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1
Q

MELD components

A

creatinine
bilirubin
INR

range 6-40

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2
Q

Pre-e criteria

A

Mild is 1, 2 or 3 of:
BP>140/90 (2 times, 4 hrs apart)
proteinuria >300mg over 24 hrs
non-pedal edema

Severe
SBP>160 or DBP>110
proteinuria>5gm over 24 hrs
e/o severe end-organ damage w severe oliguria
cerebral headache or visual changes
pulmonary edema
epigastric pain
intrauterine growth retardation
HELLP syndrome is a form of severe pre-e characterized by hemolysis, elevated liver enzymes, and low platelets
Low plts may occur due to adherence of hte platelets at sites of endothelial damage, resulting in a consumptive coagulopathy

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3
Q

pao2 rule of thumb

A

fio2 times 5 = Pao2

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4
Q

ARDS criteria

A

1 PaO2/FiO2 ratio <300
2 acute onset (within 7 days of inciting event, e.g. sepsis, trauma, aspiration, etc)
3 bilateral infiltrates identified by chest radiography
4 respiratory failure that is not fully explained by cardiac failure or fluid overload

(mild ARDS if PaO2/FiO2 ratio is 200-300)

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5
Q

Aortic stenosis transvalvular gradients

A

mild <25
moderate 25-40
severe 40-50
critical > 50

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6
Q

Aortic stenosis valve area

A 
normal 2.5 - 4
mild stenosis 1.5-2
moderate 1.0-1.5
severe 0.7-1.0
critical < 0.7
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7
Q

Aortic stenosis jet velocity

A

mild <3
moderate 3-4
severe 4-4.5
critical > 4.5

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8
Q

intraop factors contributing to arrhythmias

A

General anesthetics - volatiles, ketamine
Local anesthetics
Abnormal ABG/electrolytes (pH, hypoxia, hypercarbia)
sympathetic response to stimulation/laryngoscopy
Reflexes (vagal - brady, AV block, asystole; carotid sinus stim - brady; oculocardiac reflex - brady/asystole)
CNS stim
Dysfunction of autonomic nervous system
Pre-existing cardiac disease (MI, CHF, cardiomyopathy, valvular disease, conduction system abnormalities)
Central venous cannulation
Surgical manipulation of the cardiac structures (atrial sutures, venous bypass cannulas)
Location of the surgery (Dental - stim para and sympathetic NS; trigeminal stim can lead to stim of ANS)
Pain
Hypovolemia
Hypotension
Anemia
Endocrine abnormalities - Hyperthyroid, pheo
Temperature abnormalities (Hypo/er)

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9
Q

normal CI

A

2.6-4.2

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10
Q

normal PCWP

A

2-15 mmHg

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11
Q

normal PA pressure

A

15-30/4-12 mmHg

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12
Q

Normal mixed venous O2 sat

A

65-75%

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13
Q

Signs and symptoms of PE

A 
dyspnea
chest pain
cough
blood-tinged sputum
fever
tachycardia
tachypnea
coarse breath sounds
new S4 heart sound
accentuation of the pulmonic component of the S2 heart sound
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14
Q

GCS

A

Eye Opening Response
• Spontaneous–open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point

Verbal Response
• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point

Motor Response
• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point

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15
Q

c-spine clearance criteria

A 
absence of cervical pain/tenderness
absence of paresthesias/neuro deficits
normal mental status
no distracting pain
>4 years old
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16
Q

potential complications lithium

A

polyuria, skeletal muscle weakness, ataxia, cognitive changes, widening QRS, AV block, hypotension, seizures

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17
Q

anesthetic management changes for patient on lithium

A

1 eval for signs of toxicity (weakness, cognitive changes, ataxia, widening qrs, av block, hypoT, seizures

2 determine current lithium level

3 avoid any drugs that could lead to toxicity (thiazide diuretics, NSAIDs, ACE-i)

4 administer sodium containing fluids to prevent excessive renal reabsorption of lithium

5 watch EKG for lithiu-induced av blockade or dysrhythmias

6 closely monitor both anesthetic depth and neuromuscular blockae throughout the case (lithium can reduce anesthetic requirements and prolong effects of depol and non depol muscle relaxants)

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18
Q

alpha stat vs pH stat management

A

alpha-stat, CO2 is NOT added to maintain a PaCO2 of 40 and a pH of 7.40

pH-stat: CO2 IS added to maintain a PaCO2 of 40 and a pH of 7.40

Alpha stat = improved neuro outcome in adults (primary mechanism of brain injury is embolic not ischemic)

Pediatrics: Primary mechanism is ischemic, so pH-stat strategy is preferred (enhanced cerebral blood flow)

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19
Q

PCW tracing waves and what they represent

A

c wave - elevation of mitral valve during early ventricular systole

v wave - venous return against a closed mitral valve

x descent - downward displacement of atrium during ventricular contraction

y descent - decline in atrial pressure as MV opens during diastole

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20
Q

Kerley A lines

A

Kerley A lines are linear opacities extending from the periphery to the hila caused by distention of anastomotic channels between peripheral and central lymphatics

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21
Q

Kerley B lines

A

Kerley B lines are small, horizontal, peripheral straight lines demonstrated at the lung bases that represent thickened interlobular septa on CXR. They represent edema of the interlobular septa and though not specific, they frequently imply left ventricular failure

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22
Q

what is pulsus paradoxus

A

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus

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23
Q

pulsus paradoxus ddx

A

cardiac tamponade, airway obstruction, COPD, PE

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24
Q

CRPS-1 diagnosis

A 
initiating event
burning pain
allodynia or hyperalgesia
cyanosis
edema
cutaneous vasomotor instability (changes in blood flow)
sudomotor instability (sweating)

over time, also get
smooth/glossy skin
bone demineralization
stiff/painful joints

must exclude other causes for pain/dysfunction

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25
dif between crps 1 and 2
CRPS-1 has specific noxious inciting event examples of noxious events: crush injuries, lacerations, fractures, surgery, sprains or burns. CRPS-2 develops following nerve injury, with characteristic symptoms not limited to the distribution of the injured nerve.
26
treatment options for crps
``` PT CBT anticonvulsants (gabaP) andtidepressants (amitriptylline) opioids sympathetic nerve blockade (stellate ganglion block) somatic blockade IV ketamine gtt TENS spinal cord stimulation ```
27
Pacemaker code
``` Paced - O, A, V, D Sensed - O, A, V, D Response - O, T, I, D Rate modulation - O, R Multisite pacing - O, A, V, D ```
28
Defibrillator code
Stock chambers - O, A, V, D Antitachycardia pacing chambers - O, A, V, D Tachycardia detection - E, H Antibradycardia pacing chambers - O, A, V, D
29
What does a magnet do to pacemaker? | to ICD?
pacemaker to asynchronous mode does not affect pacing mode of ICD disable tachydysrhythmia sensing and treatment of ICDs (most)
30
What drugs are in ACLS and for what situations?
Amiodarone (300mg, then 150mg) - VF/PVT 2 min after epi Lidocaine (1-1.5mg/kg, then half that) - VF/PVT 2 min after epi Epi infusion 0.1-0.5mcg/kg/min post-cardiac arrest Dopamine infusion 5-10 mcg/kg/min post cardiac-arrest Norepinephrine infusion 0.1-0.5 mcg/kg/min Atropine 1mg - bradycardia with a pulse (repeat up to 3mg) Dopamine IV gtt 5-20 mcg/kg/min - brady with pulse epi gtt 2-10mcg/min brady with pulse Adenosine 6mg, then 12mg - stable wide QRS tachycardia Procainamide 20-50mg/min - stable wide QRS tachycardia Amiodarone IV 150mg over 10 min, then 1mg/min for 6 hours - stable wide QRS tachycardia Sotalol - 100mg over 5 min, avoid if prolonged QT - stable wide QRS tachycardia Adenosine - Stable, narrow QRS B-blocker - stable narrow QRS
31
type of vtach for unsynchronized shock
polymorphic
32
BP classifications
normal 120/80 or less pre-hypertensive: 120-139/80-89 stage 1 HTN: 140-159/90-99 stage 2: SBP 160+ or 100+ DBP
33
Signs of end-organ damage from HTN
``` LVH Angina MI CHF Stroke TIA CKD Retinopathy PAD ```
34
implications of LBBB
LBBB pattern hides ST-segment, making MI difficult to diagnose Widened QRS could cause SVT to appear as VT PA cath can lead to third-degree block 2/2 transient RBBB during placement LBBB stronger association than RBBB with ischemic heart dz, aortic valve dz, LVH, CHF, HTN
35
avoid dobutamine (stress echo) for who
severe HTN serious arrhythmias hypotension
36
EKG abnormalities that hinder accurate computerized ST-segment analysis
``` LBBB WPW acute pericarditis LVH with strain digitalis effect hypokalemia ```
37
Protamine reactions
1 - pharmacologic; histamine-induced 2 - immunologic; anaphylactic vs anaphylactoid vs delayed anaphylactoid that causes noncardiogenic pulm edema 3 - catastrophic pulm HTN -> right heart failure and sig hypotension
38
thyroiditis ass'd with
myasthenia gravis
39
difficulty swallowing could be
myasthenia bulbar sx
40
myasthenia gravis treatment
anticholinesterase (pyridostigmine) immunosuppresive drugs (steroids, azathioprine, cyclophosphamide, cyclosporine) thymectomy
41
why avoid sux in myasthenia gravis
because the pyridostigmine may result in decreased plasma cholinesterase activity. ok to give if not yet on pyridostigmine (undiagnosed), as they will likely be resistant to sux but it may still work
42
cholinergic crisis signs
``` constricted pupils weakness/fasiculations bradycardia bronchorrea salivation nausea vomiting abdominal cramps diarrhea urinary frequency and urgency pallor diaphoresis ```
43
drug to determine if myasthenia or cholinergic crisis
edrophonium improves strength if MG worsens symptoms if cholinergic crisis
44
cholinergic crisis cause sx tx
cause: overstimulation of nicotinic and muscarinic receptors at the neuromuscular junctions (usually 2/2 inhibition of acetylcholinesterase) ``` symptoms: S- Salivation L- Lacrimation U -Urinary frequency D-Diarrhea G- Gastrointestinal cramping and pain E- Emesis M- Miosis ``` ``` treatment: consider intubation discontinue anticholinesterase administer antimuscarinics (atropine) provide supportive care consider plasmaphoresis or IV IG ```
45
neuroleptic malignant syndrome cause symptoms treatment
cause - adverse reaction to neuroleptic or antipsychotic drugs. symptoms - high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction treatment - Generally, intensive care is needed. The neuroleptic or antipsychotic drug is discontinued, and the fever is treated aggressively. A muscle relaxant may be prescribed. Dopaminergic drugs, such as a dopamine agonist, have been reported to be useful.
46
circle system advantages
more effective preservation of heat/humidity reduced waste of anesthetic agents reduced operating room pollution reduced dead space
47
normal fibrinogen levels
adults 200-400 possible DIC if below 100 severe if below 50 mg/dl give cryo if below 50
48
inferior leads
ii, iii, avf
49
anterior leads
v3, v4
50
lateral leads
i, avL, v5, v6
51
dose epi gtt
0.01-0.05 mcg/kg/min
52
dose milrinone gtt
0.375-0/75 mcg/kg/min
53
dose NTG gtt
20-250 mcg/min
54
dose Nitroprusside
0.5 - 10 mcg/kg/min | doses less than 0.5 mg/kg/hr have minimal cyanide toxicity risk
55
dose norepi gtt
0.02 - 1.0 mcg/kg/min
56
phenylephrine dose gtt
0.1-5 mcg/kg/min
57
vasopressin gtt dosing
0.01-0.04 units/min
58
treatment for cyanide toxicity
discontinue offending agent 100% o2 drugs: 1 sodium thiosulfate 2 amyl nitrate or sodium nitrate 3 hydroxocobalamin
59
systemic effects of chronic renal failure
metabolic derangements (hyperkalemia, hyponatremia, hypOcalcemia, hypermagnesemia, hyperphosphatemia, hypoalbuminemia, uric acid accumulation, met acidosis) ``` periph/autonomic neuropathy seizures uremic encephalopathy anorexia delayed gastric emptying insulin resistance cardiac arrhythmias conduction blocks accelerated atherosclerosis renal osteodystrophy uremic pericarditis HTN -> LVH, CHF, CAD, CVD pulmonary edema restrictive pulm dysfunction anemia platelet dysfunction ```
60
brain swelling from hyponatremia disapears at what level
130
61
cancel case form hyponatremia and why?
120 that level may result in serious manifestatinos (cerebral edema, cardopulm arrest, seizures, coma, brain stem herniation)
62
discharge criteria from same day surgery
``` PADSS system vital signs activity n/v pain surgical bleeding ``` 2 points each. 9 or higher fit for discharge
63
aldrete
``` activity breathing circulation consciousness o2 sat ``` score 9 or greater to dc
64
lung cancer association
lambert eaton
65
thymoma or mediastinal mass association
myasthenia gravis
66
von Willebrand dz: defect of what factor how does that factor work type 1 vs other types
qual or quant defect in vW factor vWF mediates platelet adhesion and aggregation and is carrier protein and stabilizer for factor VIII type 1 = quantitative defect, impaired release but stores ar enormal type 2 = qualitative type 3 = extremely low levels
67
abnormal labs for vWF dz
``` mild = normal labs severe = prolonged bleeding, thrombocytopenia, prolonged PTT depending on type of dz ```
68
DDAVP treatment for vWF what types
good for type 1 | bad for type 2B (causes thrombocytopenia)
69
prophylactic vWF replacement
cryoprecipitate or Humate P
70
goal in vWF dz for prophylaxis for major surgery
vWF:RCo and factor VIII levels greater than 100
71
direct acting inotrope
isoproterenol
72
list of antihypertensive drugs
``` nitroglycerin sodium nitroprusside phentolamine esmolol labetolol magnesium diltiazem? ```
73
apnea-hypopnea index formula and scale
dividing the number of apnea events by the number of hours of sleep severe >30 moderate 16-30 mild 5-15
74
RVSP pulm htn severity scale
normal <35 Mild 35-45 moderate 46-60 severe >60
75
Mean PA Pressure pulm htn severity
mild <30 moderate 30-45 severe >45
76
Systolic PA Pressure pulm htn severity
mild 40-60 moderate 60-90 severe >90
77
lipophilic drug classes
benzos, opioids, barbiturates
78
hydrophilic drug example
neuromusclar blocking agents
79
initial loading dose lipophilic based on what weight
total body weight bc larger volume of distribution 2/2 increased deposition into body fat
80
maintenance dose lipophilic drugs base on what weight
ideal (increased clearance time)
81
reasonable approach to dosing drugs for obesity
start with IBW, then titrate to effect as effects of obesity on drugs is unpredictable.
82
post op management and | predictors of severe myasthenia
Ensure that the patient is reminded prior to induction of the possibility of a prolonged intubation. Extubation: performed on awake patients and hopefully close to his/her baseline status. Reinstitute anticholinesterase medication, either by IV infusion or by reimplementation of the patient’s oral regimen. Leventhal criteria: Predictive scoring system for the need for postoperative ventilation 1) duration of disease for 6 years or longer 2) chronic comorbid pulmonary disease 3) pyridostigmine dose >750 mg/d 4) VC <2.9L 5) Other indicators include preoperative use of steroids, and previous episode of respiratory failure. These predictors have not been widely validated. (1) Drugs to avoid: Calcium Channel blockers, Magnesium, Aminoglycoside antibiotics as all of these may contribute to muscle weakness Post-Op Bed: Patients should be monitored in either a ICU or step-down unit but NOT to a conventional surgical ward.
83
closed circle system
``` gas reservoir bag - yes rebreathing exhaled gases - total chemical neutralization of co2 - yes unidirectional valves - three fresh gas inflow rate - low ``` advantages: maximal humidification and warming, less pollution of atmosphere, economy in use of anesthetics disadvantages: inability to rapidly change the delivered concentration of anesthetic gases and o2 becasue of low FGF, unpredictable concentration of o2, unknown conc of anesthetic gas
84
semiclosed circle system
this is what our vents are ``` gas reservoir bag - yes rebreathing exhaled gases - partial chemical neutralization of co2 - yes unidirectional valves - three fresh gas inflow rate - moderate ``` some conservation of heat and moisture decreased pollution of surrounding atmosphere increased resistance from valves/co2 absorbent enhanced opportunity for malfunction 2/2 complexity of apparatus
85
semiopen circle system
Maplesons ``` gas reservoir bag - all but E rebreathing exhaled gases - no (if adequate FGF) chemical neutralization of co2 - no unidirectional valves - one (none in E) fresh gas inflow rate - high ``` ``` For mapeson F (Jackson-Rees) disadvantages: need for high FGF possibility of high airway pressure/barotrauma lack of humidification ```
86
open circle system
``` gas reservoir bag - no rebreathing exhaled gases - no chemical neutralization of co2 - no unidirectional valves - no fresh gas inflow rate - unknown ```
87
fena prerenal
less than 1%
88
post op delirium vs post op cognitive dysfunction
``` delirium 1-3 days post op acute state of confusion significant morbidity multiple causes: metabolic, sepsis, pain, disorientation, etc treat underlying cause may benefit from haloperidol ``` ``` POCD not acutely confused of agitated weeks/months later usually resolves in 6-12 months increased mortality rate unknown role of anesthetics ```
89
Where mixed venous blood drawn from
tip of PA catheter it is usually higher than ScvO2 (ScvO2 contains predominantly SVC blood - brain has higher O2 extraction, but anesthesia can alter that)
90
porphyra
defect in heme biosynthetic pathway -> overproduction of porphyrins type of porphyria depends on enzyme deficiency acute forms of porphyria are inducible by medication, can be life-threatening. ab pain, n/v, psych disturb, ANS instability, electrolyte disturb, hypovolemia, seizures, weakness, resp failure preop: H&P, severity, precipitating factors, treatment, symptoms; neuropathy, ANS intability, weakness, electrolytes, fluid status if in exacerbation, delay elective surgery reduce risk: avoid fasting, dehydration, stress, infection, D10NS, check what drugs are safe use regional porphyric crisis treatment: dc pophyrinogenic drugs, supportive care, D10NS, treat nausea, correct lytes, treat seizures with benzo or prop; if no improvement after 2 days, consider hematin
91
physiologic effects of ECT
parasympathetic before sympathetic
92
drug keeps pda open
prostaglandins | NSAIDs inhibit prostaglandins
93
after ect: disorientation, inability to consistently follow commands, motor agitation
postictal agitation | treat with benzo or dexmedetomidine
94
Recurrent and superior laryngeal nerve interaction and function and how to block
recurrent laryngeal - sensory cords and trachea, intrinsic muscles of larynx; transtracheal block superior laryngeal - sensation above cords (internal), cricothyroid muscle (external); block with needle at greater cornu hyoid bone
95
APGAR score
``` Appearance Pulse 0, 0-100, 100+ Grimace Activity Respirations ```
96
anticholinergic does what to bronchi
bronchodilates

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