies.

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18
Q

What are medications that commonly cause drug fever?

A
  • Amphotericin
  • Cephalosporins
  • Penicillins
  • Phenytoin
  • Procainamide
  • Quinidine
  • Hydralazine
  • Cimetidine
  • Streptokinase
  • Carbamazepine
  • Rifampin
  • Vancomycin

Treatment involves stopping the offending medication and providing supportive care.

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19
Q

What is the treatment of choice for methemoglobinemia in patients with G6PD deficiency?

A

Ascorbic acid

G6PD deficiency complicates treatment options.

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20
Q

What is methemoglobinemia?

A

Fe2+ becomes Fe3+ due to agents like prilocaine, benzocaine, nitroglycerin, sodium nitroprusside, phenytoin, sulfonamides, and metoclopramide; causes functional anemia and left shift of the oxygen-hemoglobin dissociation curve

Oxygen saturation of 84-85% on pulse oximetry; treatment includes methylene blue or ascorbic acid in G6PD patients.

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21
Q

What is the highest priority in drowning after pulmonary and cardiovascular systems have been stabilized?

A

Optimizing cerebral perfusion and minimizing intracranial pressure after hypoxic-ischemic cerebral injury

Cerebral protection is critical for recovery.

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22
Q

What is CAM-ICU?

A

Confusion Assessment Method for the Intensive Care Unit, used to assess for delirium

It assesses acuteness or fluctuation in course along with inattention.

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23
Q

What is the initial treatment for cyanide poisoning?

A

Supplemental oxygen and hydroxocobalamin

Sodium thiosulfate is administered afterward; nitrites can worsen carbon monoxide-induced hypoxia.

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24
Q

What does qSOFA stand for?

A

Quick Sequential (Sepsis Related) Organ Failure Assessment

Components include altered mentation status, respiratory rate > 22/min, and SBP < 100.

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25
What are the cardiovascular derangements seen in obstructive shock?
* Decreased pulmonary capillary wedge pressure * Decreased cardiac output * Decreased mixed venous oxygen saturation * Increased systemic vascular resistance ## Footnote Tension pneumothorax decreases venous return.
26
What is common in victims who survive drowning regardless of the source of water?
Hypoxic-ischemic encephalopathy, leading to cerebral edema and elevated intracranial pressures ## Footnote Treatment can include hypertonic saline and diuretics.
27
What is inhaled nitric oxide used for?
A potent pulmonary vasodilator used in the treatment of pulmonary hypertension; can cause methemoglobinemia ## Footnote It does not significantly affect systemic blood pressure.
28
What is the role of corticosteroids in septic shock?
Patients with septic shock not responsive to fluid resuscitation and vasopressors may benefit from corticosteroid replacement, such as hydrocortisone 200 mg IV per day ## Footnote Steroids are not recommended for patients responsive to fluids or vasopressors.
29
What is the urinary anion gap?
Measures the net electrochemical neutrality in urine; indicates the presence of unmeasured ionic substances ## Footnote In renal tubular acidosis, the urine anion gap will be neutral or elevated despite systemic acidosis.
30
What is strong ion difference (SID)?
SID = (strong cations) - (strong anions) = (Na + K + Ca + Mg) - (Cl + lactate); normal is 40-42 ## Footnote Changes in SID affect plasma pH and can lead to alkalosis or acidosis.
31
What does resuscitation of an unresponsive drowning victim begin with?
Rescue breaths then initiation of cardiopulmonary resuscitation ## Footnote Immediate action is crucial for survival.
32
What are broad spectrum antibiotics effective for treatment of MRSA?
* Ceftaroline * Tigecycline * TMP-SMX ## Footnote These antibiotics treat both gram positives and gram negatives.
33
What is acidosis?
A condition characterized by an increase in acidity in the blood and other body tissues ## Footnote Acidosis can result from various factors, including respiratory or metabolic issues.
34
What effect does high nasogastric tube output have on plasma SID?
It increases plasma SID, causing alkalosis ## Footnote Plasma SID refers to the strong ion difference, which can significantly affect acid-base balance.
35
What does resuscitation of an unresponsive drowning victim begin with?
Rescue breaths then initiation of cardiopulmonary resuscitation
36
What broad spectrum antibiotics are effective for treatment of MRSA?
* ceftaroline * tigecycline * TMP-SMX ## Footnote These antibiotics are effective against both gram-positive and gram-negative bacteria.
37
Which stress situation is characterized by an initial increase in arginine vasopressin (AVP) followed by a decrease?
Septic shock
38
What is the management of hemorrhagic shock?
* Early balanced blood product administration * Limited crystalloid or colloid therapy ## Footnote Early recognition and treatment with balanced blood products improve long-term survival in bleeding trauma patients.
39
What is hypovolemic shock?
* Decrease in intravascular volume * Decrease in pulmonary capillary wedge pressure * Decrease in cardiac output * Increased systemic vascular resistance ## Footnote Tissues extract more oxygen due to decreased blood flow, leading to lower mixed venous oxygen saturation.
40
What is the first line medication in the treatment of acute cocaine intoxication?
Benzodiazepine ## Footnote Benzodiazepines decrease central nervous sympathetic outflow and beta blockers should be avoided due to potential risk of unopposed alpha adrenergic stimulation.
41
What risk does cyclosporine carry?
Nephrotoxicity ## Footnote Other drugs with specific toxicities include tacrolimus (nephrotoxicity), doxorubicin and daunorubicin (cardiotoxicity), and methotrexate (myelosuppression).
42
What is the management of sepsis and septic shock?
* Broad spectrum antibiotics started in the first hour * 30 mL/kg of intravenous crystalloid within the first 3 hours * Vasopressor therapy targeting an initial MAP of 65 mmHg, with norepinephrine as the recommended initial vasopressor
43
Which mode of ventilation is most appropriate for weaning a patient from mandatory controlled mechanical ventilation?
Pressure support ## Footnote Evaluating whether patients will resume ventilation on their own can be done through a spontaneous breathing trial or pressure support trial.
44
What is tension pneumothorax?
A subtype of pneumothorax where air enters the pleural space on inspiration but cannot exit, leading to increased pressure and potential lung collapse ## Footnote Clinical signs include oxygen desaturation, hypotension, tachycardia, and narrowing pulse pressure.
45
What is the most common root cause of multiple organ dysfunction syndrome (MODS)?
Sepsis ## Footnote MODS involves altered functionality of at least two organs due to critical illness, assessed with lactic acid and mixed venous oxygen saturation.
46
How to calculate the amount of sodium bicarbonate needed perioperatively to correct metabolic acidosis?
Sodium bicarbonate = 0.2 * patient weight (kg) * base deficit
47
What is the standard initial therapy for TCA toxicity?
Sodium bicarbonate ## Footnote It increases serum pH, favoring the non-ionized form of the drug, making it less available to bind to fast sodium channels.
48
Which value is not directly measured in arterial blood gas analysis?
Base excess ## Footnote Directly measured values include pH, PaCO2, and PaO2.
49
Enteral vs parenteral nutrition: what is the advantage of enteral feeding?
Facilitates maintenance of gut integrity and should be initiated early in critically ill patients ## Footnote Parenteral nutrition should not be started for at least 7 days except in special circumstances.
50
What is refeeding syndrome and its relation to phosphate?
Severe hypophosphatemia during aggressive refeeding can reduce ATP availability and alter enzymatic activities ## Footnote Complications include weakness, myocardial depression, arrhythmias, and impaired oxygen delivery.
51
What is the Parkland formula?
4 mL x %TSBA x weight (kg) ## Footnote Used for estimating initial 24-hour fluid resuscitation after a total body surface area burn.
52
What test has high sensitivity and low specificity for C. difficile and is used as a screening test?
Enzyme immunoassay (EIA) or nucleic acid amplification test for glutamate dehydrogenase ## Footnote Confirmatory tests include EIA for toxins A and B.
53
What is the most important measure to reduce the risk of central line associated bloodstream infections?
Strict adherence to proper hand hygiene and aseptic technique during insertion and dressing changes ## Footnote Other measures include appropriate catheter selection and site care.
54
What anatomical characteristic increases the risk of complications with left internal jugular vein cannulation?
When the head is rotated to the contralateral side > 30 degrees, increasing the risk of carotid puncture ## Footnote The right IJV is often preferred due to its larger diameter and more direct path to the superior vena cava.
55
What is hypophosphatemia?
Occurs when phosphate levels drop below 2.5 mg/dL, leading to severe dysfunction at levels < 1 mg/dL ## Footnote Decreased 2,3 biphosphoglycerate levels can cause a left shift in the oxygen-hemoglobin dissociation curve.
56
What are absolute contraindications for percutaneous tracheostomy placement?
* Operator inexperience * Infants * Insertion site infection * Severe/uncontrolled coagulopathy * Unstable cervical spine injury ## Footnote Relative contraindications include abnormal anatomy such as tracheomalacia.
57
What are general indications for tracheostomy placement?
* Emergency airway access * Airway access for continuing mechanical ventilation * Functional or mechanical upper airway obstruction * Decreased/incompetent clearance of tracheobronchial secretions
58
What is the risk of seroconversion for each bloodborne infection after needlestick injury?
Hepatitis B > Hepatitis C > HIV
59
Why is clinical examination considered superior to ancillary testing for brain death diagnosis?
Because of the limitations and confounding factors in ancillary studies ## Footnote Ancillary studies can support diagnosis when clinical examination prerequisites cannot be met.
60
What are the four anatomical sites recommended for intraosseous (IO) access?
* Sternum (manubrium) * Proximal humerus * Proximal tibia * Distal tibia
61
Which antifungal inhibits 1,3 beta D glucan synthase and cell wall synthesis?
Echinocandins (micafungin) ## Footnote First line treatment of candidemia.
62
What characterizes pressure controlled ventilation?
Constant inspiratory pressure, decelerating inspiratory flow, and more homogenous distribution of tidal ventilation ## Footnote Associated with lower peak airway pressure and higher mean airway pressure compared to volume controlled ventilation.
63
What is pyridostigmine used as prophylaxis for?
Nerve agent exposure (sarin gas, soman, tabun, VX) ## Footnote They are organophosphates acting as acetylcholinesterase inhibitors.
64
What is the mnemonic for remembering cholinergic effects?
Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, Emesis, Miosis
65
What should be monitored during total parenteral nutrition (TPN)?
Electrolytes, specifically potassium, phosphate, glucose ## Footnote Blood should not be administered through the same line as TPN.
66
What is the initial compensatory mechanism for acute respiratory acidosis due to hypoventilation?
Plasma protein buffers, followed by renal retention of bicarbonate hours to days later
67
What are prevention measures for intravascular catheter related infections?
* Educating healthcare personnel * Using maximal sterile barrier precautions * Using > 0.5% chlorhexidine skin preparation * Avoiding routine replacements * Using chlorhexidine-impregnated dressings ## Footnote A minimum of a cap, mask, sterile gloves, and a small sterile fenestrated drape should be used during arterial catheter insertion.
68
What drug best treats the central neurologic symptoms of nerve gas poisoning?
Atropine ## Footnote It is an anticholinergic agent that helps block the muscarinic effects of nerve gases.
69
What happens to acid-base status after large volume resuscitation with normal saline?
* Decrease in plasma SID * Results in dilutional acidosis ## Footnote This occurs with large saline infusion where metabolic acidosis results from the reduction in strong ion difference.
70
What is the treatment for nerve gas exposure?
Early resuscitation with atropine, oxygen, respiratory support, and fluids to improve oxygen delivery to tissues.
71
What is the effect of large volume resuscitation with normal saline on plasma SID?
Decreases the plasma SID, resulting in dilutional acidosis.
72
What causes a hyperdynamic cardiac state in cirrhosis?
Increased cardiac output and decreased systemic vascular resistance secondary to vasodilating factors like nitric oxide.
73
Which neuromuscular blocking drug has an active metabolite that is nearly as potent as the parent drug?
Vecuronium, with the metabolite 3-desacetyl-vecuronium having 80% of its potency.
74
What are recommendations for ventilator-associated pneumonia prevention?
* Avoiding intubation with noninvasive positive pressure ventilation * Daily sedation weaning with spontaneous breathing trials * Early mobilization * Subglottic secretion drainage ports on endotracheal tubes * Avoidance of changing the ventilator circuit * Elevating the head of the bed to 30 to 45 degrees.
75
How is systemic vascular resistance (SVR) calculated?
SVR = 80 * (MAP - RAP) / CO, with CVP substituted for RAP.
76
What are early manifestations of aspirin toxicity?
* Tinnitus * Vertigo * Nausea and vomiting * Diarrhea * Respiratory alkalosis (hyperventilation).
77
What treatment is most likely to attenuate some effects of radiation exposure?
Potassium iodide, effective at reducing I-131 uptake by the thyroid.
78
What is propofol infusion syndrome?
A rare complication of prolonged, high-dose propofol administration characterized by metabolic lactic acidosis, cardiac failure, renal failure, rhabdomyolysis, hyperkalemia, hypertriglyceridemia, hepatomegaly, and pancreatitis.
79
What are preventative measures for catheter-related bloodstream infections?
* Use of appropriate hand hygiene * Use of chlorhexidine for skin preparation (>0.5% chlorhexidine preparations) * Use of full barrier precautions during central venous catheter insertion * Avoidance of the femoral vein for catheter placement in adults * Removal of nonessential catheters.
80
What supportive modalities are used in the treatment of ARDS?
* Tracheal intubation * Mechanical ventilation with low tidal volumes (6-8 mL/kg) * Low plateau pressure (< 30) * Increased PEEP.
81
What results from organophosphate poisoning?
Cholinergic crisis due to an overabundance of acetylcholine at the synaptic cleft.
82
What occurs with saltwater drowning in survivors?
Aspiration leads to pulmonary surfactant dilution and disruption of the alveolar-capillary membrane.
83
What are the hemodynamic parameters of cardiogenic shock?
* Severe hypotension * Elevated pulmonary capillary wedge pressure * Decreased cardiac output/index.
84
What are the 5 causes of hypoxemia?
* Hypoventilation (normal A-a gradient) * Ventilation/perfusion mismatch * Right to left shunt * Diffusion impairment * Low PO2 (normal A-a gradient).

Anesthesiology Advanced TL (5 decks)

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