exam 3 Flashcards
(444 cards)
1
Q
what is the leading cause of cancer deaths in the US
A
bronchogenic cancer
2
Q
COPD patients are __x more likely to get lung cancer
A
4x
3
Q
___% needing resections are disqualified due to poor pulmonary function
A
40%
4
Q
biggest risk factor for lung cancer
A
smoking
5
Q
Consider __-week delay if coronary bypass needed
A
6-week
6
Q
true or false
radiographic airway evaluation for mediastinal masses
is very important
A
true
7
Q
neuroendocrine tumors cause
A
carcinoid syndrome
8
Q
______calcemia occurs in up to 25% of lung cancer patients
A
HYPER
9
Q
symptoms of HYPERcalcemia
A
polyuria
polydipsia
confusing
vomiting
abd cramping
bradycardia
10
Q
Paradoxical breathing
Tympanic chest percussion
Rhonchi
Wheezing
A
COPD symptoms
11
Q
Jugular vein distention
Peripheral edema
Split S2
Rales
A
cor pulmonale
12
Q
CXR looks at
A
Evaluation for airway infringement*
Tracheal shift*
CHF
PTX
PA enlargement (signs of increased PulmVR)
13
Q
Tall R in V1
A
RVH
14
Q
Biphasic P in V1
A
R atrial hypertrophy
15
Q
Pathologic Q waves + LVH
A
increased risk of ischemia/infarction
16
Q
EKG
A
tall R
biphasic P
ST depression
BBB
T inversion
Pathologic Q wave
LVH
17
Q
Best INITIAL tool for pulmonary HTN
A
echo
18
Q
room air COPD
> ___ = poor function
A
> 45
19
Q
spO2 < ___ = increased risk of postop complications
A
<90%
20
Q
albumin < ____ = 2.5x risk
A
<3.6
21
Q
BUN > ___
A
> 2
22
Q
Pulm Function Tests
“Significant improvement” = ___% increase in FEV1 after bronchodilators
A
12%
23
Q
true or false
NO single test is a good predictor or lung function
A
true
24
Q
increased risk
PPO FEV1 & DLCO <___%
VO2 max <___-___
A
<40%
VO2 < 10-15*
25
Maximum volume of O2 utilization
vo2 max
26
vo2 max
Ability to climb 5 flights of stairs = >___
Inability to climb 1 flight = <____
>20 for 5 flights
<10 for 0 flights
27
forced expiratory volume/1 second
FEV1
28
diffusion in the lung of carbon monoxide
DLCO
29
mortality for smokers with lung cancer
1.5% mortality
30
pack-year index***
packs/____ x ______
packs/day x years
31
pack year index
>___ = increased complications over "moderate" smokers
>20
32
cessation of smoking
<___ weeks has NO difference in outcomes
<4
33
best option for cessation of smoking
8 weeks
34
which lead EKG for dysrhythmias
Lead II
35
which lead EKG for ischemia
V5
36
which side should the aline be on
dependent
37
CVP should be inserted on*
NON-dependent, operative side
38
trachea
___-___ cm long
11-12
39
trachea begins
C6 (cricoid cartilage)
40
trachea bifurcates
T5 (stermomanubrial joint)
41
which bronchus is WIDER and has LESS of an angle
R mainstem bronchus
(20 degrees)
42
which bronchus is NARROWER and has STEEPER angle
L mainstem bronchus
(45 degrees)
43
3 lobes
R lung
44
*Orifice of R upper lobe:
__-__cm from carina
can be a major problem for double lumen tube
1-2cm
45
Orifice of L upper lobe:
__ cm from carina
5 cm
46
sitting up
zone 1
clavicle/apices
47
sitting up
zone 2
axillary
48
sitting up
zone 3
lower ribs/base
49
if you are LAYING down, on the L side, where is zone 3
mostly L lung
50
true or false
normal, sitting person
perfusion AND ventilation BOTH increase from apex to base
they are both HIGHEST at BASE
true
51
BASE is more compliant
most tidal breathing is here
true
52
lateral + awake
perfusion AND ventilation are higher/better in the _____________ lung
dependent
53
lateral + awake has NO change in V/Q
true
54
diaphargm is displaced
cephalad
55
lateral + anesthetized, spontaneous ventilation
which lung has better VENTILATION
NON-dependent
(better compliance)
56
lateral + anesthetized, spontaneous ventilation
which lung has better PERFUSION
dependent
(more gravity)
57
lateral + anesthetized, spontaneous ventilation
net result
V/Q mismatch
58
lateral + anesthetized + NMB, mechanical ventilation, chest closed
which lung has better VENTILATION
non-dependent
59
lateral + anesthetized + NMB, mechanical ventilation, chest closed
net result
GREATER V/Q mismatch
60
lateral + anesthetized + NMB, mechanical ventilation, chest closed
treatment
PEEP
61
lateral + anesthetized + NMB, chest open
net result
GREATEST V/Q mismatch
(large increase in ventilation for NON dependent lung)
62
lateral + anesthetized + chest open
mediastinum shifts ___________ due to
LOSS of negative intrathoracic pressure
downward
63
lateral + anesthetized + chest open
what is something that is a hypothetical situation that we do NOT want to occur (patient should be paralyzed)
"paradoxical" respiration
64
"paradoxical" respiration
what occurs during INSPIRATION
air FROM the open-chest non-dependent lung
moves into the
dependent lung
65
"paradoxical" respiration
what occurs during EXPIRATION
air moves FROM the dependent lung
to the
open-chest non-dependent lung
66
"paradoxical" respiration
air movement, net result
Vt moves back-and-forth between the lungs
67
treatment for "paradoxical" respiration
mechanical ventilation
PEEP
68
"paradoxical" respiration
net result
physiologic ________ in _____________ lung
physiologic SHUNT in DEPENDENT lung
69
which lung is better PERFUSED
dependent
70
which lung is better VENTILATED
non-dependent
71
PERFUSION without ventilation
SHUNT
dependent lung
72
VENTILATION without perfusion
DEAD space
NON-dependent lung
73
What is the worst V/Q mismatch?
Lateral + Anesthetized; Paralyzed; Chest Open
74
one-lung ventilation
we STOP ventilation to the _____-____________ lung
non-dependent is STOPPED
75
Non-dependent lung (which now has NO ventilation)
diverts/forces perfusion to dependent lung,
and DECREASES the shunt effect
hypoxic pulmonary vasoconstriction (HPV)
76
HPV
net result
less V/Q mismatch
less shunt
77
which lung is clamped
non-dependent = operative
78
what lumen tube is most often used
L
79
true or false
It does NOT matter what side the tube is in
it matters what lumen is clamped
true
80
sizing for females
35, 37
81
sizing for males
39, 41
82
what is sizing based on
height
83
external french range
26, 28, 35, 37, 39, 41
84
internal diameter
____-____mm
3.4-6.6 mm
85
DLT have large ______ diameter
outer
86
which lumen is BLUE
bronchial
87
which lumen is WHITE
tracheal
88
which lumen has the STYLET
bronchial
89
what type of blade
MAC
90
insert the DLT with an __________ curve
anterior
"shotgun"/over & under
91
once the DLT is through the vocal cords, turn it ____ degrees
turn it 90 degrees
92
advance DLT until resistance
females: ___ cm
27 cm
93
advance DLT until resistance
males: ___ cm
29 cm
94
true or false
inflate cuff
do F/O scope
position lateral
reverify with F/O
true
95
Up to ___% of DLTs are mal-positioned when verified by auscultation only
80%
96
absent/weak R breath sounds
tube is too shallow, occluding the distal trachea
97
where do you clamp
high, at the adapter
98
L DLT tube
R middle lobectomy, which side is clamped
tracheal (L) side
99
L DLT
L middle lobectomy, which side is clamped
bronchial (L) side
100
CONTRAindications for L DLT
distorted L main bronchus
compression of L main bronchus due to aortic aneurysm
L-sided:
pneumoectomy,
sleeve resection,
single lung transplant
101
*what is the most common DLT complication
malpositioning
102
Catheter with inflatable balloon to block operative lung bronchus
bronchial blockers
103
indications for bronchial blocker
difficult airways
ETT change risky
some children
infections/cysts/bullae
104
which lung would become shunt flow during OLV
this would be withOUT HPV kicking in
non-dependent=operative
a 40% shunt would result normally, without HPV
105
HPV occurs within
seconds
106
HPV improves SaO2 during ___-___% lung hypoxia: the usual condition present with OLV
20-80%
107
AVOID
______capnia with HPV
______thermia
HYPOcapnia
HYPOthermia
108
AVOID
>____ MAC
>1.5 MAC
109
which NMB agents are best for OLV
intermediate
110
true or false
regional sympathectomy does NOT effect HPV
true
111
Vt __-__ is ideal
6-8
112
limit PIP ___-___
20-25
113
it is BETTER to be HYPERcapnic
<___
< 60
114
use _________-limiting ventilation mode
pressure-limiting
115
true or false
R lung is larger than L, so hypoxemia will be WORSE in R-side procedures
true
116
The degree of drop when shifting to OLV is proportionate to perfusion of the ____-___________ lung:
non-dependent
The greater the initial drop in EtCO2 = the greater the chance of hypoxia during OLV!
117
what is most common cause of hypoxia
tube malposition
118
**if patient is hypoxic, which lung should be given PEEP 1st
NON-dependent = operative lung
start at 2 PEEP
119
unclamping, use PIP of ___-___ to re-inflate
30-40
120
which drugs are good to reinflate lung
nitriC oxide
prostacyclin
121
__________* to non-dependent lung + nitric to dependent lung = 100% increase in PaO2
Almitrine
122
promotes HPV in non-dependent lung
Carotid body chemoreceptor agonist
almitrine
123
mediastinal tumors
HTN
HYPERcalcemia
cushings
myasthenia
etc.
124
true or false
mediastinal mass surgery is very dangerous
true
125
Venous distention of thorax and neck
Redness/edema of face, neck, torso, airway, conjunctiva
SOB
Headache
Confusion
SUPERIOR Vena Cava Syndrome
126
place peripheral IVs in ______ extremities
lower
127
radiation ______ surgery
before
128
*MAJOR goal of mediastinal mass surgery
maintain SPONT ventilation
129
best choice for intubation
mediastinal mass surgery
awake F/O
130
what helps minimize turbulence
helium/O2 mixture
131
mediastinoscopy
you can knick something very easily!!!
true
132
which arm should be monitored due to pressure on innominate artery
R arm
133
For COPD patients with bullae
bullectomy
134
best anesthesia for bullectomy
low Vt
high RR
100% O2
PIP < 20
135
highest risk for complications
post-thoracotomy
>___ years
FEV1 DLCO <___%
ASA status > or = ___
>____ min surgery time
>80 years old
FEV1 DLCO < 40%
ASA 3
>80 min surgery time
136
highest risk factors for
acute lung injury
R pneumonectomy
overhydration*
high PIP
preop ETOH abuse
137
Chest tube drainage should NOT exceed
< 500 ml/day
138
____ ml/day = surgical exploration
200 ml/day
139
treatment for supraventricular dysrhythmias
beta blockers
140
which artery can lead to spinal cord injury
radicular
141
3 ABSOLUTE CONTRAindications to laparoscopic proceudres
diaphragmatic hernia*
CHF*
peritonitis*
ileus
intraperitoneal hemorrhage
severe cardiopulm disease?
bowel obstruction?
142
when does the uterus interfere
23rd week
143
we want a slightly _________ state for mother
alkalotic
144
___ degree L uterine displacement
30 degree
145
pregnancy
limit intraperitoneal pressures to < or = ____
12
146
what are the 4 potential causes of major physiologic changes during pregnancy
creation of pneumoperitoneum
Potential for systemic absorption of CO2
Initial trendelenburg position
Reverse trendelenburg position
147
best gas to use
CO2
148
HYPERcarbia leads to _____________ acidosis
respiratory
149
insufflate at a pressure <___ (3L)
<19
150
once distended, maintain pressure at ___
12 maintenance
151
> ___% of complications occur during entry and insertion of trocars
>50%
152
___-___% of injuries from the beginning of the case are NOT diagnosed intraop, resulting in
mortality of 3.5-5%
30-50%
153
true or false
we canNOT control the volume of CO2 absorbed
true
154
pneumoperiteneum
INCREASED:
___
___
___
____
____
____
SVR,
MAP,
HR
CVP (initially, then decreased)
CBF
ICP
155
pneumoperiteneum
DECREASED:
_________ ________
___
___
___
___
___
_________ __________
______ __________
____ __________
venous return
SV
CVP
CI, initially
UOP
GFR
creatinine clearance
pulm compliance
lung volumes
156
what can help the decrease in SV
periop hydration
change patient position (put in t-burg)
compression stockings
157
bradycardia can occur with INITIAL insufflation
who is MOST at risk*
young, healthy patients
158
best treatment for bradycardia
stop insufflation
159
**_________ myocardial filling pressures INITIALLY, followed by sustained __________ in preload (decreased venous return)
Increased initially, followed by decrease
160
avoid _____ventilation
with pneumoperiteneum
avoid HYPOventilation/hypercarbia
161
true or false
pneumoperitenum
hypoxemia is NOT normally seen with healthy patients
true
162
best PEEP and Vt for laparoscopic **
5-8
163
how do we help the respiratory acidosis that occurs with laparoscopic procedures
increasing RR (this increases Mv)
164
max CO2 absorption pressure
10
165
PaCO2 reaches plateau ___ min after start of insufflation
40 min
166
rate of absorption
is determined by (3)
tissue solubility
blood flow
diffusion pressure
167
PaCO2
Increased absorption with _____peritoneal
extra
168
EtCO2 ACCURATELY predicts changes in PaCO2 with (2)
HEALTHY
mechanically ventilated patients
169
sick, pulm, cardiac patients need to check PaCo2 how
with aline (since EtCO2 is NOT accurate)
170
___-___ degrees t-burg for decreased risk with small/bowel
10-20 degrees
171
what can occur with t-burg
R mainstem intubation
172
Combined with pneumoperitoneal pressure, the trendelenburg position increased ICP ___% over baseline
150%
173
durant position
L lateral tilt
we want to avoid air bubble going to RV outflow
174
reverse t burg
head UP tilt
175
t burg
head DOWN tilt
176
reverse tburg
decreased:
venous return
LVEDV
EF (only in SICK)
177
reverse tburg
EF is _____________
maintained = healthy
decreased = sick
178
we like _______carbia for laparoscopic
normocarbia (35-45)
179
major concern for laparascopic
must PREVENT HYPERcarbia
180
premedicate with
anxiolytic
181
use _____% oxygen
100%
182
best anesthetic option for laparoscopic procedure
regional + GA
183
true or false
STOP ventilation during insertion of Veress needle
true
184
there is an INCREASED risk of PONV during laparoscopy
true (48%)
185
treatment for opioid spasm
glucagon
186
Deferred pain to SHOULDERS related to irritation of the
diaphragm
187
when does shoulder pain occur
1st day postop
188
why does bradycardia occur
due to vagal stimulation/stretching
189
what can occur during laparoscopic procedure (CV)
bradycardia
asystole
arrythmias
PEA
190
signs of CO2 emboli**
HYPOtension
JVD
tachy
mill-wheel
short increase in EtCO2, followed by decrease
hypoxemia
cyanosis
191
treatment for CO2 emboli*
stop insufflation
release pneumo
L side down (durant)
HYPERventilate
increase CVP (volume)
CVL (aspirate)
192
signs of lung rupture or PTX or pneumomediastinum
increase in pressure
hypoxemia
severe CV compromise
HYPOtension
SQ emphysema
193
there is LESS pulm dysfunction, but it can still occur
true
194
Diaphragmatic dysfunction may last up to ___ hr
24 hr
195
treatment for SQ emphysema
give ____% O2
100%
196
lithotomy w/ steep trendelenburg
pelvis, robotic
197
steep trendelenburg
prostatectomy, robotic
198
robotics
limit fluid to ___-___ L of crystalloid
1-2 L
better to use colloids
199
average age for radical prostatectomy
60 years
200
patient positioning for thoracoscopy
lateral decubitus
201
true or false
avoid LA with laparocopic, robotic
true
202
VATS requires
OLV
203
Uses no pneumoperitoneum; no gas, purely mechanical
Gasless laparoscopy
204
gasless lap
lifts abd wall ___-___ cm, with only __-__ IAP
10-15 cm
1-4 IAP
205
best indication for gas-less
ASA III-IV
206
true or false
GA is NOT preferred with hysteroscopy
true
207
what can cause TURP syndrome
resectoscope
208
best option of fluid for resectoscope
saline
209
what 2 things do we want to avoid with resectoscope (TURP)
HYPERvolemia
HYPOnatremia (HYPOosmolarity)
210
true or false
Must have a sodium level baseline*
true
211
HYPERvolemia
HYPOnatremia (HYPOosmolarity)
this causes
cerebral edema, which leads to TURP syndrome
212
turp syndrome
symptoms
HTN (both diastolic and sys)
BRADYcardia
CNS changes
N/V
headache
agitation
lethargy
cardiac arrest
213
AVOID GA with resectoscope**
true
cannot assess patient for TURP!
214
EKG changes with TURP
nodal/junctional
ST changes
U wave
widening of QRS
215
resectoscope
average rate of absorption is ___ ml/min (>__ L/hr)
20 ml/MIN
> 1 L/hr
216
best anesthetic with resectoscope
regional
217
try to limit surgical time to
< __ hr
< 1 hr
can occur within 15 min!
218
2 best drugs for TURP
saline
furosemide (lasix)
219
glycine deficits/absorption of ____ml
lead to decrease in Na of ____
500ml
Na decrease of 2.5
220
organogenesis occurs
1st 8 weeks
221
rapid growth
2nd trimester
222
preterm
<37 weeks
223
term
37-42 weeks
224
post-term
> 42 weeks
225
what is gestational age assessed by (4)
crown-rump length
1st trimester
ultrasound
1st day of LMP
226
Combination of physical and neuro characteristics to estimate gestational AGE
this is MORE accurate
dubowitz score
227
true or false
Gestational age is INDEPENDENT of weight
true
228
what type of age should be used
"corrected" gestational age
229
how long should "corrected" gestational age be used for
until 2 years old
230
current age of viability
22, 23-24 weeks
231
when are AIRWAYS formed
16th week
232
when are PULM VASCULATURE formed
16th week
(complete at late adolescence)
233
when are ALVEOLI formed
up to 8 years of age
234
3 stages of lung embryology
1) glandular
2) canalicular
3) alveolar
235
glandular stage
7-16 weeks
236
canalicular stage
16-24 weeks
237
alveolar stage
24 weeks to term
238
segmental airways, vessels, cartilage differentiation in the trachea and bronchi
glandular
239
Formation of gas exchange surface and beginning of surfactant production
Type II pneumocytes
canalicular
240
surface area grows quickly, membrane thins, surfactant levels in amniotic fluid becoming indicator of lung maturity
alveolar
241
Heart tube formed, connects to arterial and venous systems
Aorta divides
3rd week
242
Fetal circulation in place
7th week
243
Bronchial arteries develop between __-___ weeks
9-12
244
fetal circulation is _________
PARALLEL (2 at once)
245
bypass the LIVER
ductus VENOSUS
246
bypass the LUNGS
RA to LA
patent foramen ovale (PFO)
247
bypass the PULM ARTERIES
RV to AORTA
patent ductus ARTERIOSUS (PDA)
248
R sided pressure is high because pulm pressure is high; there is a whole between RA and LA, so there is no blood flow to the lungs
PFO
249
RV to aorta
PDA
250
2 unoxygenated
arteries
251
1 oxygenated
vein
252
1st critical event
1st gasp
253
1st gasp leads to***
_________ pulm blood flow
_________ pulm O2
_________ SVR
_________ pulmVR
INCREASE in blood flow, O2, SVR
DECREASE in pulmVR
254
true or false
normal, physiologic R to L shunting occurs for several hours after birth
true
255
LOW level of Type __
for infants
1
256
elastic recoil is _______ at infancy
LOWEST
257
big determinant of static lung volume
elastic recoil
258
Total lung capacity (TLC)
low
259
FRC
SIMILAR to other ages per kg
however, LOW elastic recoil makes it go to 10% of predicted
260
**Reason for rapid desaturation in infants with airway loss
disproportionately low O2 reserve
(TLC, FRC, low elastic recoil)
261
Closing volume is NOT able to be measured in children < ___ years of age
<5 years
262
airway dynamics
HIGH resistance =
even higher =
High resistance = newborns
even higher = premies
263
resistance DECREASES in peripheral airways (>___th) generation
around 5 years of age
>12th generation
264
*Reason for severe respiratory impairment in very young children with only minimal airway inflammation (bronchiolitis)
high resistance
265
tracheal compliance
___x higher in infants
2x (but higher risk of collapse)
266
pulm
increased
PaCO2
Vt
RR
267
lung inflation
leads to
induced apnea (positive pressure extubation)
hering breuer reflex
268
periodic breathing
___-___ second pause
normal!
5-10 second
269
treatment for apnea
increase central ventilation drive (theophylline)
chest wall stabilization (PEEP)
tactile stimulation
270
**Apnea of ___________ has huge GA implications
prematurity
271
***when is the highest risk post-conceptual age for apnea
< 55 weeks
(normal preterm babies)
272
infant O2 consumption is >___x higher than adults
2x
273
compensation for increased O2 consumption
increased RR
274
PaO2 __________ in neonates**
DECREASES
(consumption increases)
275
why does PaO2 decrease
L shift
276
babies have _______ affinity for O2
HIGHER (less to the tissues)
277
newborn HR
120
278
1 month HR
160
279
adolescent HR
75
280
SYSTOLIC BP
6 weeks - 1 year
99
281
SYSTOLIC BP
1 year - 6 year
minimal change
282
CO
>___-___x higher
>2-3x higher
283
best measurement for CO
echo (doppler)
284
PR interval
QRS duration
increase with age
285
QRS axis is ___ at birth, rotates ___ during 1st month
QRS R = birth
rotates L
286
at birth, GFR is <___% of adults
< 30%
287
when is GFR normal
2 years old
288
infants have a normal, physiologic __________
acidosis
(bicarb is poorly reserved)
289
true or false
infants have NORMAL BUN
true
290
Biliary tract completed at ____th week gestation
10th
291
premies are at risk of _____glycemia
HYPOglycemia
292
jaundice is normal
true
293
encephalopathy due to increased bilirubin
kernicterus
294
cause of cholestatic jaundice
long-term TPN
295
GI tract “migrates and rotates” into abdominal position: __-__ weeks gestation
5-7 weeks
296
Duodenal motility maturation: ___-___ weeks’ gestation
29-32 weeks
297
Peristaltic waves absent in infant’s lower esophagus
cause
"spitting"
298
what can lead to inadequate swallowing
CNS damage
299
___% of newborns have reflux for several days
40%
300
should be passed in the 1st ___ hours
48 hours
301
3 symptoms of meconium aspiration
pneumonia
PTX
persistent pulm HTN
302
if a baby has increased insulin levels at birth, that can lead to
rapid HYPOglycemia
303
Maintain glucose at > ___-___ in newborns
40-45
304
symptoms of HYPERglycemia (2)
cerebral bleeding
infection
305
symptoms of HYPOglycemia (3)
jittery
lethargic
seizures
(may have NO symptoms!)
306
initial blood volume
___ mL/kg = immediate clamping
80
307
initial blood volume
premies: ___ mL/kg
90
308
newborn Hgb
14-20
309
3 month old Hgb
10
310
who has the greatest decrease in Hgb
premies at 2 months
311
3 month- 2 year old Hgb
12
312
true or false
anemia is NORMAL
true
313
as baby ages, they have a ___ shift of oxyhgb
R
314
Hct >___% is polycythemia
> 65%
315
vitamin K dependent factors
2, 7, 9, 10
316
true or false
Decreasing perinatal mortality has NOT led to a decrease in cerebral palsy
true
317
predictors of CP
LBW
congenital anom
low placental weight
fetal position
asphyxia
318
what can lead to handicapping?
malnutrition until the age of 2 years
this leads to impaired myelination
319
always assess by ___________ age
conceptual
320
What must be considered with motor deficits? (3)
drug interactions
hepatic/renal function
enzyme induction
321
drug dosing for infants
the SAME
more sensitive + larger Vd
322
key point for safe drug dosing**
titrate to effect!
323
metabolism
CP450 system
decreased
324
2 diseases that cause decreased metabolism
cystic fibrosis
celiac's
325
elim 1/2 life
increases
326
drug clearance
prolonged
327
infants have an ___________ risk of toxicity
INCREASED
328
renal blood flow: ___-___% of CO
adult:
peds: 5-6% of CO
adults: 15-25%
329
true or false
creatinine is NOT a useful indicator
true
330
what must be considered when dosing infants
renal function
331
true or false
we can still USE unapproved drugs
true
332
neurons are genetically programmed to “commit suicide” if they fail to make synaptic connections on time
apoptosis
333
“anesthesia induced neuroapoptosis”
anesthetics cause
___________ death for good neurons
___________ death for weak neurons
abnormal = good
inhibited = weaker neurons
334
2 receptors involved**
N-methyl-D-aspartate (NMDA) glutamate
y-aminobutyric acid (GABA)A
335
NMDA antagonists (3)
ketamine
nitrous
ETOH
336
GABA antagonists (3)
benzos
inhalational agents
propofol
337
who is MOST at risk for brain issues with anesthetics (2)
with LENGTHYYYY procedures (> 3 hrs)
children < 3
pregnant in 3rd trimester
338
the rate of equilibrium of alveolar to inspired anesthetic partial pressures [FA/FI]
wash-in
339
wash-in is ______ ______ in neonates
more RAPID
340
why is wash-in more rapid in neonates
higher ventilation/FRC ratio
lower tissue/blood solubility
lower blood/gas solubility
341
lethal dose (LD50) is ___________ in neonates
very DECREASED
342
caution with centrally acting meds in children < __ year of age
< 1
343
EXTREMEEE caution with centrally acting meds in children < __ weeks post-conceptual
<48 weeks
344
volatiles
___________ cerebral blood flow
___________ CMRO2
increase blood flow
decrease CMRO2
345
best to use <___ MAC with mild HYPERventilation
<1 MAC
346
2 best volatiles
sevo
iso
347
true or false
BIS monitoring is not reliable in children
true
348
Overall, __________ margin of safety in children
decreased
349
**** for every 1 MAC, there is a ___% DECREASE in SYSTOLIC for children
30%
350
hypoxia,
_______cardia,
dysrhythmias
lead to the death spiral
BRADYcardia
351
Hepatic metabolism reaches adult levels by ___ years old
2 years old
352
2 volatiles used for induction
sevo
halo
353
2 options for induction with sevo
sevo + ___-___% nitrous
sevo + ____% O2
sevo + 50-70% nitrous
sevo + 100% O2
354
biggest factor in emergence
NOT reducing agent in timely manner
355
true or false
NO difference for solubility, laryngospasm, vomiting between agents
true
356
what causes the worst emergence delirium
SEVO
des
357
risk factor for emergence delirium
< 6 years
358
best drug for emergence delirium
dexmedetomidine
359
What is the primary determinant of IV anesthetic agents duration of action?
re-distribution
360
**2 huge NEONATAL factors for redistribution
body maturation
BBB maturation
361
propofol
________ doses create good intubating conditions after inhalation induction
smaller
362
seen in children after prolonged propofol sedation
> 48 hours
>70 mcg/kg/hr
Propofol Infusion Syndrome (PRIS)
363
symptoms of
Propofol Infusion Syndrome (PRIS)
Refractory BRADYcardia
Metabolic acidosis
HYPERkalemia
Rhabdomyolysis
CV instability, refractory CV arrest
364
3 different routes for ketamine
PO
nasal
rectal
365
ketamine increases
HR
SBP
PA pressure
366
3 indications for ketamine
HYPOvolemia (trauma)
cyanotic R to L shunt
asthma/wheezing
367
ketamine
SVR is ____________
maintained
368
true or false
ketamine
maintains spont vent
neonates tolerate very well
true
369
3 indications for etomidate
TBIs, CV compromised
HYPOvolemia
cardiomyopathy
370
true or false
etomidate
must give steroids for stress coverage, especially for CRITICALLY ILL CHILDREN
true
371
80% of children < ___ will have BRADYCARDIAAAA after Sch
80% under < 10
372
what should you pre-treat with for Sch
vagolytic
(atropine)
373
2 major CONTRAindications with Sch
MH
hyperkalemia
(upper/lower motor neuron disease)
neuromuscular disorders (duchenne's MD)
374
true or false
defibrillation is NOT helpful for Sch
true
375
true or false
Sch
fasciculation is NOT seen in infants
true
376
best RSI alternative to Sch
high dose roc (with sugg)
377
what type of metabolism for atracurium
hoffmann elimination
(NO plasma cholinesterase involved)
378
atracurium
___-___x the ED95
2-3x ED95
379
atracurium
intubating conditions ___min
2 min
380
atracurium
duration ___ min
20 min
381
atracurium
children generally require _______
MORE
382
atracurium
children recover _________ than adults
recover FASTER
383
indications for atracurium
hepatic/liver dysfunction**
continuous infusions
384
atracurium metabolite
laudanosine
385
true or false
atracurium
laudanosine can be ELEVATED in children with HEPATIC impairment
true
386
what does laudanosine cause
excitation, seizures
NO NMB properties
387
nimbex is ___x as potent
3x
slower onset
duration the same
388
nimbex
__________ recovery in children
FASTER
due to LARGER Vd
389
major advantage of Vec**
NO CV effects, even with large doses!
390
major DISadvantage of Vec**
metabolized by LIVER
391
roc
neonates are ______ sensitive with marked variability in duration of action
MORE
392
roc
why are neonates more sensitive
due to reduced clearance and P450 substrates
393
true or false
roc can be given IM
true
394
dose of roc for IM
1.8mg/kg
395
roc
how long does IM intubating conditions take
up to 4 min
396
pancuronium
__________ effects
vagolytic effects
there is NO histamine
397
what is the only NMB that has some histamine (minimal)
nimbex
398
PANC
indications/USES/GOOD FOR
cardiac surgery
high-risk infants/neonates
frequently used in NICU
399
PANC
true or false
Very predictable recovery in neonates, infants, and young children compared to vec and roc
true
400
even with a slight residual NM blockade, you can have ________ and ___________
hypoxia
HYPERcarbia
401
___________ elimination ½-life of NMBs
longer
402
babies have less of type __ fibers
less type I
403
true or false
observe preop clinical conditions and aim for “back to baseline” at emergence
true
404
4 things to assess for with antagonizing of NMB*
facial nerve
hip/arm flexing
leg lift
abd muscle tone
405
_____ infants before attempting antagonism
WARM
406
what drug do you give 1st BEFORE neostigmine
anticholinergic (robinul)
MUST wait for HR to increase
407
who is sugg approved for
> 2 and higher
408
who can sugg be used with
everyone
409
morphine**
who has RAPID/FAST clearance
children
410
morphine**
who has REDUCED/slower clearance
infants
411
opioids
what is the BIGGEST respiratory depressant
morphine
412
morphine
neonatal brain has ___x uptake of adult
this is due to:
3x
due to the immature BBB
413
AVOID morphine with < __ year old
< 1 year old
414
best drug for decreasing shivering
meperidine
415
meperidine
what is the elimination 1/2 life for NEONATES
3.3-60 hrs (huge variation!)
416
what metabolite with meperidine
normeperidine
417
what can normeperidine cause
seizures
418
true or false
many peds centers have REMOVED meperidine from their formularies
true
419
Most common opioid for peds GA
fentanyl
420
true or false
fentanyl
HUGE doses are tolerated well by premies/neonates for cardiac procedures
true
however, only give if you are NOT planning on extubating at the end of the case!
421
true or false
fentanyl
Dynamics VARIABLE in all peds age groups, especially premies
Titrate to effect!
true
422
___________ + _________ profound hypotension, especially in neonates
fentanyl + versed
423
fentanyl
what can occur in neonates
increased vagal tone
bradycardia
DECREASED CO
424
fentanyl
what route can be used with BMT for GA
nasal
425
what opioid has a very brief 1/2 life (<10 min)
remifentanil
426
for creating ideal intubating conditions, when Sch should be avoided
use _____________ + __________
remifentanil + propofol
427
Indication
Prevention of withdrawal symptoms when weaning from opioid infusions
methadone
428
true or false
methadone has elim variation in children
true
429
true or false
ketorolac (NSAID)
has NO respiratory depression
true
430
431
what is current evidence with T&A
OKAY to use ketorolac
432
CONTRAindications for ketorolac
ortho (especially spinal)
GI/renal/allergy
433
Most common benzo for peds
midazolam
434
midazolam
CONTRAindications (3) as
OSA
neuro patients (VP shunt issue)
increased ICP
Opioids
435
indications (2) for zofran
strabismus repair (eye)
ENT
436
4 indications for precedex
sedation, maintaining spontaneous ventilation
opioid-sparing
emergence delirium
ETT tolerance for weaning from vent
437
4 indications for atropine
decrease secretions (common for infants)
pre-treat Sch
block oculocardiac reflex
prevent/treat bradycardia
438
which form of atropine is given to infants < 6 months old
IM
439
atropine
IM
BEFORE
inhalational induction
for < 6 months old
true
(infrequent now with sevo)
440
true or false
atropine CROSSES the BBB
true
441
glycopyrollate
has MINIMAL BBB penetration
(mimimal CNS effects)
true
442
true or false
physostigmine is NOT for NMB blocker
true
instead, it is used for central cholinergic syndrome and delirium
443
narcan
brief 1/2 life, need to be monitored
neonates/children often need _______ doses
LARGE
444
3 side effects of narcan
HTN
dysrhythmias
pulm edema
