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UPR- RCM Advanced Anesthesia I > Final Exam Deck > Flashcards

Final Exam Deck Flashcards

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1
Q

Mention the three paired Larynx cartilages

A
  1. Arytenoid
  2. Corniculate
  3. Cuneiform
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2
Q

Mention the three unpaired cartilages of the Larynx

A
  1. Epiglottis
  2. Thyroid
  3. Cricoid
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3
Q

Which nerve supplies Sensory innervation to the Larynx?

A
  1. SLN (internal branch-Vagus)
  2. RLN
  3. Glossopharyngeal
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4
Q

Which nerve supplies Motor innervation to the Larynx?

A
  1. RLN
  2. SLN (external branch)
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5
Q

Which structures of the Larynx are innervated by the SLN-internal branch (Vagus)?

A
  • Laryngeal mucosa above the vocal cords
  • Inferior to the epiglottis
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6
Q

Which structures of the Larynx are innervated by the RLN?

A
  • Laryngeal mucosa below vocal cords
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7
Q

Which structures of the Larynx are innervated by the Glossopharyngeal nerve?

A
  • Superior aspect of epiglottis
  • Base of the tongue
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8
Q

Which muscle group of the Larynx are innervated by the RLN-Motor?

A
  • ALL intrinsic muscles
  • Except Cricothyroid muscle
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9
Q

Which muscle of the Larynx is innervated by the SLN-external branch Motor?

A

Cricothyroid muscle

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10
Q

Identify the structures of the image below.

A
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11
Q

What are the muscle groups of the Larynx?

A
  1. Intrinsic Muscles
  2. Extrinsic muscles
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12
Q

What is the function of the Cricothyroid muscle of the Larynx?

A
  • Tension vocal cords
  • Elongates vocal cords
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13
Q

What is the function of the Thyoarytenoid and Vocalis muscle of the Larynx?

A
  • Relax the vocal cord
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14
Q

What is the function of the Posterior Cricoarytenoid muscle of the Larynx?

A
  • ABduts vocal cords
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15
Q

What is the function of the Lateral Cricothyroid and Transverse Arytenoid muscle of the Larynx?

A
  • ADducts vocal cords
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16
Q

What is the function of the Aryepiglottic muscle of the Larynx?

A
  • Closes glottis
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17
Q

Identify the function of each of the Intrinsic muscles of the larynx in the image below.

A
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18
Q

Mention the Extrinsic Muscles of the Larynx.

A
  1. Sternohyoid
  2. Sternothyroid
  3. Thyrohyiod
  4. Thyroepiglottic
  5. Stylopharyngeus
  6. Inferior pharyngeal constrictor
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19
Q

Which Extrinsic muscles of the larynx are innervated by the Cervical plexus and C1, C2, and C3?

A
  • Sternohyoid (draws hyoid bone inferiorly)
  • Sternothyroid ( draws thyroid cartilage caudad)
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20
Q

Which Extrinsic muscles of the larynx are innervated by the Cervical plexus, Hypoglossal nerve, and C1, C2?

A

Thyrohyoid muscle

Pulls Hyoid Bone Inferiorly

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21
Q

What’s the function of the Thyrohyoid muscle?

A
  • Pulls hyoid bone inferiorly
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22
Q

What’s the function of the Thyroepiglottic muscle?

A
  • Inversion of aryepiglottic fold
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23
Q

What’s the function of the Stylopharyngeous muscle?

A
  • Folds thyroid cartilage
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24
Q

What’s the function of the Inferior pharyngeal constrictor muscle of the larynx?

A

Aids swallowing

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25
Which Extrinsic muscle of the larynx is innervated by the Glossopharyngeal nerve?
**Stylopharyngeus muscle**
26
The Thyroepiglottic muscle is innervated by:
**The Recurrent Laryngeal Nerve (RLN)** ## Footnote **Only extrinsic muscle innervated by the RLN** Fx: Inversion of Aryepiglottic fold
27
The Thyrohyoid is innervated by:
- Cervical plexus - Hypoglossal nerve - C1 and C2
28
Which topical anesthetic has the vasoconstrictive ability and blocks the reuptake of NE and EPI at adrenergic nerve endings?
- Cocaine 4% Sln - Dose 3 mg/kg
29
What are the doses of Lidocaine as a topical anesthetic?
- 4 mg/kg plain - 7 mg/kg with EPI 200-300mg
30
What are some notable features of Lidocaine?
- Rapid onset - Suitable for all areas of the tracheobronchial tree
31
What are some notable features of Benzocaine?
- Short duration of action (10min) - Produce methemoglobinemia
32
What is the dose of Bupivacaine and what are some notable features?
- Dose 2.5 mg/kg plain - Slow hepatic clearance - Long duration of action
33
What are the dose and notable features of Mepivacaine?
- 4 mg/kg - Intermediate potency - Rapid onset
34
What are the dose and notable features of Dyclonine?
- 300 mg maximum - Topical spray or gargle - Frequent use for laryngoscopy - Absorbed through skin and mucous membranes
35
What are some Ester Local anesthetics drugs for ENT procedures?
- Procaine - Chloroprocaine - Tetracaine - Cocaine - Benzocaine
36
What are some Amide Local anesthetics drugs for ENT procedures?
- Lidocaine - Mepivacaine - Prilocaine - Bupivacaine - Ropivacaine - Articaine
37
What are the characteristics of Anticholinergic drugs used during ENT procedures?
- Produce antisialogogue effects - Useful in certain intraoral procedures requiring a dryer field.
38
Which Anticholinergic drug, Glycopyrrolate or Atropine, is better during ENT procedures?
- Glycopyrrolate - Produces less tachycardia - Does not cross the BBB - Lacks sedative effects
39
What are the common agents used for Hypotensive techniques?
- Sodium nitroprusside - Dexmedetomidine - Esmolol - Nitroglycerine - Nicardipine - Remifentanil with Propofol - Propofol
40
What are the does, advantages, and disadvantages of Sodium Nitroprusside for Hypotensive techniques?
- Young adults 1-5 mcg/kg/min - Children 6-8 mcg/kg/min Advantages: - Potent - Reliable - Rapid onset and recovery - CO well-preserved Disadvantages: - Reflex tachycardia - Rebound HTN - Pulmonary shunting - Cyanide toxicity
41
What are the doses, advantages, and disadvantages of Dexmedetomidine for Hypotensive techniques?
- 1 mcg/kg/ over 10 min - Then 0.2-0.7 mcg/kg/min Advantages: - Dose-dependent sedation and analgesia. - Hypotension - Decreases IV and inhaled anesthetic requirements - Smooth emergence Disadvantages: - Bradycardia - Hypotension - Heart block
42
What needs to be determined before the controlled hypotension technique?
- A safe MAP - MAP not < 50-60 mmHg - No more > a 20% decrease in baseline MAP
43
What must be monitored regardless of the chosen technique during permissive hypotension?
- UOP - MAP - CPP - Cardiac perfusion pressure - ABG's
44
What are the two most common lasers used during an ENT procedure?
1. CO2 ( 10,600nm) 2. Nd: YAG (1064nm)
45
What are the characteristics of the CO2 laser?
- Produces beam with long wavelengths - Absorb almost entirely the tissue-vaporizing cell water - Burn the cornea
46
What are the characteristics of the Nd: YAG laser?
- A shorter beam passes through the garnet - shorter wavelength less absorption by water and tissue - beam light passes through the cornea
47
What are the appropriate color eye-protection glasses for the Nd: YAG laser?
- Green-lensed protection
48
What are the appropriate color protection glasses for the CO2 laser?
- Any clear glass or plastic that surrounds the face.
49
What are the appropriate color protection glasses for the **Potassium titanyl-phosphate (KTP)** laser?
Orange-red
50
What are the appropriate color eye-protection glasses for the **Argon laser**?
Orange glasses
51
What is the general safety protocol for Surgical lasers?
52
Thyroid Gland?
- Butterfly-shaped - Composed of two lobes
53
The two lobes of the Thyroid gland are connected by a tissue mass named:
Thyroid Isthmus
54
Where is the Thyroid located?
- Anterior and Anterolateral aspect of the trachea - inferior to the larynx
55
What is the largest endocrine gland in the body?
- Thyroid gland - weights 20g in healthy adults
56
What is the blood supply of the thyroid gland?
Superior and inferior thyroid arteries. ## Footnote branches of common carotid artery
57
Which nerve is associated with the motor function of the larynx that abducts, adducts, and tenses the vocal cords?
- RLN - SLN- external branch
58
What is the primary PreOp goal for Thyroid surgery?
- Ensure Pt is Euthyroid - Assess the degree of organ complication - Determine the extent of airway involvement
59
Which medication regimen should be continued until the morning of surgery for a patient undergoing a thyroid procedure?
- Antithyroid medications - Beta-blockers
60
Which lab values are increased or decreased in a patient with Hypothyroidism?
- T3 and T4 increased - TSH decrease or normal
61
What are the oral drugs used to treat Hyperthyroidism?
- Methimazole (Tapazole) - Propylthiouracil (TPU) - Iodine - SSKI - Lugol solution - Propranolol (Inderal) - Atenolol (Tenormin) - Metoprolol
62
Which is the drug of choice to treat Hyperthyroidism?
- **Methimazole (Topazole**) - Easy dosing - Better side effect - 10-40mg start QD - 5-15mg maintenance
63
How long in advance is **Iodide** added to a patient undergoing thyroid surgery?
- 1 week prior to surgery - Continue through the day of surgery.
64
Which drug is used in emergency thyroid surgery for adrenergic suppression?
- Beta Blockers without intrinsic sympathomimetic activity
65
What is the adjunct Gold standard of visual nerve identification during thyroid and parathyroid surgery?
Intraoperative nueral monitoring (IONM)
66
Which monitors are used to assess RLN and Vocal cord function during thyroidectomy?
- A special ETT, Medtronic nerve integrity monitor (NIM) - EMG endotracheal tube (NIM 3.0 ETT)
67
What's the anesthesia technique of choice for thyroidectomy?
- General endotracheal anesthesia - Standard induction and maintenance drugs are used.
68
What is the NMBD of choice for paralysis during thyroidectomy?
Succinylcholine because of short duration and spontaneous degradation.
69
The PreOp airway assessment for a patient undergoing thyroidectomy involves:
- Full visualization and palpation of the neck for thyroid goiter. - Airway should be assessed in the supine position.
70
A patient with Hyperthyroidism is at higher incidence for:
- Myasthenia gravis - Skeletal muscle weakness - Increased sensitivity to muscle relaxants
71
What are the three types of Le Fort fractures?
- Le Fort I fracture - Le Fort II fracture - Le Fort III fracture
72
Le Fort I Fracture characteristics
- Horizontal fracture of the maxilla - Extend from the floor of the nose and hard palate - Nasal septum to pterygoid plates posteriorly
73
Which structures are mobilized in a patient with Le Fort I?
- Palate - Maxyllary alveolar bone - Lower Pterygoid plate - Part of palatine bone
74
Le Fort II Fracture characteristics
- Triangular fracture running from the bridge of the nose
75
Le Fort III Fracture characteristics
- Fracture totally separates the midfacial skeleton from the cranial base
76
Which Le Fort fracture causes little difficulty for the anesthesia provider?
- Le Fort, I fracture - Patient may be intubated orally or nasally. - Airway is secure without a problem
77
Which Le Fort fractures are a concern when contemplating nasal intubation?
- Le Fort II - Le Fort III - Disruption of the cribriform plate may occur and an opening of the underside of the cranial cavity
78
Please Mark the extraocular(recta medial) muscle responsible for eye adduction. In the image below.
79
The **Oculocardiac reflex** is generated by pressuring the following structures:
- Pressure on the globe - Orbital structures (optic nerve) - Conjunctiva - Traction of the extraocular muscles(particularly the medial rectus muscle)
80
What is the **afferent pathway for the Oculocardiac reflex**?
- Via long and short ciliary nerves - Ciliary ganglion - Gasserian ganglion - Ophthalmic division of CN V - Ends at trigeminal sensory nucleus in the fourth ventricle.
81
The **Efferent pathway** of the **Oculocardiac reflex** consists of the following:
- Vagus nerve to the cardioinhibitory center.
82
The oculocardiac reflex often results in the following:
- Sinus bradycardia - Nodal rhythms - AV block - Ventricular ectopy - Idioventricular rhythm - Asystole
83
What should you do if an oculocardiac reflex occurs?
- Cease all pressure or traction by the surgeon - Assess Pt for adequate oxygenation and ventilation - Anesthetic depth - Atropine 2-3 mg for complete vagal blockade (careful use - causes dysrhythmias) - Glycopyrrolate for less severe bradycardia
84
Ocular medications
85
Which ocular **Carbonic Anhydrase inhibito**r drug **Reduces Aqueous Humor Production**?
**Acetazolimide (Diamox)**
86
Which ocular B-blocker drugs Reduce Aqueous Humor production?
Timolol (Timoptic)
87
Risk factors of Glaucoma
- Chronic Increase in IOP - Leads to retinal artery compression - IOP is reduced by drugs that reduce aqueous humor production or facilitate aqueous humor drainage
88
Which drugs decrease Aqueous Humor production?
- Acetazolimide - Timolol
89
Which drugs facilitate Aqueous Humor Drainage?
- Echothiophate ## Footnote Prolongs Succinylcholine duration
90
What's the goal of strabismus surgery?
- Correct misaligment of the extraoular muscles - Reestablishes the visual axis
91
Patients undergoing Strabismus surgery are at risk for the following:
- Increase PONV - Increase the risk of activating the oculocardiac reflex (afferent CN 5 + efferent CN 10)
92
Which gas bubble is placed over the retina during retinal detachment, vitrectomy, and macular hole repair?
Sulfur Hexafluoride (SF6)
93
What are the effects of Nitrous oxide with SF6 bubble placement?
- Expand SF6 bubble - Compromise retinal perfusion - Cause permanent blindness
94
How long in advance is N2O discontinued before the SF6 bubble placement?
15 minutes
95
How long is N2O avoided after SF6 bubble placement?
7 to 10 days after SF6 placement
96
What are the alternative gases to SF6, and how long is the N2O avoid?
- Silicone oil = 0 days - Air bubble = 5 days - Perfluoropropane (C3F8) = 30 days
97
What is the most common injury occurring after general anesthesia for eye surgeries?
Corneal abrasion
98
What are the risk factors of Corneal Abrasion?
- Drying of the exposed cornea - Direct trauma - Chemical injury - Central retinal artery occlusion
99
What patient positions increase the risk for Corneal abrasion?
Prone position
100
How long in advance is Cefazolin given for orthopedic surgeries?
Within 1 hour of incision time
101
How long in advance is Vancomycin given for orthopedic surgeries?
Within 2 hours of incision time
102
What are the organisms commonly associated with orthopedic procedures?
- Staph Aureus - Gram-neg bacilli - Coagulase- neg staph - B-hemolytic Strep
103
In which surgical procedures are prophylactic antibiotics not indicated?
- Clean procedures - Diagnostic arthroscopic - Procedures not involving implantations.
104
Spinal surgery with or without instrumentation should be covered with:
Antimicrobial agents
105
Why are Tourniquets used in orthopedic surgeries?
- Minimize blood loss - Provide a bloodless operating field
106
Why is important to use the proper cuff size and inflation pressure of tourniquets?
- Reduce risk of neuromuscular injury
107
What is the inflation pressure of tourniquets for upper and lower extremities?
- Upper: 70-90 mmHg > SBP - Lower: 2 times > SBP
108
For how long can a tourniquet be safely placed?
2 hours
109
How long after placement of the tourniquet can the patient start complaining of pain?
- 45-60 mins after inflation - Transmitted by C fibers (slow pain)
110
What transient physiologic changes are produced by the release of the tourniquet?
- Increase ETCO2 - Decrease body Temp - Decrease BP - Decrease SVO2 - Metabolic acidosis
111
Safety measures for preventing Tourniquet complications
112
Physiologic changes caused by Tourniquets
113
What are the clinical features of Bone Cement Implantation (BCIS)?
- Hypoxia - Hypotension - Cardiac arrhythmias - Cardiac arrest - Increased pulmonary vascular resistance - Unexpected loss of consciousness when regional anesthesia is given
114
What is the first indication of BCIS under general anesthesia?
Decrease ETCO2
115
What are the early signs of BCIS in the awake patient undergoing regional anesthesia?
- Dyspnea - Altered Sensorium
116
What is the treatment if BCIS is suspected in a patient?
- Increase Inspired O2 concentration to 100% - Supplemental O2 PostOP - Cardiovascular collapse Tx: Right-sided HF - Hypotension Tx: alpha-agonist
117
What are the actions that should be taken before cementing a patient?
- BP optimized - 100% fraction inspired O2 (FiO2) - Pressure bags - available - IV fluid bags - Document cement time on the anesthesia record (important)
118
Position-related complications during shoulder arthroscopy
119
Prevention of Position-related complications during shoulder arthroscopy
120
What is the drug used for patients undergoing total joint hip replacement?
Tranexemic acid (TXA)
121
The use of TXA has been shown to decrease the following:
- Periopertive blood loss - Transfusion requirements - Minimal risk of complications
122
How is TXA administered?
1-2 g PeriOp IV or Topically at the surgical site
123
What are the preferred regional anesthesia techniques used for breast surgery?
- Thoracic paravertebral - Pectoral nerve blocks (PECS) I and II - Serratus anterior (SA) plane block
124
What are the advantages of Regional anesthesia during extrathoracic surgery?
- Excellent PostOp analgesia - Opioid sparing - Reduce PONV
125
What are some factors that reduce Liver blood flow?
- Increased splanchnic vascular resistance (SNS stimulation, pain, hypoxia) - Things that increase CVP ( positive-pressure ventilation, excessive hydration, and CHF) - Some beta-blockers (propranolol reduces CO and increases splanchnic vascular resistance) - Intraabdominal surgical procedures - Laparoscopic surgery
126
What percentage of CO does the liver receive?
- 25 % - 1,500 mL via a dual blood supply
127
How much blood does the Portal vein provide to the liver?
- 75% of total liver blood flow - 50% of the liver's oxygen supply
128
How much blood does the Hepatic artery provide?
- 25% total liver blood flow - 50% of liver oxygen supply
129
What reduces portal vein flow?
- Increased splanchnic vascular resistance
130
What are the effects of General and Neuraxial anesthesia?
- Reduce MAP - Reduce CO This can reduce liver blood flow in a dose-dependent fashion.
131
Liver function
132
The liver plays an essential role in
- Protein synthesis - Vital role in carbohydrate, protein, and lipid metabolism
133
The liver produces all the clotting factors except:
- Factor 3 & 4 - Von Willebrand factor
134
Vitamin K-dependent clotting factors include:
- Factors 2, 7,9, & 10 - Protein C, S, and Z (anticoagulants)
135
How is Factor 8 produced in the liver?
- Liver sinusoidal cells - Endothelial cells - Not hepatocytes
136
What stimulates Platelet production?
- Synthesis of fibrinolytic like plasminogen and thrombopoietin
137
The liver is an important regulator of
- Serum glucose - Clears insulin from circulation - Patients with liver failure are at risk of hypoglycemia.
138
The liver produces all the plasma proteins except for
Immunoglobulins
139
What is the most abundant protein?
- Albumin - Serves as a blood reservoir for acid drugs - Also binds with basic drugs
140
What is the blood reservoir for basic drugs?
Alpha-1 acid glycoprotein
141
What are the effects of reduced Pseudocholinesterase production in patients with severe liver disease?
- Increase Succinylcholine duration - Increase the duration of Ester-type local anesthetic
142
What is the byproduct of protein metabolism?
- **Ammonia** - Lead to hepatic encephalopathy
143
What is the byproduct of hemoglobin metabolism?
- Bilirubin - Unconjugated Bilirubin is neurotoxic
144
Drug Metabolism in the Liver
145
Which labwork provides information of the Liver synthetic function?
- PT - Albumin
146
Which labwork provides information on Hepatocellular injury?
- AST (10-40 Units/L) - ATL (10-50 Units/L)
147
Which labwork provides information on Hepatic clearance?
**Bilirubin (0-11 units/L)**
148
Which labwork provides information on Biliary duct obstruction?
- Alkaline phosphate - Y glutamyl transpeptidase - 5-nucleotidase
149
Which labwork is sensitive for acute hepatic injury?
- Prothrombin time (PT) - Factor 7 has a half-life of only 4-6 hr
150
Which labwork is NOT sensitive for acute hepatic injury?
- Albumin - Has a half-life of 21 days
151
Clinicopathologic Features of Halothane Hepatitis
152
Hepatitis?
- Liver inflammation - Associated hepatocellular injury with variable degrees of necrosis - Can be acute or chronic
153
What is the most common cause of Liver cancer?
Hepatitis
154
A common indication of liver transplant?
Hepatitis
155
What is the etiology of Hepatitis?
- Viruses - Hepatotoxins - Autoimmune response
156
In the U.S. viral Hepatitis is most caused by:
- By one of the four hepatitis viruses: A, B, C, D
157
What is the most common hepatitis type in the US?
Hepatitis E
158
What are other viral etiologies of Hepatitis?
- Herpes simplex - CMV - Epstein-Barr
159
What are the routes of transmission of Hepatitis A and Hepatitis E
Fecal-oral
160
Which hepatitis virus is transmitted via the parental route?
- Hepatitis C
161
Which hepatitis virus is transmitted via the parental-sexual route?
- Hepatitis B - Hepatitis D
162
What are the Antibodies of acute viral hepatitis?
163
What is the most common cause of drug-induced hepatitis?
Alcohol
164
What is the most common cause of acute liver failure in the U.S.?
- Acetaminophen overdose - Max dose 4g/day - Tx: Oral N-acetylcysteine within 8 hours of intake
165
What is the effect of impaired fatty Acid Metabolism?
- Fat accumulation in the liver - Leads to hepatomegaly
166
Chronic hepatitis
- Hepatic inflammation > 6 mons - Leads to progressive destruction of hepatic parenchyma - cirrhosis - Liver failure
167
What is the most common cause of chronic hepatitis?
- Alcoholism - Hep C ( 2nd most common)
168
How is Chronic Hepatitis diagnosed?
- Liver enzymes - Bilirubin + Histologic evidence of liver inflammation
169
Chronic Hepatitis Signs and Symptoms?
- Jaundice - Fatigue - Thrombocytopenia - Glomerulonephritis - Neuropathy - Arthritis - Myocarditis
170
How are PT and albumin affected by chronic hepatitis?
- PT is prolonged - Albumin is decreased
171
Anesthetic management with Acute Hepatitis
172
What are the anesthesia considerations for Hepatitis?
**Acute hepatitis:** * non-emergent sx should be postponed until symptoms have resolved and the liver function test returns to normal **Chronic hepatitis:** * PT may proceed to sx. as long as the condition is stable
173
Anesthetic considerations for Acute hepatitis include:
- Maintaining liver blood flow - Avoid PEEP - Avoid hepatotoxic drug - Avoid drug that inhibits hepatic enzyme - Monitor neuromuscular junction
174
Most common places to find carcinoid tumors (70%)
- Appendix 45% - Jejunoileum 28% - Rectum 16% - Duodenum 4%
175
How is Carcinoid syndrome diagnosed?
- Elevated level of 5-hydroxyindoleacetic acid (5-HIAA) >30mg in 24hr in urine - Normal levels are from 3-15 mg/24 hr
176
Carcinoid syndrome
177
Signs and symptoms of Carcinoid syndrome
178
Carcinoid Crisis
179
Carcinoid treatment
180
Anesthetic considerations for Carcinoid syndrome

UPR- RCM Advanced Anesthesia I (5 decks)

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