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1
Q

Signs and symptoms of cholinergic crisis

A
  • Salivation
  • Miosis
  • Bradycardia
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2
Q

ACC/AHA criteria to diagnosis pulmonary hypertension

A

Requires right-heart catheterization and the following findings:

  1. Resting mPAP > 25 mmHg
  2. PCWP/LAP < 15 mmHg
  3. PVR > 3 Woods unit (<500 dynes)
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3
Q

Adverse effects from celiac plexus neurolytic blocks

A
  • Hypotension
  • Diarrhea
  • Hiccups
  • Retroperitoneal bleeding
  • Abdominal aortc dissection
  • Transient motor paralysis
  • Paraplegia
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4
Q

Factors that increase local anesthetic onset time

A
  • Lower pKa/lipid solubility
  • Increased solution pH
  • Increased LA concentration
  • Increased LA dose
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5
Q

Bainbridge reflex

A

Ultimately increases HR when intravascular volume increases

  • mechanoreceptors in RIGHT and LEFT ATRIA sense increased intravascular volume
  • signal carried by VAGUS nerve to medulla
  • increased sympathetic discharge at SA node with decreased parasympathetic discharge
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6
Q

Bezold-Jarisch reflex

A

Ultimately decreases HR due to intravascular volume depletion

  • mechano/chemoreceptors in VENTRICLES sense decreased filling
  • decreased sympathetic discharge
  • results in bradycardia, vasodilation and worsening HoTN
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7
Q

Causes of increased PVR

A
  • decreased PaO2
  • increased PaCO2
  • acidoses
  • increased airway pressure
  • hypothermia
  • vasoconstrictors (phenylephrine)
  • polycythemia
  • “light” anesthesia
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8
Q

Causes of increased SVR

A
  • low cardiac output
  • “light” anesthesia
  • alpha adrenergic agonist (phenylephrine)
  • hypothermia
  • acidosis
  • polycythemia
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9
Q

Classification of burn injury

A
  • First degree - superficial, confined to epidermis
  • Partial thickness (second degree) - epidermis and dermis
  1. superficial dermal - upper dermis
  2. deep dermal - deep dermis (req’s excision, grafting)
  • Full thickness (third degree) - full destruction of epidermis and dermis
    1. Fourth degree - involves muscle, fascia, bone
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10
Q

Clinical manifestation of serotonin syndrome

A

Mild to Life-threatening:

  • akathasia (restlessness)
  • tremor
  • AMS
  • inducible clonus
  • sustained clonus
  • hypertonia/rigidity
  • hyperthermia
  • cardiovascular collapse
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11
Q

Complications of retrobulbar block

A

MOST COMMON= retrobulbar hemorrhage

  • increased IOP resulting in proptosis
  • oculocardiac reflex
  • central retinal artery occlusion (sudden, PAINLESS monocular vision loss)
  1. inadvertant brainstem anesthesia
  2. postop strabismus (d/t intramuscular injection of LA)
  3. globe puncture
  4. optic nerve damage
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12
Q

Consequence of LV overload due to pressure

A

increased end-systolic wall stress –> parallel replication of sarcomeres –> increased wall thickeness –> concentric hypertrophy –> HFpEF

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13
Q

Consequence of LV overload due to volume

A

increased end-diastolic wall stress –> series replication of sarcomeres –> wall dilation –> eccentric hypertrophy –> HFrEF

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14
Q

Contraindications to intraoperative autologous hemodilution during cardiopulmonary bypass

A
  • perioperative anemia
  • unstable angina
  • left main disease
  • aortic stenois
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15
Q

Contraindications to retrobulbar and peribulbar blocks

A
  • Age <15 yrs
  • Surgery >90 min
  • AMS, cognitive dysfxn
  • Uncontrolled cough, tremors, movement d/o
  • Bleeding, coagulopathies, use of anticoagulation
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16
Q

Conversion ratio of HM, PO:IV

A

5:1

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17
Q

Describe anatomic landmarks of the Petit triangle used for TAP block

A

Lumbar triangle:

  • iliac crest = inferior wall
  • external oblique = anterior wall
  • latismus dorsi = posterior wall
  • triangle floor = external oblique fascia
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18
Q

Describe benefits of isovolemic hemodilution

A
  • Increased cardiac output
  • Increased tissue oxygen extraction
  • Decreased sheer forces in capillary beds
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19
Q

Describe considerations in drug therapy during resuscitation for LAST

A
  • Avoid vasopressin
  • Administer reduced epinephrine dose
  • Avoid calcium channel and beta blocker
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20
Q

Describe ECG leads with myocardial territories

A
  • Inferior= II, III, aVF
  • Septal= V1, V2
  • Anterior= V3, V4
  • Lateral= I, aVL, V5, V6
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21
Q

Describe hemodynamic effects of isovolemic hemodilution. Why?

A

Increased CO:

  • decreased blood viscosity
  • sympathetic surge d/t anemia and relative hypoxemia
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22
Q

Describe the pathology associated with Ebstein’s anomaly

A

Ebstein’s anomaly affects the tricuspid valve and right ventricle and can result in a hypoplastic right ventricle, enlarged right atrium, and a redundant anterior tricuspid valve leaflet. Most patients also have an atrial septal defect.

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23
Q

Describe wind-up phenomenon

A

Caused by repeated stimulation of peripheral C fibers resulting in increased action potentials at the dorsal horn causing an amplified pain response.

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24
Q

Differential diagnosis: Irregularly irregular ECG rhythm

A
  • atrial fibrillation
  • multifocal atrial tachycardia
  • wandering atrial pacemaker
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25
Differential diagnosis: PEA arrest
H&T's * Hypoxemia * (H+) acidosis * Hypothermia * Hyper/hypo kalemia/calcemia * Hypovolemia * Tamponade * Tension PTX * Thrombosis (MI, PE) * Toxins
26
Drugs and factors that potentiate NMBD
* inhaled anesthetics * aminoglycoside abx (gentamycin, neomysin, tobramycin, streptomycin) * hypothermia * magnesium * lithium * local anesthetics * ACUTE phenytoin use
27
ECG: Describe criteria to diagnosis axis deviation
28
ECG: Diagnostic criteria for left bundle branch block (LBBB)
* QRS \>120 msec * dominant S wave in V1 * monophasic R wave lateral leads (I, aVL, V5-V6)
29
ECG: Diagnostic criteria for right bundle branch block (RBBB)
* QRS \>120 msec * RSR' in V1-V3 (M shaped QRS) * wide, slurred S wave in lateral leads (I, aVL, V5-V6)
30
Estimate the progression of aortic stenosis by year
Approximately 0.1cm2 per year progression ie: AV area 1.0cm2; 5 yrs later would be 0.5cm2
31
Factors that cause overdamping of arterial line waveform
Overdamping results in underestimated SBP, overestimated DBP, unaffected MAP and loss of dicrotic notch * kinked tubing * increased compliance of tubing * increase length of tubing * blood clot * air bubble
32
Factors that increase r/o desaturation during OLV
* High perfusion and/or ventilation on preop V/Q scan * Poor PaO2 during 2 lung ventilation * Right-sided thoracotomy * Normal PFTs * Restrictive lung disease * Supine positioning during OLV
33
In terms of bronchoscopy, describe anatomic landmarks for carina
* Anterior = sternal angle * Posterior = 5th thoracic vertebra
34
Indications for PA catheter placement
* evaluation/diagnosis pulm HTN * distinguish etiology of shock * assess volume status * evaluate cardiac shunt * evaluate right-sided HF
35
Main determinant for closure of ductus arteriosus in neonates?
Increasing PaO2 \> 50 mmHg (leads to smooth muscles within the vessel to constrict, leading to its closure and loss of patency)
36
Management of tracheoesophageal fistula in newborn
* IV access, correct anemia, electrolytles * T&C * ECHO * +/- gastrotomy tube (vents the stomach, best utlized if difficulty ventilating d/t ab distention)
37
Name the adverse side-effects of succinylcholine
* Cardiac arrythmias: * sinus bradycardia * junctional rhythm * sinus arrest * Fasciculations, myalgias, trismus (lockjaw) * Hyperkalemia * Myoglobinuria * Increased intraocular pressue * Increased intragastric pressure
38
Name the benzylisoquinolinium ndNMBD
* Cisastricurium * Atracurium * Mivacurium
39
Name the cardiovascular criteria for positive epidural test dose with epinephrine in pediatric patients under GA
Changes that mark intravascular injection: * elevation in T-wave amplitude by 25% (most sensitive) * increase in HR by 10 bpm * increase in SBP by 15 mmHg
40
Name the largest branch of the lumbar plexus
Femoral nerve
41
Name the most important accessory muscles for ventilation
\*Diaphragm is main muscle of ventilation * Inspiration = cervical strap muscles (scalenes, sternocleidomastoids) * Expiration = abdominal muscles
42
Name the reversal agent for dabigatran
Idarucizumab
43
Name the aminosteroid ndNMBD
* Pancuronium * Rocuronium * Vecuronium
44
Nerve distribution commonly spared with supraclavicular block
Ulnar nerve distribution * medial surface of hand * 5th digit
45
Order of NMBD potentiation by inhaled anesthetics
Desflurane \> Sevoflurane \> Isoflurane \> Nitrous oxide
46
Oxygen content calculation
CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2)
47
Pathogen most responsible for croup
Parainfluenza virus
48
Pregabalin: MOA Side-effects
MOA: * binds the alpha-2 delta subunit of the presynaptic N-type voltage-gated calcium channels Side-effects: * increases slow wave sleep (somnolence) but is correlated with restorative sleep and less nighttime awakening * fluid retention and peripheral edema (contraindicated in pts with CHF)
49
Principle determinants of myocardial oxygen demand
* contractility * wall tension
50
Recommendations for DAPT duration and elective non-cardiac surgery
* BMS- 30 days * DES- 6 months\* \*unless risk of delayed surgery too high, then DES 3-6 months
51
Rectus sheath block nerve target
Thoracic intercostal nerve
52
Respiratory effects with spinal anesthetic resulting in T4 sensory blockade
* Minimal to no effect on TV * Decreased peak expiratory flow * Decreased expiratory reserve volume, therefore, reduced vital capacity
53
Risk factors of IV Amiodarone: short-term, long term
Short term: * bradycardia * HoTN * phlebitis Long term: * visual disturbance * skin discoloration (gray-blue) * thyroid dfxn * pulm toxicity
54
Risk factors of retinopathy of prematurity
* Prematurity (GA \<31 weeks) * Low birth weight (\<1250 grams) * Hyperoxia/hypoxia * Low IGF-1 levels (insulin-like growth factor) * Hyperglycemia
55
Risks of arterial line placement
* hematoma * ischemia * pseudoaneurysm * AV fistula * arterial dissection
56
Side-effects of supraclavicular block
Horner's syndrome * ipsilateral ptosis * miosis * anhydrosis Phrenic nerve block * Dyspnea
57
Structures innervated by medial branch of dorsal rami
* Facet joint * Multifidus muscle (connect spinous process to lamina) * Interspinous ligament
58
Tx: Air embolism
* Discontinue nitrous oxide * Aspiration through a right heart catheter * Supplemental oxygen * Prevent further air entry into circulation (flood surgical field with saline, jugular compression, lower head of bed in neurosurgical cases) * Left lateral decubitus position (allows air to move toward right ventricular apex, thereby relieving the obstruction of the pulmonary outflow tract)
59
What are absolute indications for GI prophylaxis (think SICU)?
* coagulopathy (plt \<50k, INR \> 1.5, aPTT \>2x nl * mechanical ventilation \> 48hrs
60
What conditions increase the volume of Zone 1 (West zones) of pulmonary circulation?
Decreased perfusion: * low CO * hypotension * PE * upright positioning Increased alveolar pressure: * PEEP * positive pressure ventilation Decreased vasculature: * emphysema * pulmonary fibrosis
61
What constitutes anatomic dead space?
Volume of the regions of the airway that histologically can't participate in gas exchange: * upper airways (oral cavity, nasopharynx, larynx) * cartilaginous airways (trachea, bronchi, membraneous bronchioles) * measured via single-breath nitrogen wash-out test (Fowler's method) * ~2mL/kg ideal body wt
62
What is an absolute contraindication for single-lung transplant (vs double-lung transplant)?
Infectious lung dz, ie: CF, bronchiectasis
63
What is normal chest wall compliance? How is it calculated?
100 mL/cm H20 C chest wall = change chest vol / change transthoracic pressure
64
What is normal lung compliance? How is it calculated?
150-200 mL/cm H20 Clung = change lung volume/ change transpulmonary pressure
65
What is the blood supply to the AV node?
RCA (85% of population)
66
When should rapid deflation of IABP occur?
* Peak of R wave on ECG * Just before systolic upstroke on arterial waveform
67
When should rapid inflation occur of IABP?
* Middle of the T wave on ECG * Dicrotic notch on arterial waveform
68
Which abx class does NOT augment neuromuscular blockade?
Macrolides: * azithromycin * erythromycin * clarithromycin
69
Which area of the heart is most vulnerable to ischemia? Why?
Subendocardium of LV * directly exposed to intracavitary pressure * greatest metabolic requirements due to systolic shortening
70
Which chamber do cardiac myxomas typically arise?
Left atrium (70%)
71
Which coronary artery provide blood supply to AV node?
RCA
72
Which coronary artery provides blood supply to SA node?
59%- RCA 38%- LCA 3%- both
73
Which drug should be avoided in tx LAST? Why?
Vasopressin Afterload augmentation w/o increased ionotropy would worsen cardiovascular compromise d/t LAST
74
Which factor has the greatest effect on spread of local anesthetic in the epidural space? Why?
**Age** * Dura mater is more permeable in the elderly due to increased number of arachnoid villi providing more surface area for permeation of local anesthetic to diffuse into subarachnoid space * Compliance of epidural space increases with age, therefore increasing spread of sensory blockade * Decreased number of myelinated nerve fibers in the elderly may allow local anesthetic to more easily penetrate nerve roots
75
76
Which nerve is not anesthetized via supraclavicular (brachial plexus) block?
Intercostobrachial nerve (T2; skin of the proximal part of the medial side of the arm)
77
Which nerve is often spared during retrobulbar block?
CN VII, Facial nerve * Pt can close eyelid (orbicularis oculi) but not open eyelid (levator muscle, CN III/oculomotor nerve)
78
Which nerve supplies sensory innervation of cornea, iris and ciliary body?
Nasociliary nerve (branch of opthalmic nerve, trigeminal nerve V1)
79
Which NMBD inhibits reuptake of norepinephrine by adrenergic nerves?
Pancuronium
80
Which patient factor is most implicated in development of cauda equina syndrome following spinal anesthesia? Why?
Hx of spinal stenosis * Increases risk of local anesthetic accumulation and subsequent injury to nerves.
81
Which valvular disease is commonly associated with bicuspid aortic stenosis? Why?
Aortic regurgitation Aortic root post-stenotic
82
Why do [some] anticonvulsant drugs interfere with OCP efficacy?
Administration induces CYP3A4 expression. CYP3A4 is the primary metabolic pathway for estrogen and progesterone, especially ethinyl estradiol, which can reduce the efficacy of OCP. Anticonvulsants that interfere with OCPs: * Topiramate * Carbamazepine * Lamotrigine * Phenytoin
83
Risks of repeated plasmapheresis
* Infection * Hypotension * Pulmonary embolism
84
Factors that predict postop ventilation requirement following transsternal thymectomy
* Disease (myasthenia gravis) duration \>6 yrs * H/O COPD * Daily pyridostigmine dose \>750mg * VC \<2.9L
85
Treatment for cerebral vasospasm
Triple H therapy: * hypervolemia (increase CVP by 10 mmHg) * hypertension (increase CPP) * hemodilution (decrease blood viscosity, improve CBF) \*Nimodipine is a prophylactic drug used to prevent vasospasm
86
Inherited risk factors for intracranial aneurysms
* Polycystic kidney dz * Type IV Ehlers-Danlos * Hereditary hemorrhagic telangectasia * Neurofibromatosis type I * coarctation of the aorta * Pheochromocytoma * Klinfelter's syndrome * Tuberous sclerosis * Noonan's syndrome
87
Non-inherited risk factors for intracranial aneurysms
* Age \>50 * Female * Smoking * Cocaine use * Head trauma * Septic emboli * HTN * Alcohol use disorder * OCPs * HLD
88
Hyperkalemic Periodic Paralysis: Triggers
* rest after exercise (elevation of ECF potassium) * potassium-rich foods * stress * alcohol * fatigue * hypothermia * fasting * pregnancy * corticosteroids
89
Hyperkalemic Periodic Paralysis: Interventions during attacks
* glucose ingestion * inhaled albuterol * thiazide diuretics * acetazolamide
90
Describe the 2 main causes of succinylcholine-induced hyperkalemia
1. extrajunctional receptors (burns, spinal cord injury, immobile) 2. rhabdomyolysis (seen in muscular dystrophy)
91
Anesthetic agents and effects on CBF, CRMO2
92
Calcitriol: MOA
Active form of vitamin D, increasing GI uptake of calcium and decreasing renal calcium excretion; used in treatment of hypoparathyroidism
93
Signs of venous air embolism
* increase in dead space (decreased EtCO2, elevated PaCO2) * HoTN * Tachycardia * Acute RV failure (flash pulmonary edema, hypoxia)
94
Describe differences between hypo vs hyper kalemic periodic paralysis
95
Name examples of a potassium-wasting diuretic and examples of a potassium-sparing diuretic
_Wasting:_ * thiazides (HCTZ, chlorthalidone) * loop diuretics (furosemide, torsemide, ethacyrnic acid) _Sparing_: "SEAT" * aldo antagonist: spironolactone, eplerenone * ENaC blockers: amiloride
96
Which neuromonitoring technique is most sensitive to volatile anesthetics?
Visual-evoked potentials (VEP)
97
Which neuromonitoring technique is least sensitive to volatile anesthetics?
Auditory-evoked potentials (AEP)
98
Pathophysiology: * tetanus * botulism * diptheria * pertussis
Tetanus: * clostridium tetani, inhibits neurotransmitter release from inhibitory neurons in CNS Botulism: * clostridium botulinum, inhibition of AcH release from NMJ Diptheria: * inhibition of elongation factor 2 of transcription Pertussis: * bordetella pertussis, ribosylation of Gi protein inhibits the inhibitor of cyclic AMP

ABA Advanced Exam (1 decks)

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