Final Flashcards
1
Q
What provides motor innervation to all intrinsic muscles except the cricothyroid?
A
RLN
2
Q
Who is most at risk for latex allergy?
A
healthcare workers and spina bifida
3
Q
What are some disadvantages for regional anesthesia of the eye?
A
potential for complications, usually need deep sedation for placement
4
Q
What kind of murmur is caused by aortic regurgitation?
A
decrescendo diastolic at 2nd ICS RSB
5
Q
What is the functional unit of the kidney?
A
nephron
6
Q
The Laser-Flex tracheal tube (Nellcor) is flexible, stainless steel that is resistant to CO2 and KTP lasers- in the event of proximal cuff rupture, what happens?
A
distal cuff maintains tracheal seal and prevents anesthetic gases from leaking into path of laser beam
7
Q
What are some risk factors for intraop awareness?
A
female, young (not children), obese, clinical experience, previous awareness, after normal hours operations, emergency procedures, OB/cardiac/thoracic cases, use of nondepolarizing relaxants
8
Q
What are some things that reduce the effectiveness of hypoxic pulmonary vasoconstriction?
A
alkalosis, excessive TV or PEEP, hemodilution, hypervolemia, hypocapnia, hypothermia, prostacyclin, shunt fraction <20% or >80%, vasodilators, PDEIs, CCBs, volatile anesthetics >1.5 MAC
9
Q
Why should you avoid hypotension in a patient with AS? What should you use to treat hypotension?
A
have to maintain coronary perfusion pressure; use neo
10
Q
What are some complications of thoracic surgery?
A
ALI, low cardiac output from hemorrhage, hypovenolemia, R HF, heart hernation; bronchopleural fistula, thoracic duct injury, nerve injury (phrenic, spinal, RLN)
11
Q
Which anesthesia drugs are known to decrease NK function?
A
propofol, thiopental, opioids, volatile agents
12
Q
What is bleomycin known to cause?
A
blebs- pulmonary toxicity
13
Q
What are effects on the lungs during establishment of pneumoperitoneum?
A
decreased VC, FRC, compliance
14
Q
What are the components of an RCA?
A
what, where, who, when, how many
15
Q
What are some some symptoms of hypocalcemia?
A
hyperexcitability of nerve and muscles due to lowered threshold potential- muscle cramps, paresthesias, hyperactive DTRs, tetany, restless, irritability, larygospasm, Chvostek and Trousseau
16
Q
What is thromboxane a2?
A
COX product of arachadonic acid in platelets that is synthesized due to vascular damage- potent vasoconstrictor and stimulus for platelet aggregation (inhibits AC and CAMP)
17
Q
What does vitamin D deficiency cause?
A
poor ingested calcium- rickets in children, osteomalacia in adults
18
Q
How much can you increase tolerated apnea time by when preoxygenating an OSA patient with 100% FiO2 and 5-10 of CPAP?
A
50%
19
Q
At what size is a thoracic aneurysm at risk of rupture in someone with Marfan syndrome or other connective tissue disease?
A
4-4.5 cm
20
Q
What happens in the collecting duct?
A
water reabsorption under influence of ADH
21
Q
What are some goals/anesthetic management for thoracic surgery?
A
maintain normovolemia, keep MAC <1.5, avoid N2O, ABGs as needed, air/O2 mix to maintain adequate PO2, minimize narcotics, extubate at the end of the case
22
Q
What are some things that are neurotoxic to peds patients?
A
iso, sevo, propofol, barbiturates, nitrous, versed, ketamine
23
Q
What vessels branch off of the aortic arch?
A
innominate/brachiocephalic, L common carotid, left subclavian
24
Q
What things affect LV compliance?
A
structural properties of heart muscle, as well as state of contraction and relaxation (?)
25
Who is the second victim?
practitioner involved in unanticipated adverse event who becomes victimized and traumatized
26
What are some things that increase GFR?
afferent arteriole dilation, increased renal BF, efferent arteriole constriction
27
What is plasminogen?
proenzyme that is synthesized in the liver- it is incorporated into the clot as it is being formed but lays dormant until it is activated
28
What are the 3 requirements for fire to occur?
flammable agent (alcohol, benzoin, drapes, ETT, hair), source of ignition (lasers, light sources defibrillator), gas that supports combustion (oxygen, nitrous)
29
What does cryo contain and what do we give it for?
fibrinogen, factors V, VIII, XIII, vWF- hypofibrinogenemia, massive hemorrhage
30
How do you avoid airway fire?
keep FiO2 at a minimum (may discontinue temporarily during laser use), avoid N2O, vent excess O2 from under drapes
31
What does protamine do?
reverses effects of heparin
32
What drug should you avoid if a patient is on cyclophosphamide?
succs
33
What is the first thing you do with AAA rupture?
control the bleeding- establish large bore PIV and give blood
34
What provides motor innervation to the cricothyroid?
SLN
35
What allows excessive pressure to be vented out of the middle ear?
eustachian tube
36
What are some goals for a patient with sickle cell disease?
maintain normothermia, hydration, O2, and prevent acidosis and vascular stasis- maintain Hct 30-35%, manage pain (avoid drugs that impair renal function)
37
Between what range is autoregulation of the kidney maintained?
50-180
38
What gas may cause an acceleration in metastasis?
nitrous oxide
39
What does the RAA system result in?
Na/H20 reabsorption and vasoconstriction
40
What is sickle cell disease?
hereditary hemoglobinopathy- autosomal recessive abnormality of beta globin gene codes for production of variant hemoglobin, Hgb S
41
Are laser-resistant tubes laser-proof?
No- carry inherent risk of ignition
42
What does pRBCs contain and what do we give it for?
RBCs- symptomatic anemia, massive hemorrhage, decreased O2 carrying capacity
43
What are the forces that determine GFR?
pressure inside glomerular capillaries, pressure inside Bowman's capsule, colloid oncotic pressure inside capillary
44
What compensatory response happens if the blood flow to the kidney is decreased?
afferent arteriole dilation
45
What happens to an obese patient's lungs when you lie them flat?
abdominal contents pushed up --> decreased FRC, compliance, impaired gas exchange
46
What is TF? What does it do?
cofactor from coagulation cascade- activates clotting cascade pathway when vessel injury occurs
47
What percentage of emergency and elective AAA patients undergoing OAR have an MI?
emergency- >50%, elective- >25%
48
At what size is a descending thoracic aneurysm at risk for rupture?
>6.5 cm
49
How does celecoxib work?
COX 2 inhibitor (antiplatelet)
50
What are absolute indications for OLV?
isolate 1 lung to prevent contamination, control distribution of ventilation, unilateral bronchopulmonary lavage
51
How many posterior and anterior spinal arteries are there? What supplies motor function?
2 posterior, 1 anterior; anterior provides motor function and receives most BF
52
What are some disadvantages of general anesthesia for eye procedures?
most invasive, PONV, sore throat, dental injury
53
Describe HIT type 1
heparin induced platelet aggregation 1-4 days after a large heparin dose which resolves spontaneously even if heparin is continued
54
Describe naturally active immunity
immune response generated after antigen/pathogens enter body (chicken pox)
55
What are some things you can do to improve intubating conditions in someone with OSA?
preoxygenate for 5 minutes with 100% O2 and CPAP, use ramp, minimize preop sedation, have an extra set of hands
56
Why might local anesthetics be beneficial for cancer patients?
they prevent tumor proliferation
57
What is vWD?
inherited or acquired coagulable disease characterized by lack or dysfunctional vWF- lifelong bleeding episodes, prolonged bleeding time
58
What are some things that may contribute to metastasis during surgery?
tumor manipulation, most anesthesia medications (especially opioids), stress response
59
What are some risk factors for OSA?
male, obese, micro/retrognathia, large tongue, large tonsils, large neck circumference, HTN
60
What happens in the loop of henle?
establishment of osmotic gradient
61
What are some complications of sickle cell disease?
vaso-occlusive crisis, acute chest syndrome, sequestration crisis, aplastic crisis, pneumococcal disease, pulmonary HTN
62
What are elements of good communication?
clear and concise, include context and intent, receive information (show listening), identify and address barriers
63
What kind of murmur is mitral stenosis?
diastolic rumbling murmur- heard best at apex
64
Describe the order of the intrinsic pathway
1) blood trauma/exposure to collage activates factor XII (Hageman)
2) Factor XII activates XI (PTA)- requires kininogen and is accelerated by prekallikrein
3) Factor XI activates IX (Christmas)
4) Factor IX and VIII (antihemophilic) activate X (SPF)
5) prothrombin activator and tissue phospholipids activate thrombin (factor II)- identical to last step of extrinsic pathway
65
How does desmopressin (DDAVP) work?
stimulates factor VIII and vWF release
66
What does desmopressin do?
stimulates release of vWF
67
What can methotrexate cause?
hepatic and renal toxicity
68
What does nitric oxide do?
potentiates prostacyclins which inhibits platelet adhesion, aggregation, and binding of fibrinogen between GpIIb/IIIa complexes; causes muscle relaxation and vasodilation; increases BF to wash away procoagulant mediators
69
What are some arteries that branch off the abdominal aorta?
celiac, superior mesenteric, renal, inferior mesenteric, common iliac, internal and external iliac, femoral
70
How does warfarin work?
vitamin K antagonist (anticoagulant)
71
Where does the artery of Adamkiewicz arise from?
radicular branches of the intercostals, T8-T12 (sometimes T5-L5)
72
What should you do if an airway fire occurs?
stop ventilation, disconnect circuit, remove ETT and place in a bucket of water, extinguish flame debris in pharynx with water or saline
73
What type of vWD is characterized by a complete absence of vWF? What should you give them?
type 3- cryo or purified vWF
74
What is vWF?
necessary cofactor for adherence of platelets to subendothelial layer
75
What factors lie in the vessel intima (endothelial layer)?
vWF, TF, prostacyclin, and nitric oxide
76
What are the risks in % of AAA rupture at certain sizes?
0.5-5% at 4-4.9 cm
3-15% at 5-5.9 cm
10-20% at 6-6.9 cm
20-40% at 7-7.9 cm
77
The LaserTubus (Rusch) is soft, white rubber that is resistant to argon, YAG, and CO2 lasers- the lower 17 cm is covered with laser guard wrap that does what? What can you do to decrease ignition potential? Who should you avoid this tube in?
dissipates laser light and prevents backscatter; soak the tube in water; latex allergy
78
What are some advantages of EVAR over OAR?
shorter procedure, fewer blood loss/fluid shifts/hemodynamic changes, less ischemia and end organ damage, fewer complications
79
When a surgeon deflates a leg tourniquet, what will you expect?
fall in core temperature, metabolic acidosis, fall in central venous oxygen, release of acid metabolites in systemic circulation, increase in end tidal CO2
80
What are relative indications for OLV?
surgical exposure, pulmonary edema after removal of PE, severe hypoxemia d/t unilateral lung disease
81
What are some things you can do to avoid metastasis?
avoid hypothermia, avoid giving blood, use regional technique when available, keep FiO2 <80%
82
What are the final cells of the lymphoid pathway?
T and B cells, NK cells
83
What does vitamin K do?
required for production of factors II, VII, IX, X and protein C and S (reverses effects of warfarin)
84
How does clopidogrel work?
ADP receptor inhibitor (antiplatelet drug)
85
What vessels branch off of the ascending aorta?
coronary arteries
86
At what size is an ascending thoracic aneurysm at risk for rupture?
>5.5 cm
87
When do episodes of intraop awareness occur most often?
during maintenance of anesthesia
88
What are some connective tissue disorders? Specifically which one did Abe Lincoln have?
Marfan (Abe Lincoln), Ehlers Danlos, Loeys-Dietz
89
How do aminocaproic acid (amicar) and tranexamic acid (TXA) work?
plasminogen activation inhibitors
90
Describe naturally passive immunity
antibodies passed from mother to baby (short lived)
91
With a DLT, which lung is getting ventilated?
The dependent lung (nondependent lung is getting operated on and will be isolated)
92
After platelets aggregate, what completes a clot?
fibrin is incorporated into the platelet plug, and activated FSF (XIIIa) facilitates cross linkage of fibrin fibers
93
What were the problems with the metallic foil wraps around ETTs to protect them from lasers?
laser reflection damage, exposed tube, unprotected cuff, need for smaller ID tube, airway damage
94
How long from exposure may a latex allergy show a reaction?
30 minutes
95
What are the cellular elements of innate immune pathways?
neutrophils, macrophages, NK cells, monocytes
96
What does Vitamin K do?
stimulates action of factors II, V, VII, IX
97
What are some other anesthetic considerations for AAA rupture besides establishing lines and giving blood?
intubate immediately if LOC, do RSI with etomidate and succs, avoid coughing/bucking which can increase rate of bleeding
98
What should you place proximal to the ETT cuff during laser surgery?
saline moistened cotton gauze
99
What is one of the problems with the Bivona Fome-Cuf (Portex) laser resistant ETT?
inability to deflate the foam after cuff rupture
100
How does heparin work?
inhibits factor 2 and 10a (anticoagulant)
101
How long should you wait before a laser is used after reinflation of an ETT or repositioning for correction of a leak?
1 minute
102
Which has lower periop risk, EVAR or OAR? What about 2 year mortality?
EVAR has lower periop risk, but same 2 year mortality
103
What factors does Coumadin affect, and in what order?
Indirectly blocks the manufacturing of Vitamin K dependent factors (II, VII, IX, X, Protein C and S)
104
What are some advantages of general anesthesia for eye procedures?
useful for uncooperative patients and for longer surgeries, complete ocular anesthesia
105
What are the final cells of the myeloid pathway?
monocytes, macrophages, dendritic cells, eosinophils, mast cells, basophils, platelets
106
What might the use of nitrous oxide cause in middle ear procedures?
graft disruption, tympanic membrane rupture, N/V, serous otitis media, stapes disarticulation and hearing loss
107
What do platelets contain and what do we give it for?
platelets and clotting factors- thrombocytopenia, massive hemorrhage, platelet function deficit
108
How is plasminogen activated, and what does its activated form do?
tissue plasminogen activator (tPA) activates plasminogen into plasmin, which dissolve thrombi and restore blood flow
109
What is the lateral rectus muscle innervated by and what does it do?
supplied by CN 6 and causes abduction of the eye
110
What are some ways to minimize aspiration in someone with esophageal disorders?
NPO for 8 hours, prokinetics (Reglan), H2 blockers, PPIs, antacids, RSI if necessary, cuffed ETT, decompress stomach with NG if necessary
111
What is normal GFR?
125 ml/min
112
How soon should N2O be stopped before graft placement in a middle ear procedure?
30 minutes
113
What does the cricothyroid muscle do?
tenses and elongates the cords
114
What do the juxtaglomerular cells release in response to hypotension?
renin
115
How do argatroban and bivalrudin work?
inhibit thrombin (anticoagulant)
116
What happens in the proximal tubule?
sodium reabsorption
117
Describe HIT type 2
antiplatelet antibodies (IgG) attack factor 4 immune complexes which causes platelet aggregation and is resistant to heparin anticoagulation- this occurs after any heparin dose 5-14 days after administration and can lead to a hypercoagulable state with high risk of amputation and death
118
What are anesthetic considerations for mediastinoscopy?
2 large bore IVs, type and cross, A line or pulse ox on right, standard induction if asymptomatic, if obstruction- minimize preop sedation, do awake FOB, maintain spontaneous ventilation
119
What is a consideration of the cuffs of laser resistant ETTs? What should you confirm before a laser is used?
cuff rupture is often the prelude to airway fire- fill them with saline and possibly methylene blue to alert surgeon of cuff rupture; absence of air leak
120
What is adriamycin (doxorubicin) known to cause?
cardiac toxicity
121
How do aspirin and NSAIDs work?
COX 1-2 inhibitor (antiplatelet)
122
If a patient is getting an endovascular aortic repair, how would you treat hypertension? What drug should you avoid?
beta blocker before vasodilator (vasodilators change radius of vessel); sodium nitroprusside (associated with worse outcomes)
123
What can be facilitated by anesthesia during thoracic surgery?
isolate the movement of one lung during ventilation and create a quiet surgical field
124
How low can platelets drop with HIT type 2? What do you need to do?
<50k; need to d/c heparin and anticoagulate with direct thrombin inhibitor like bivalirudin or argatroban
125
Which type of immunity has a more delayed onset but is capable of developing memory and specific antigenic responses?
adaptive immunity
126
What are some advantages for regional anesthesia of the eye?
more complete anesthesia, eye is more likely to be immobile, less invasive
127
What is hemophilia?
X linked recessive disorder characterized by unpredictable bleeding patterns- either deficient in factor VIII or factor IX
128
How does abceximab work?
GpIIb/IIIa receptor antagonist (antiplatelet drug)
129
What are some indications for thoracic surgery?
tumor, infection, lavage, lung reduction sx, vascular sx, cardiac sx, spine sx
130
What does a TEG measure?
process of clot formation over time- gives indication of clot strength, platelet number and function, intrinsic pathway defects, thrombin formation, and rate of fibrinolysis
131
Which types of LeFort fractures are of concern to the anesthesia provider?
II and III- avoid nasal intubation due to possible disruption of cribiform plate
132
What are the different forms calcium exists in the body?
9% bound to anions, 41% bound to proteins, 50% ionized
133
What does FFP contain and what do we give it for?
all coag factors- warfarin bleeding, massive transfusion, TTP, coag factor deficiencies, ATIII deficiency
134
What are some arteries that branch off the descending thoracic aorta?
esophageal, bronchial, mediastinal, intercostals
135
What are physiologic effects of aortic cross clamping?
increased afterload (HTN), often increases in CVP and PAP, increased MAP and sVR, increased LV work (decreased CO), tissue ischemia
136
What is innate immunity?
immunity that is genetically determined
137
What do you want to ensure as far as IVs in robotic surgery?
2 IVs and possibly A-line established before tucking arms (make sure they work)
138
What is atrial natriuretic factor?
secreted by atria in response to stretch- acts as diuretic (antagonizes ADH)
139
What substances are released during the surgical stress response that may contribute to immunosuppression?
cortisol, cytokines
140
What is the only tube wrap that has FDA approval for ETT protection from lasers?
Merocel Laser-Guard
141
Where do we get Vitamin D? Where is it converted to its active form?
ingested food and ultraviolet light; liver and kidneys
142
What do the kidneys release in response to hypoxia?
EPO
143
Describe the order of the extrinsic pathway
1) tissue trauma liberates TF, which activates pathway
2) TF activates factor 7 (stable), which activates factor X (SPF) in presence of factor IV (Ca)
3) prothrombin activator and platelet phospholipids activate factor II (thrombin), and factor V (labile) acts as positive feedback mechanism that accelerates the continued production of prothrombin activator
144
Describe artificially active immunity
immunity developed from a vaccine
145
What provides sensory innervation to the superior epiglottis and base of the tongue?
glossopharyngeal
146
What factors lie in the vessel media (subendothelial layer)?
collagen and fibronectin
147
What are some triggers for sickle cell crisis?
pain, hypothermia, hypoxemia, acidosis, dehydration
148
What are elements of team working?
support, solving conflicts, exchanging info, coordinating activities
149
What are the most common allergens used in anesthesia?
NMBs (roc and succs), antibiotics (beta lactams, sulfas, vancomycin, quinolones), latex
150
What does active vitamin D do?
increases Ca, Mg, and phosphate ion concentrations by promoting their absorption across the intestinal epithelium to the ECF
151
What medication may stimulate NK cell activity and be a good drug of choice for cancer patients?
tramadol
152
When do you open fluids during robotic surgery?
when anastamosis are complete
153
What are some potential complications of EVAR?
failed deployment/malposition, rupture/dissection, contrast reactions, plaque embolization, ischemia, endoleak, infection, graft migration or thrombosis, postimplantation syndrome
154
Describe artificially passive immunity
preformed antibodies given via antiserum or antivenom (short lived)
155
How does tPA and streptokinase work?
activates plasminogen (fibrinolytic)
156
What are some concerns when doing a shared airway for head and neck surgery?
the bed may be 90-180 away (may need second anesthesia provider to monitor ventilation), ETT will be smaller, potential for neck flexion/extension and movement of ETT, need to use circuit and line extensions
157
What does prostacyclin do? How is it made?
powerful vasodilator that interferes with platelet formation and aggregration; derived from arachadonic acid and is synthesized by endothelial cells
158
What drugs have antiangiogenic and antitumor properties?
COX 2 inhibitors
159
What do you give someone with vWD?
depends on what type- desmopressin, vWF, immunoglobulins, plasma exchange
160
What supplies sensory innervation to the laryngeal mucosa below the vocal cords?
RLN
161
What happens in the distal tubule?
sodium reabsorbed in exchange for K under influence of aldosterone
162
What are the afferent and efferent limbs of the oculocardiac reflex?
afferent- trigeminal (CN V)
| efferent- vagus (CN X)
163
What supplies sensory innervation to the laryngeal mucosa above the vocal cords?
SLN (internal branch)
164
What is the oculocardiac reflex? How do you treat it?
bradycardia and asystole caused by stimulus to the eye- stop stimulus, give anticholinergics (glyco, atropine)
165
Where is cancer ranked in leading causes of death?
2nd
166
What is the most common closed claim about anesthesia care outside the OR?
respiratory complications
