Focus Flashcards
(393 cards)
1
Q
How to calculate size and depth of pediatric tube
A
2
Q
Max cuff pressures on a LMA?
Max PPV pressure on a LMA?
A
Cuff 40-60cm H20
PPV - 20 cm H20
3
Q
LMA sizing
A
4
Q
What stage should deep extubation occur in?
A
Guedel stage 3
NEVER IN STAGE 2
5
Q
Which PFT is the most sensitive indicator of small airway disease?
A
FEF 25-75%
6
Q
PFT
A
7
Q
Dynamic Airflow
A
8
Q
Lung disease
A
9
Q
Lung
A
10
Q
What is the one induction drug that bronchodilates?
A
Ketamine - but also increases secretions
11
Q
What increases and decreases PVR
A
12
Q
Which halogenated anesthetics create carbon monoxide? What about compound A?
A
Des + Iso = Carbon monoxide
Sevo = Compound A
13
Q
Order of management for OLV hypoxia?
A
- 100% oxygen
- Check placement
- Apply CPAP to non-dependent lung
- Apply PEEP to dependent
-Intermittently reinflate non-dependent lung
-Clamp PA
-Resume 2 lung ventilation
14
Q
What can a bronchial blocker not do?
A
CANNOT
-Ventilate the isolated lung
-Suction
-Prevent contamination from collateral lung infection
IT CAN
Be used in kids under 8 and be used for nasotracheal intubation
*Placed through single lumen Ett
15
Q
Which lung is ventilated when using a bronchial blocker?
A
The opposite lung of the blocker
16
Q
OxyHgb Curve
A
17
Q
Does hypercarbia cause hyperkalemia or hypo?
A
Causes hyperkalemia (K is released as a buffer)
Causes Hypercalcemia as well
18
Q
Ventilatory Response curve
A
19
Q
Vd - body water breakdown
A
20
Q
Context-sensitive half time
A
21
Q
A
22
Q
Does albumin bind with acid or basic drugs? What about alpha 1-acid glycoprotein?
A
Albumin binds with acidic drugs
Alpha 1-acid glycoprotein binds with basic drugs
23
Q
How does advanced age affect alpha 1-acid glycoprotein and albumin?
A
Alpha 1-acid glycoprotein - More of it
Albumin - Less of it
24
Q
first order or zero order; which one is a constant amount of the drug is metabolized per unit time?
A
25
first order or zero order; which one is a constant fraction of the drug is metabolized per unit time?
26
What do the majority of drugs undergo? zero or first order kinetics?
The majority undergo first order.
Examples of zero order; aspirin, alcohol, warfarin, heparin, phenytoin, and theophylline
27
First order graph
28
Zero order graph
29
What is a phase 1 reaction?
Oxidation - Removes an electron
Reduction - Adds an electron
Hydrolysis - add water compound
30
What is a phase 2 reaction?
CONJUGATES - adds a highly polar, water substrate
31
What are three phases of metabolism?
1. Modification
2. Conjugation
3. Elimination
32
Does enzyme induction increase or decrease clearance?
33
Does an enzyme inducer increase or decrease drug clearance? Do you need more or less of the drug?
It increases drug clearance, so you need more of the drug
34
Does an enzyme inhibitor increase or decrease drug clearance? Do you need more or less of the drug?
It decreases drug clearance, so you need less of the drug
35
Examples of enzyme inducers?
Ethanol
Rifampin
Barbiturates
Tamoxifen
Carbamazepine
St. Johns Wort
Tobacco
Cannabis
36
Examples of enzyme inhibitors?
Grapefruit juice
Omeprazole
SSRI's
Erythromycin
Cipro
Antifungals
Cimetidine
37
How does acidic urine effect acidic drugs and basic drugs?
38
How does basic urine effect acidic drugs and basic drugs?
39
Do hydrophilic or lipophilic drug tend to be eliminated in the urine?
Hydrophilic tend to be eliminated in the urine and lipophilic tend to be reabsorbed
40
Is a drug further to left or right on the dose response curve more potent?
41
If a drug is shifted to the left, does it have a higher or lower affinity for the receptor? Do you need more or less of the drug?
Higher.
More to the left is more potent, higher affinity for the receptor, and you less drug
42
If a drug is shifted to the right on the dose response curve, do you need more or less of the drug?
You need more of the drug because it is less potent
43
What is efficacy?
The measure of the ability of the drug to elicit a given clinical effect
44
Does a higher or lower plateau imply greater efficacy? Once the plateau is reached, what does giving more of the drug do?
Higher plateau means greater efficacy
Once plateau is met, more drug will only increase risk of toxicity
45
What does slope tell us?
The steeper the slope means more of the receptors need to be occupied to observe clinical response
Ex; NMB and volatile anesthetics
46
What is ED50 and ED90?
The dose required to achieve a response in 50% of the population and 90% of the population
47
A - Agonist
B - Partial agonist
C- Antagonist
D- Inverse Agonist
48
What is a racemic mixture? Ex?
Two enantiomers in equal amounts
Ketamine
Thiopental
Methohexital
Iso
Des
Prilocaine
Bupivacaine
Methadone
Morphine
Ibuprofen
Toradol
49
#1 source of heat loss in the OR? Best way to combat it?
1. Radiation (60%)
2. Convection
3. Evaporation
4. Conduction
Forced air warmer
50
First thing you do with an airway fire?
1. Remove the ET tube
2. Stop all gases
51
When should N20 be D/C and avoided after the placement of an SF6 bubble?
-D/C N20 15 minutes before
-Avoid N20 for 7 days after placement
52
Alternatives to SF6 and when to avoid N2O?
Silicone oil
Air bubble
Perfluoropropane
Silicone oil - 0 days
Air bubble - 5 days
SF6 - 7 days
Perfluoropropane - 30 days
53
What does the oculocardiac reflex cause?
Bradycardia
54
Landmarks for TAP blocks?
55
What does the H1 receptor produce?
-Vasodilation
- Increased vascular permeability
- Smooth muscle contraction (not vascular)
56
What does the H2 receptor produce?
- Cardiac stimulation (tachycardia)
- Gastric acid secretion
57
What type of Ig reaction is anaphylaxis?
IgE
58
Most common cause of allergic reactions in the OR?
1. NMB (succ)
2. Latex
3. Antibiotics (beta-lactam)
4. Other
59
How does Epi treat anaphylaxis?
1. Prevents degranulation
2. Provides CV support
3. Dilates the airways
60
Chemo man
61
Which PONV medication is contraindicated with a small bowel obstruction?
Metoclopramide - prokinetic effect
62
What is the triad for Fat embolism syndrome?
Petechial Rash
Respiratory insufficiency
Neurologic changes
63
How long must the tourniquet be inflated for a Bier Block before deflating?
At least 20 minutes
64
What are the inflation pressures for tourniquets for upper and lower extremity surgery?
Upper - 80 points over SBP
Lower - 2x over SBP
65
What are the inflation pressures for tourniquets for Bier blocks upper and lower extremity surgery?
Upper - 250 or 100 over SBP
Lower - 350-400
66
Difference between COX 1 and COX 2?
COX 1 - Normal, always present, impairs Plt, reduces renal blood flow, gastric irritation
COX - Present during inflammation, Inhibition causes analgesic, anti-inflammatory, antipyretic
67
What is the Precursor to COX?
Arachidonic Acid
68
Examples of COX-2 inhibitors?
Celecoxib
Everything ending -coxib
Most are removed from the market due to the cardiovascular risks
69
What drug causes the most acute liver failure in the United States?
Tylenol
70
What is Samter's triad? What should be avoided? Why?
Asthma
Allergic rhinitis
Nasal polyps
AVOID ASPIRIN - could lead to bronchospasm
71
What are the 4 supplements that cause bleeding?
4 G's
Garlic
Ginger
Ginkgo
Ginseng
72
73
What are the most common claims in anesthesia?
1. Regional
2. Respiratory events
3. CV
4. Equipment failure
74
What color cylinders are safe in the MRI room? Which metals are safe?
Silver
Stainless steel. titanium, aluminum, copper
75
MRI zones
76
What is the Alderete score? What score means they can D/C? What is not factored?
Readiness to D/C from PACU
9 or greater can D/C
PONV is not factored
77
Best way to prevent ulnar injury?
78
What is "claw hand"
Ulnar nerve injury
Impaired sensation to fourth and fifth digits
Inability to ABduct or oppose the pinky finger
79
Which nerve is likely to be injured during an IV insertion in the antecube?
Median nerve
80
Elbow hyperextension can injure which nerve?
Median nerve
81
Sensory for the median nerve includes? Motor?
Sensation to the palmer surface of the thumb, index finger, middle finger, and lateral of the ring finger
Motor - inability to oppose thumb
82
Hand benediction or ape hand are injuries to which nerve?
Median nerve
83
What is the only nerve to pass through the carpel tunnel?
Median nerve
84
Which nerve is most likely injured by an IV pole pressing on the humerus?
Radial nerve
85
Sheets tucked too tight can cause which nerve injury?
Radial
86
Excessive BP cuff cycling can cause nerve damage to which nerve?
Radial
87
Wrist drop is a sign of which nerve injury?
Radial
88
UE tourniquet can cause injury to which nerve?
Radial
89
Scapular winging is a sign of which nerve injury?
REMEMBER SALT (serratus anterior long thoracic)
Long thoracic nerve
Innervates the serratus anterior
90
Dull shoulder pain is a sign of which nerve injury?
Suprascapular nerve
91
Foot drop is a sign of which nerve injury?
Common peroneal
92
Inability to evert the foot is a sign of which nerve injury?
Common peroneal
93
Inability to extend the toes dorsally is a sign of which nerve injury?
Common peroneal
94
Which nerve is injured in stirrups when the medial aspect of the leg is compressed?
Common peroneal
95
LE innervation
96
Clinical assessment of LE
97
Which nerve allows for hip flexion?
Femoral
98
Which nerve allows for hip extension?
Sciatic
99
Which nerve allows for knee flexion?
Sciatic
100
Which nerve allows for hip extension?
Femoral
101
Which nerve allows for plantar flexion?
Tibial
102
Which nerve allows for dorsiflexion of ankle?
Common peroneal
103
A popliteal nerve block will block which nerves? Where do they rise from?
It will block the tibial nerve and the common peroneal nerve right as they branch from the sciatic nerve
104
Most common cause of eye injury in the perioperative setting?
Corneal abrasion
105
Which positions reduce cardiac output the most?
Sitting
Prone
106
Three most common causes of intraoperative anaphylaxis? Which Ig is responsible?
1. NMB (succ)
2. Latex
3. Antibiotics (beta-lactam)
IgE
107
Which two antiemetics prolong QT interval?
Droperidol and ondansetron
108
2 contraindications for metoclopramide?
Do not use in bowel obstruction because it is a prokinetic
Do not use in Parkinson's because it is a dopamine antagonist
109
30mg of ketorolac is equal to how much morphine?
30mg Ketorolac = 10mg morphine
110
What is Samter's triad?
Aspirin exacerbated respiratory disease
- Asthma
- Allergic rhinitis
- Nasal polyps
111
Which two supplements reduce mac?
Kava Kava
Valerian
112
Which supplement can mimic Conn's?
Licorice
113
Metabolic syndrome
114
Do obese people have an increased or decreased FRC?
Decreased
Normal Co2. If CO2 is high then impending respiratory failure is likely
115
How does CO, SV, HR, and blood volume change in obesity?
Increased CO, SV, and blood volume to feed fat
HR stays the same
116
In obesity, HTN is the result of?
Activated RAAS and SNS
Hyperinsulinemia
Elevated cytokine
117
Which valvular defect is highly suggestive of Pulmonary HTN in the obese population?
Tricuspid regurgitation on TEE
118
How are propofol and narcotics dosed?
Propofol
Loading - LBW
Maintenance - TBW
Narcotic
Loading - TBW
Maintenance - LBW
119
How is remifent dosed?
Both are LBW
120
How are succ/cis/atracurium dosed?
TBW
121
How are roc/vec dosed?
LBW
122
What tool is used for undiagnosed OSA? What score?
STOPBANG
>3 means high risk
123
Which drug should be avoided with an anastomotic leak repair?
Ketorolac - increases the incidence
124
What is Ma Huang?
Natural source of Ephedrine
125
What is orlistat? Complications?
Lipase binder - hinders absorption of fat
Impairs Vit D, A, K, E absorption
Without Vit K, factors 2,7,9,10 are impaired and may cause bleeding
126
Venous air embolism vs paradoxical air embolism, which one affects the lungs? Which would cause a stroke?
Venous - pulmonary vasculature
Paradoxical - stroke
127
What is the best table for a prone patient?
Jackson
128
Hormones of adrenal gland
129
Hormones of adrenal gland 2
130
Liver synthesis
131
How does hypoparathyroidism affect calcium levels?
Directly linked
hypoparathyroidism = hypocalcemia
132
S&S of hypoparathyroidism
133
Which drugs heavily rely on the kidneys for excretion and caution should be used in CKD
Anything with an active metabolite
Meperidine
Morphine
Dilauded
Cephalosporins
Panc, Vec
Reversal agents
134
When is ANP released?
During hypervolemia
A stretched atrium signals the body to excrete sodium and decrease reabsorption
135
Drug of choice for a pheochromocytoma?
Phenoxybenzamine
Must alpha block before beta block
136
What is the order for thyroid hormone production?
1. Hypothalamus
2. Thyrotropin-releasing hormone
3. Anterior pituitary gland
4. thyroid-stimulating hormone
5. Thyroid
6. T4, T3
137
What is T3 and T4?
T4 = Thyroxine
T3 = Triiodothyronine
T4 stimulates T3
138
What complications are seen in the reperfusion of the liver after transplant?
Hyperkalemia
Hypocalcemia
Cytokine release
Lactic acidosis
Embolic debris
Hypovolemia
Decreased SVR
Increased PVR
Hypothermia
139
Conns
Cushing
Addisons
Graves
140
An AST/ALT ratio > 2 times is a sign of which disease? What about a ratio of 1:1?
2:1 Alcoholic liver disease
1:1 viral hepatitis
141
Is ALT or AST more specific to a liver injury?
ALT (think of the L)
AST is found in other organs
142
T3 vs T4
143
When does the ductus arteriosus, ductus venosus, and foramen ovale close?
144
gastroschisis vs omphalocele
145
Which respiratory parameter is unchanged in the obese population compared to the nonobese?
Closing capacity
146
Fluid requirements should be based on IBW, LBW, or TBW?
LBW
147
Which bariatric surgeries place the patient at risk for lifelong nutritional deficiencies?
Jejunoileal bypass
Roux-en Y
148
What is the most common cause of Nonalcoholic Steatohepatitis? (NASH)
Obesity
149
Why is CO increased in the obese population?
SV increases, not HR
150
Does the Vd of lipophilic or hydrophilic increase or decrease in the obese population?
Both increase, lipophilic increases much more
151
Which agents provide the fastest emergence in the obese population?
Sevo
Propofol
Iso
Des
1. Sevo
2. Des
152
What is the most common cause of respiratory morbidity and mortality?
Inadequate ventilation
153
Which two gases are liquid at room temperature ?
Nitrous
CO2
154
Magnesium levels
155
lung volumes in obesity
156
What is a clinical sign of fulminant malignant hyperthermia?
Rigidity of extremities
157
Fire triad?
158
What is the most liability claims made against chronic pain providers?
Cervical injections
159
Loading and maintenance dose for propofol?
Loading - LBW
Maintenance - TBW
160
ASA scale
161
Which nerve does the fascia iliaca block?
Lateral femoral cutaneous
162
A smaller volume of injectate or if the injectate is too cold, will the CO be under or overestimated?
Overestimated CO
163
TEG
164
On TEG, if the maximum amplitude is decreased, what is happening? Treatment?
Thrombocytopenia
Give Plts
165
What is the most common cause of transfusion related mortality?
TRALI
166
How many hours for P50 to return to normal after quitting smoking?
12
167
Which fiber transmits burning pain?
C fibers
168
APGAR score
169
How many attempts till it's considered a failed intubation?
2-4
also 5-10 minutes
170
What happens to fibrinogen levels during pregnancy?
They double
Pregnancy is considered a compensated DIC state or hypercoagulable
171
What is the treatment for aspirin toxicity?
Hemodialysis
172
Treatment for Tylenol overdose?
Acetylcysteine
173
Which spinal nerve will be affected with an L4-L5 disc herniation?
L4
174
Which lab tests should be tested for a pheochromocytoma?
VMA (vanillylmandelic acid)
Metanephrine
175
If the TEG time is delayed, the patient is likely deficient in? Treatment?
Coagulation factors
Give FFP
176
How much does the BP change for every inch below the level of the heart?
2 mmHG
177
Do the elderly have an increased resting sympathetic tone? Responsiveness?
increased tone
Decreased responsiveness
178
A patient has a magnet on their defibrillator and develops a life threatening arrythmia, what do you do?
Remove the magnet and allow it to shock
179
Will CO2 or Sevo rebreathing happen if the FGF is changed from 2 to 0.25?
SEVO rebreathing will occur
180
Black box warning for carbamazepine?
Aplastic anemia
181
What is the first change to the respiratory system at higher altitudes?
Pulmonary hyperventilation
182
Which factors increase preterm labor?
Multiple gestations
183
What is an acceptable leak pressure on a pediatric ETT? If there is a large leak, what should be done?
< 25 cm H20
If a large leak - replace ETT with a smaller size
184
What is the first and second line uterotonic?
Oxytocin 3-5 units IV
Methylergonovine 0.2 mg IM
185
Which uterotonic is given PR
Misoprostol 800 mcg
186
What is the third line uterotonic?
Prostaglandin (hemobate or carboprost)
187
As the blood pressure cuff is moved distally, does the diastolic increase or decrease?
Decreases
188
Which nerve innervates the foot and is blocked during an ankle block?
Saphenous
189
4 ways CO2 is carried in the blood?
1. As Bicarb (90%)
2. Dissolved (5%)
3. Protein bound (5%)
4. Carbonic acid
190
How many times more soluble is CO2 compared to O2?
20x
191
How much CO2 is produced per minute?
200ml/min
2.5 ml/kg/min
192
What do central chemoreceptors respond to in the CSF?
H+
193
How do peripheral chemoreceptors respond to?
1. Decreased PaO2
2. Increased CO2
3. Increased H+
194
What is the normal P50? What about neonates?
Adult - 26.5
Neonates - 19.5
195
An SaO2 0f 90% is = to what PaO2?
What about 70% ?
SaO2 90% = 60mmHg PaO2
SaO2 70% = 40mmHg PaO2
196
S&S of a pneumothorax?
Hypotension
Hypoxemia
Tachycardia
Increased CVP
Increased PIP
Tracheal shift
Absences of unilateral breath sounds
197
For every 3 Na that move out, how much K comes in ?
2
198
Which law describes ventricular afterload?
Law of Laplace
199
Wiggers
200
LV pressure volume loop
201
Ejection fraction normal values
Normal = >50%
Mild = 41-49%
Moderate = 26-40%
Severe = <25%
202
What is the best TEE view for diagnosing myocardial ischemia?
Midpapillary muscle level short axis
203
Which factors increase O2 demand?
Tachycardia
HTN
SNS stimulation
Increased wall tension
Increased end diastolic volume
Increased afterload
Increased contractility
204
Which factors reduce O2 delivery?
Tachycardia
Decreased aortic pressure
Increased end diastolic pressure
Hypoxemia
Anemia
Left shift on OxyHgb curve
205
What is the precursor to nitric oxide?
L arginine
206
Does increased cGMP increase or decrease calcium? How does it affect smooth muscle?
Decreases calcium which causes vasodilation
207
What is the S1 heart sound?
Closure of mitral and tricuspid valves
Marks onset of systole
208
What is the S2 heart sound?
Closure of aortic and pulmonic valves
Markes onset of diastole
209
What is the S3 heart sound?
Suggests flaccid heart - HF
Right after S2
Gallop sound
210
What is the S4 heart sound?
Heard before S1
211
Most common dysrhythmia with Mitral stenosis?
Afib
212
When is the highest risk factor greatest for a reinfarction after an acute MI?
Within 30 days
213
How long should you wait for an elective surgery after an MI?
4-6 weeks
214
What are high risk surgeries according to cardiac risk?
High > 5%
-emergency (especially in the elderly)
-open aortic surgery
-Peripheral vascular
-Long procedures with fluid shifts
215
What are intermediate risk surgeries according to cardiac risk?
1-5%
-Carotid enterectomy
- Head and neck
- Intrathoracic or intraperitoneal
- Orthopedic
- Prostate
216
What are low risk surgeries according to cardiac risk?
<1%
-Breast
-Cataract
-Superficial
-Endoscopic
-Ambulatory
217
What cardiac lab values are most sensitive to MI?
Troponin's
218
Cardiac lab values
219
Compliance
220
Is heart failure with a preserved EF, systolic or diastolic failure?
Diastolic failure - doesn't fill properly (can't stretch)
221
Is heart failure with a reduced EF, systolic or diastolic failure?
Systolic failure - doesn't empty well
Caused by volume overload
222
How to treat systolic failure?
Preload is usually high so give diuretics
Decrease afterload but maintain CPP
Contractility - inotropes like dobutamine
HR - whatever you need to preserve CO
223
How to treat diastolic failure?
- Need volume to stretch noncompliant ventricle
-Keep afterload elevated to perfuse coronaries
224
Classification of heart failure?
Class 1 - asymptomatic
Class 2 - symptomatic with moderate activity
Class 3 - symptomatic with mild activity
Class 4 - symptomatic at rest
225
How should constrictive pericarditis be treated?
Avoid bradycardia
Preserve HR and contractility
Maintain afterload
226
What is Kussmaul's sign?
Indicates impaired RV filling due to poorly compliant RV
Causes JVD and increased CVP
MOST PRONOUNCED DURING INSPIRATION
227
Which two conditions are associated with Kussmaul's sign?
- Pericarditis
- Pericardial tamponade
228
What is pulsus paradoxus?
Drop by more than 10mmhg during inspiration. Impaired diastolic filling
same conditions as Kussmauls sign
Pericarditis and tamponade
229
What is becks triad?
Signs for acute tamponade
Hypotension
JVD
Muffled heart tones
230
Preferred anesthetic for pericardiocentesis?
Local anesthesia because we want to prevent CV collapse
231
Crawford AAA
232
DeBakey
233
What measurements are recommended for repair of a AAA?
>5.5cm
or
growing larger than 0.6cm per year
234
What is Beck's syndrome?
Anterior spinal artery syndrome
- When an aortic cross clamp is placed on the artery of Adamkiewicz
-Causes ischemia to anterior cord
235
How does Anterior spinal artery syndrome present?
-Flaccid paralysis of LE
-Bowel and bladder dysfunction
-Loss of temp and pain sensation
-PRESERVED TOUCH AND PROPRIOCEPTION
236
What regional technique can be used for a carotid? What levels must be blocked?
Cervical plexus block
C2-C4
237
Which reflex can be activated during a carotid or carotid balloon inflation?
Baroreceptor
238
Needs to be decompressed by the surgeon or us immediately
239
What state can nerve fibers be blocked?
Active or inactive
NOT DURING RESTING
240
Which type of channels do nerve fibers have? Does it affect the RMP or TP?
They are sodium channels but it does not affect RMP or TP.
Just blocks them
241
3 building blocks of a local molecule?
242
How are amide local anesthetics metabolized? How are esters? What is the exception?
Amides - P450
Ester- pseudocholinesterase
Cocaine is an ester but is metabolized by both
243
Which local is likely to have a true allergic reaction?
Esters (caused by PABA)
244
Which conditions can increase the risk of CNS toxicity in LAST?
Hypercarbia
Hyperkalemia
Metabolic acidosis
245
What is the medication of choice for arrhythmias during LAST? Which should be avoided?
Give amiodarone
Avoid - epi, vaso, lidocaine, procainamide
246
What is the maximum dose for tumescent anesthesia?
50mg/kg of lidocaine
247
S&S of methemoglobinemia?
Chocolate colored blood
Hypoxia
Cyanosis
Tachycardia
Tachypnea
Mental status change
Coma and death
248
Treatment for methemoglobinemia?
Methylene Blue 1/2mg/kg
249
Which two populations are at risk for methemoglobinemia?
Glucose-6-phosphate reductase deficiency
Fetal Hgb
250
How does Bicarb affect local onset of action?
Shortens onset time
251
Which drugs can be given with locals to provide analgesia?
Clonidine
Epi
Opioids
252
Which drug can improve local diffusion through tissue?
Hyaluronidase
253
Is there fade with a phase 1 or phase 2 block?
Phase 1 - no fade
Phase 2 - fade
High dose succ can produce a phase 2 block
254
Fade:
Normal
Phase 1
Phase 2
255
NMB recovery
256
How does succ affect HR? Can it be given in kidney failure?
Can cause tachycardia or bradycardia (tachy is more common in adults)
Can give succ in renal failure if K is normal
257
Names for enzymes that metabolize succ
258
How to treat hyperkalemia in response to succ?
1. Calcium to stabilize
2. Shift K into cells
3. Eliminate K
259
Do opioids reduce risk of myalgia?
NO
Lidocaine, nsaids, and higher dose succ will help
260
What is the metabolite of atracurium and cisatracurium?
Laudanosine - may produce seizures
261
Is ketamine highly protein bound?
No.
Has low protein binding
262
Which NMB undergo Hoffman elimination?
Atracurium (33% and 66% esterases)
Cisatracurim (100%)
263
How is the HOFFMAN elimination increased or decreased?
Faster with alkalosis and hyperthermia (duration of action is shorter)
Slower with acidosis and hypothermia (drug lasts longer)
264
Which NMB does not have an active metabolite? How is it eliminated?
Roc does not have a metabolite
>70% liver and the rest is kidneys
265
How does electrolyte abnormalities affect NMB?
Lithium
Magnesium
Calcium
Potassium
Increased Mag and Lithium cause the NMB to last longer
Decreased Ca and K cause the NMB to last longer
266
Which NMB should be avoided in hypertrophic cardiomyopathy?
Panc (vagolytic effect)
Atracurium (histamine)
Mivacurium (histamine)
267
3 ways to inhibit acetylcholinesterase?
1. Electrostatic - Edrophonium
2. Carbamyl esters - neo, pyrido, physo
3. Phosphorylation - organophosphates and echothiopate
268
Does acetylcholinesterase inhibitors dosing need to be changed in renal failure?
No because the renal failure affects AchE and NMB
269
Which AchE is faster in infants and children?
Neostigmine
270
Why can atropine cause paradoxical bradycardia?
Underdosing (<0.5mg)
271
Precursors of the endogenous opioids
272
What are the unique effects to Kappa?
Anti shivering
Diuresis
Dysphoria
Delirium
Hallucinations
273
How do opioids cause bradycardia? BP?
Mu stimulation
Hypotension is likely from histamine release
274
How do opioids affect respiration?
-Shift CO2 response curve down and to the right
-Decreased rate but larger volumes
275
Which opioid receptor causes N/V?
Mu
276
How do opioids affect biliary pressure? What reverses it?
increases - contraction of the sphincter of Oddi
Reversed with glucagon or Narcan
277
How do opioids affect the urinary system?
Mu and delta
Detrusor relaxation (need to contract to pee)
Urinary sphincter contraction (need relaxation to pee)
278
How do opioids affect immunologic?
Suppress natural killer cells and humoral immunity
279
How are all opioids metabolized? Exception?
All through liver except for Remi
280
How does Methadone reduce pain?
Mu agonist
NMDA antagonist
Inhibits MAOI
281
What can rapid administration of opioids cause?
Skeletal muscle rigidity in the chest wall but greatest resistance to ventilation occurs in the larynx
282
Best treatment for skeletal muscle rigidity?
Paralyze
Can give naloxone but dumb before surgery
283
What is the worst reversal choice for opioid induced respiratory depression?
Methylnaltrexone it is a quaternary amine that does not pass the BBB
284
Which opioid antagonist has the longest duration of action?
Naltrexone - des not undergo first pass metabolism
- Can be given orally
- Good for opioid abusers/alcoholics
285
Where are opioid receptors located?
Brain - periaqueductal grey area
Spinal cord - primary afferent neurons in the dorsal horn
Peripheral - sensory neurons and immune cells
286
Which conditions increase the risk of succ induced hyperkalemia?
Guillain Barre
MH
MS
Hyperkalemia periodic paralysis
287
If you need more of a drug to achieve a given a effect, does it have high or low potency?
Low potency
The more drug required means it is less potent
288
In order to provide optimal intubating conditions, how many more times is required of the ED95?
Need 2-3x the ED95 for optimal intubating conditions
289
What is the maximum pressure during jet ventilation via needle cricothyrotomy?
50 psi
290
What are the three determinants of GFR?
Arterial BP
Afferent arteriole resistance
Efferent arteriole resistance
291
Three side effects to tramadol?
Seizures
N/V
Decreased efficacy when administered with zofran
292
What is the jul setting for pediatric cardiac arrest?
1st shock - 2J/KG
2nd shock - 4J/kg
3rd shock - 8J/kg
293
Measurements for Swan
294
Which drug causes apoptosis in the developing brain?
NMDA - ketamine and nitrous
GABA - gases, propofol, benzodiazepine, barbiturates
295
What is the best monitor for detecting a flowmeter leak?
O2 analyzer
296
How many L of CO2 does a 70kg produce in one hour?
12L
297
Characteristics of acute epiglottis?
Rapid onset
2-6 years old
Thumb sign
High fever
Tripod
4 D's - drooling, dyspnea, dysphagia, dyspnea
298
Treatment for acute epiglottis?
O2
Secure airway
Antibiotics
Spontaneous ventilation
ENT present
ICU
299
What time period is the greatest risk for an MI with CAD?
Within 2 days of surgery
300
Depth of anesthesia with an inhaled anesthetic is primarily determined by what?
Partial pressure
301
What is the most common cause of death during liposuction?
Pulmonary embolism
302
Which opioid is highly resistant to Narcan?
buprenorphine
303
A delta wave on EKG indicates what?
Wolff-Parkinson-White syndrome
304
What is the maximum allowable leakage current for a PA catheter?
10 uA
305
Which part of the anesthesia machine must remain off during a negative pressure test?
Vaporizer
306
Which blood product most likely causes sepsis?
Platelets due to being stored at room temperature
307
What is the most common co-morbidity in the pediatric population?
obesity
308
How much CO2 is produced a minute?
200mL/min
309
What determines intrinsic heart rate?
Rate of spontaneous phase 4 depolarization in the SA node
310
Where are the cardiac accelerator fibers?
T1-T4
311
Which items are in the high-pressure circuit?
Hanger yoke
Yoke block
Cylinder gauge
Cylinder pressure regulator
312
Where does the intermediate pressure system begin and end? What's included?
Begins at the pipeline and ends at the flowmeter valve
Pipeline inlets
Ventilator power inlet
O2 pressure failure system
O2 flush valve
O2 second stage regulator
313
What are the PSI for tanks and pipeline coming into the machine?
Pipeline - 50psi
Tank - 45 PSI
Pipeline is higher so it is used
314
Where does the low system begin and end?
Starts at the flowmeter tubes and ends at the common gas inlet
Flowmeter tubes (Thorpe tubes)
Vaporizers
Check valves
Common gas outlet
315
What are the 5 tasks of oxygen?
1. O2 pressure failure alarm
2. O2 pressure failure device
3. O2 flowmeter
4. O2 flush valve
5. Drive gas for pneumatic bellows
316
Liters pressure for Air, O2, and nitrous?
317
Laminar flow is dependent on....? Which law?
Laminar dependent on viscosity
Poiseuille
318
Turbulent flow is dependent on.....? Which law?
Turbulent flow is dependent on density
Graham
319
Does Vt increase or decrease when making the I:E ratio 1:2 to 1:1
Vt increases
320
What is the pumping effect on the ventilator?
Anything that causes the gas that has left the vaporizer to re-enter
321
What is the O2 analyzer and what does it measure?
Monitors O2 concentration and the only device downstream that can detect a hypoxic mixture.
322
If you suspect a pipeline crossover, what must you do?
1. Turn on cylinders
2. D/C pipeline supply
323
What flow and PSI is the patient exposed to when pushing the flush valve?
O2 flow = 35-75 L
O2 pressure = 50 psi
324
What 2 things is the patient at risk for when pushing the flush valve?
1. Barotrauma
2. Awareness from diluting gas
325
OSHA recommendation for inhalation exposure? Halogenated agents, nitrous, combined
-Halogenated agents <2ppm
-Nitrous <25ppm
-Combined <0.5ppm and 25ppm
326
Compare and contrast breathing circuits
327
Which conditions decrease pulmonary compliance?
Usually due to a reduction in static compliance
- Endobronchial intubation
- Pulmonary edema
- Pleural effusion
- Tension pneumothorax
- Atelectasis
328
Which conditions increase pulmonary resistance?
Due to a reduction in dynamic compliance
-kinked ETT
- ETT cuff herniation
-Bronchospasm
-Bronchial secretions
-Compression of airway
-Foreign body aspiration
329
330
Which conditions alter light absorption on pulse ox?
Methylene blue
Indocyanine green
Indigo carmine
Dark skin =
Fluorescein DOES NOT (think of giving it at northfield0
331
What is the ideal bladder length and width of a BP cuff?
Length - 80%
Width - 40%
332
If the BP cuff is below the heart, what will the reading reflect?
BP cuff below the heart, the reading will be falsely high
BP cuff above the heart will be falsely low
333
Where is pulse pressure the narrowest and highest?
-Narrowest at the aortic root which means the SBP will be lowest and DBP will be highest
-As you move away towards the feet, the SBP will be the highest and DBP will be the lowest
334
For every 1 inch in change in the level of the BP cuff, how much does the BP reading change
1 inch change = 2mmHg change
335
A line reading graph
336
What will SBP, DBP, and MAP be on an under dampened a line?
SBP - overestimated
DBP - underestimated
MAP - accurate
337
What will SBP, DBP, and MAP be on an over dampened a line?
SBP - underestimated
DBP - overestimated
MAP - accurate
338
Causes of an over-dampened system?
Air bubble
Clot
339
PA distances
340
Mnemonic for increased risk of torsade's?
POINTES
Phenothiazines
Other meds
Intracranial bleed
No known cause
Type 1 antiarrhythmics
Electrolyte disturbances
Syndromes
341
Two main treatments for torsade's?
Mag
Pacing
342
What is NIRS? (cerebral oximetry)
Measures venous cerebral oxygenation
A >25% change from baseline suggests reduction in cerebral oxygenation
343
Brainwaves chart
Beta
Alpha
Theta
Delta
Burst suppression
Isoelectric
344
How do brain waves change with anesthesia?
Induction
Light
General
Deep
-Induction = increased beta
-Light = increased beta
-General = theta and delta are dominate
-Deep = produces burst suppression
345
What mac level causes complete isoelectric brain waves?
1.5 - 2.0 MAC
346
Which drugs alter BIS?
Nitrous - Does not affect BIS value but alters the wave
Ketamine - increases high frequency (produces higher level of BIS)
347
What is the line isolation monitor? What do you do if it alarms?
Alerts staff if there is fault. 2-5mA leak is when it alarms
-*****unplug the last piece of equipment that was plugged in
348
Facts about hydralazine?
- Work more on arterial
-Can cause lupus
-Baroreceptor is intact
349
What should the joules be for cardioversion?
50-100 for first shock
Maximum 360
350
What is the treatment for a C1 esterase inhibitor deficiency?
FFP
351
Do opioids increase or decrease potassium conductance? What about calcium?
Potassium conductance increases which causes hyperpolarization
Calcium conductance decreases
352
What happens when you accidently inject local into the subdural space during an SAB? How about an epidural?
Epidural dose - high spinal with a delayed onset of 15-20 minutes
Spinal dose - failed spinal
353
How does neuraxial anesthesia affect the respiratory center and stress response?
usually no effects other than accessory muscle function is reduced.
*if there is apnea it is from hypoperfusion to the brainstem
Decreases stress response
354
What is the risk with neuraxial anesthesia in coagulopathy? Labs?
Risk of spinal hematoma
-PLT < 100,000
-PT, aPTT, or bleeding time twice the normal value
355
Which cardiac pathologies are absolute contraindications with neuraxial anesthesia? Risk of CV collapse
- Severe AS
- Severe MS
-Hypertrophic cardiomyopathy
356
What is the risk for neuraxial anesthesia and intracranial hypertension?
Increased chance of brain herniation due to sudden change in CSF
357
Does a hyperbaric solution sink or rise?
Hyperbaric - sinks
Hypobaric - rises
358
Examples of hyperbaric solutions?
Hyperbaric - anything in dextrose
Isobaric - anything in saline
Hypobaric - anything in water
**except 10% procaine in water that is hyperbaric
359
Needle graph
*pitkin is also cutting
360
Epidural needles
361
What are absolute contraindications to caudal anesthesia?
Spina bifida
Meningomyelocele
Meningitis
362
Where do neuraxial opioids work?
Inhibit afferent pain transmission in the substantia gelatinosa of the dorsal horn
363
Is neurotransmission reduced by increased or decreased K conductance? What about Ca?
364
Rank opioids from most hydrophilic to most lipophilic. How does this affect absorption
364
What is the most common side effect of neuraxial opioids?
1. Pruritis
2. Respiratory depression (hydrophilic drugs)
3. Urinary retention
4. N/V
365
Presentation of a post dural headache? which position helps relieve the headache?
-Fronto-occipital headache
-N/V
-Photophobia
-Diplopia
-Tinnitus
Laying down helps, sitting makes it worst
366
Treatment for postdural headache?
Bed rest
Fluids
NSAIDS
Caffeine
Blood patch
NOT OPIOIDS
367
Risk factors for post dural headache?
Younger age
Female
Pregnant
Cutting needle
Using air with LOR
Large diameter needle
368
3 ways norepi is removed from the synaptic cleft?
1. Reuptake into presynaptic (80%)
2. Diffusion away from synaptic cleft
3. Reuptake by extraneural tissue
369
What enzymes break down NE and E? Final metabolic product?
MAO
COMT
final product is vaillamandelic acid (VMA)
370
Carcinoid tumors S&S?
Bronchoconstriction
HTN
Flushing
Headache
371
Which CCB does not produce negative chronotropic and inotropic effects?
Clevidipine
372
How is ephedrine metabolized?
Liver
373
374
High dose norepinephrine can cause ?
Decreased CO from strong alpha stimulation
375
Which drugs when combines with norepinephrine can cause excessive SNS stimulation?
MAOI
Tricyclic antidepressants
376
How does low dose epi affect svr and CO?
Increases CO (beta 1 stimulation) and decreases SVR (beta 2 stimulation)
377
Correct (Dopamine > Beta > Alpha)
Low dose causes dopamine
Intermediate activates Beta
High dose causes alpha
378
How does isoproterenol affect CCP?
Decreases it
379
Which antimuscarinic can increase IOP with glaucoma?
Scopolamine
380
What are glomus tumors? Where do they originate from? What do they secrete?
Neuroendocrine tumors in the neural crest cells
-Secrete norepi (HTN)
-Secrete serotonin and kallikrein (bronchoconstriction, HTN, flushing)
-Secrete Histamine or bradykinin (bronchoconstriction hypotension)
381
382
383
Where is the majority of exogenous administered norepi metabolized?
Liver and Kidneys
384
385
How does Bainbridge reflex respond?
Senses increased preload and then increases HR to move the fluid along
386
How is Gap acidosis caused?
Accumulation of H+
Lactic acidosis
Ketoacidosis
Renal failure
387
How is Non-Gap acidosis caused?
Low of HCO3
Diarrhea
Renal tubular acidosis
Too much sodium chloride
388
What are the final products of soda lime reaction
Sodium hydroxide
Calcium carbonate
389
390
Appropriate dose of Mannitol for a 80kg patient?
50g
.5-1g/kg
391
How does hyperventilation affect calcium levels?
Causes hypocalcemia
392
RIFLE+AKIN
