ITE block 6 Flashcards
(140 cards)
1
Q
Post MTP and QT shortening what eletrolyte issue?
A
HyperK
2
Q
EKG changes in hypoCa
A
prolonged QT due to prolonged ST segment
reduced PR interval
T wave flattening and inversion
3
Q
A
J waves
Caused by hypercalcemia and hypothermia
4
Q
One of the highest risk of leading to malpractice claims in anesthesia
A
residual anesthetic agents in PACU -> significant hypoxia
*resp events are one of the main causes
-so is cardiovasc d/o in relation to anesthetic medication
5
Q
Effects of acute normovolemic hemodilution
A
Take some of pts own blood and replace with saline
-Inc in HR -> inc in CO to compensate
-Dec in blood viscosity -> Peripheral vasodilation -> inc in regional blood flow
no increase in O2 delivery, just the same with less Hg
6
Q
O2 content equation
A
CaO2 = (SaO2 x Hg x 1.34) + (PaO2 x 0.003)
7
Q
Maximum dose of lidocaine w/ Epi 1:200,000
A
7 mg/kg
-dose used for regional anesthesia
8
Q
Maximum dose of lidocaine w/ epi 1:1,000,000
A
This is the dose used in tumescent anesthesia
-for liposuction
-dose is 35-55 mg/kg !!
-max: 5L of fat removal
9
Q
Dermatome for medial knee
A
L3
10
Q
Dermatome for medial malleolus
A
L4
11
Q
Dermatome for lateral malleolus
A
S1
12
Q
Lumbar n root that causes flexion of the lower extremity at the hip
A
L1-L2
13
Q
Lumbar n root that causes extension of the knee
A
L3 and L4
14
Q
Lumbar n root that causes flexion of the knee
A
L5 (S1-2)
15
Q
Early decelerations in OB caused by?
A
Head compression w/ contraction -> activation of vagal resp
16
Q
Late decels in OB caused by
A
Uteroplacental insuff -> fetal hypoxia and acidosis
17
Q
Variable decels in OB caused by
A
umbilical cord compression -> baroreceptor or chemoreceptor med vagal activation -> dec blood supply and transient hypoxemia
18
Q
Relative contraindications to MAC
A
unable to lie still
unable to follow instructions
unable to communicate w/ care team
19
Q
What stimulates carotid body chemoreceptors
A
arterial partial pressure of O2
20
Q
what innervates the carotid body chemoreceptor
A
glossopharyngeal nerve
-activated when partial pressure of O2 < 60-65 -> augment ventilation
21
Q
Causes an increase in SvO2
A
Cyanide tox, Met-Hg (dec O2 extraction)
Increased cardiac output
blood transfusion
Inc oxyHg saturation
22
Q
Dec SvO2
A
Decreased cardiac output
Inc catabolic state -> sepsis, shivering, fever, pain
Anemia
Dec arterial O2 saturation (PNA, pulm edema)
23
Q
Pt w/ concern for possible aspiration PNA, but hemodynamically stable what now?
A
If pt is reliable and able to follow instructions, can send home w/ outpt f/u
if not reliable -> keep admitted to monitor for fevers, labs, f/u CXRs
-can get initial decompensation at time of event or 4-6 hrs later
*it pt hasn’t developed PNA by 12-24 hrs unlikely, and only give abx if actually has PNA
24
Q
Mitral regurge hemodynamic goals
A
Normal to inc HR
Dec PVR
Dec afterload
Normovolemia
25
aortic stenosis hemodynamic goals
inc preload
inc afterload
dec HR
**maintain diastolic pressure
26
Mitral stenosis hemodynamic goals
Dec HR
Inc preload
Normal afterload
27
HOCM hemodynamic goals
Inc preload -> lots of volume
inc afterload
HR down
contractility down
28
Most rapid form of cooling for post cardiac arrest hypothermia
endovascular cooling (put in a central line and cold things)
29
Post cardiac arrest hypothermia
Goal temp: 32-36 for 12-24 hrs
cooling: endovascular fastest
-ppl most likely to die if you rewarm too fast
-use meperidine to dec shivering and dec O2 demand
30
Leading cause of malpractice claims in the 2000s?
Death (29%)
Then n injruy, permanent brain damage and airway injuries
31
DKA lytes
HypoNa (dilutional, water pulled into extracellular space due to hyperglycemia)
hyperphos (insulin def, P shifted out of cells by acidosis) -> total body phos be decreased
hyperK (but total body deficit)
Hyperglcyemia
hyperosmolality
elevated ketones
Anionn gap acidosis
32
on arrival to ED pt w/ depression is hyperthermic, tachycardia, HTN, cleaning jaw, disinhibited what drug?
3,4-Methylenedioxymethamphetamine (MDMA) -> ecstasy
-jaw clenching possible serotonin syndrome
33
Flunitrazepam
Rohypnol aka the date rape drug
-benzo -> amnesia and muscle relaxation
34
When will retrograde cardioplegia be ineffective
persistent L SVC b/c solution will be lost to the upper extremity and head instead of coronary vasculature
35
Cuffed cricothryoidotomy
-larger possibility for trauma b/c scalpel and placement
-compression on airway while placing -> inc risk of damage or perforation of the posterior trachea wall
-but cuffed so no risk of aspiration
-attaches to anesthesia vent and can be used w/ low pressures
36
Needle cricothyroidotomy cannula
involves needle placement, wire, and dilation
-only allows inspiration through cannula, expiration done passively requiring open upper airway
-less likelihood of tracheal trauma, but inc risk of complications like PTX, malposition
-requires large pressure to get TV through small cannula
37
Why does nitrous oxide cause air space expansion
because it is more soluble than nitrogen -> enters the space faster than N can leave
38
Insulin response
glycogenesis
fatty acid synthesis
TG synthesis
glucose uptake
protein synthesis
39
PDA murmur
in the first few weeks of life is systolic ->becomes continuous later on
40
premature neonate w/ apnea, bradycardia, diff weaning from vent, systolic murmur, dx? tx?
Patent PDA -> systolic in first few weeks
if symp (diff vent weaning) -> get echo and then possibly indomethacin
41
Where does aerobic glycolysis produce the majority of its ATP
mitochondria!
-NOT cytoplasm :* -> anearobic in cytosol
42
Starting substrate for aerobic and anaerobic glycolysis
Glucose!
43
End products of aerobic metabolism
CO2 and H2O
44
end products of anaerobic metabolism
lactate
45
What is a univent tube
ETT with smaller lumen for bronchial blocker to pass through -> ETT have smaller internal diameters
-smallest have internal diameters of 3.5-4 designed for peds 6 or older -> w/ internal diameter of 3.5-4, external diamter is 7.5
46
Smallest double lumen tube
designed for kids 8+
26 Fr
47
insulin and glucagon mediated in hepatocytes by which secondary messenger?
cAMP
-glucagon inc cAMP
-insulin dec
48
cGMP
secondary messenger for NG, nitroprusside, nitric oxide, sildenafil
49
IP-3
secondary messenger in cardiac myocytes -> inc in cytoplasmic Ca ions -> inc in Ca activates ryanodine receptors on SR -> promotes Ca release
50
ICAM-1
intracellular adhesion molecule
-promotes adhesion of neutrophils, monocytes, T cells and B cells
51
Tx for Met-Hg in pts w/ G6PD def
Ascorbic acid
Vit C
-acts as electron donor to aid in reduction of Fe 3+ to Fe 2+
-slower than methylene blue, but can be used safely in G6PD
52
Amyl nitrite
used to tx cyanide toxicty by oxidizing Fe 2+ to 3+
-cyanide binds more readily to Met-Hg -> this induces it and hopefully binds up all the cyanide
53
Why does indigo carmine dye dec pulse ox?
b/c absorption closer to 600nm range -> falsely lowering saturation
54
sinusoidal patterns on FHR
assoc w/ placental abruption -> very ominous sign
55
When does a fetal heart rate tracing -> change in baseline FHR?
When you have an acceleration or deceleration that lasts longer than 10 minutes
56
Normal baseline fetal HR
110-160
57
Propofol elimination kinetics order and graphic representation
1st order
so on logarithmic graph, straight incline down
on linear graph, curve down
58
HIPAA and email
compliant email: providers and pts include authentication, encryption, time-stamping and INFORMED CONSENT!
59
What triggers nonshivering thermogenesis in neonates
norepinephrine, glucocorticoids, thyroxine
60
What inhibits nonshivering thermogenesis in neonates
inhaled anesthetics and beta blockers
61
Terminology related to drowning: distress
precursor to drowning: resp impaired from being in/under liquid
62
Terminology related to drowning: active drowning
non-swimmer, unable to maintain airway above water
63
Terminology related to drowning: passive drowning
loss of consciousness
64
Terminology related to drowning: w/ or w/o ungoing health problems
what you're seeing is related entirely to drowning or other ongoing health issues
65
BISreadings and anesthesia
100: awake
80: light/mod sedation
60:GA, low probability of recall
40: deep hypnotic state
20: burst suppression
0: isoelectric EEG
target for GA: 40-60
66
Anrep effect
inc in ventricular contractility following acute in afterload (Frank-sterling(
67
Bainbridge reflex
R atrial stretch receptors
-Inc R sided filling pressure -> parasymp inhibition -> inc in HR
-so if lots of water flowing under the bridge overloaded, it's going to inc how fast it lifts up the bridge -> inc in HR
68
Bezold-Jarisch reflex
hypoTN, bradycardia, coronary artery dilatation in resp to noxious stimuli w/i LV wall sensed by chemo and mechanoreceptors
69
Dec in Hr reflex w/ laryngospasm
Baroreceptor reflex
-transient inc in LV output 2/2 compression of thoracic aorta
70
neuraxial v IV opioids
neuraxial may increase duration of 2nd stage of labor, but no inc in morbidity or mortality and no effect on c/s rates
71
How does the body compensate quickly for inc ICP?
redistribution of blood in intracranial v to extracranial v
redistribution of CSF from brain to spinal column.
72
Normal serum osmolality
275-295
73
post neurosurg polyuria, plasma osmolality over 290
Diabetes insipidus
-def of ADH
-tx: DDAVP, isotonic fluids to maintain euvolemia
74
post neurosurg, polyuria, dehydration, osmolality 250
cerebral salt wasting
75
RF for postop cognitive delerium
lower education
older age
previous hx of CVA w/ no residual deficits
76
Antecubital anatomy med -> lateral
median n ->ulnar v -> brachial artery
77
Spica casting
lower chest to the calves -> if inadequate space b/w cast and lower chest or abd -> restrictive resp defect
-airway will be disconnected due to placement on board
-hips cast in flexed, externally rotated and abducted
78
According to ASA physical exam MUST include
airway exam
lung auscultation
cardiovascular exam (no req auscultation)
vital signs
79
RF for emergence delirium
ages 2-6
use of volatile anesthetic
80
SE of methylergonovine
HTN
vasoconstriction
coronary vasospasm
81
Misoprostol
used to ripen cervix and induce labor usually in low-resources areas (b/c doesn't need to be refrigerated)
-not as effective as oxytocin
82
What do you not have to disclose as part of a COI
personal relationships
paid expert testimony
travel grants
relationships w/ outside oragnizations
83
Uteroplacental circulation
-Ovarian arteries supply up to 15% of uterine BF, rest uterine arteries
-uterus receives 20% of cardiac output at term
-terminal villi on FETAL side of placenta exchange gas, nutrients, and waste products
0primary villi form during 1st trimester
-umbilical arteries originate off fetal internal iliac arteries -> carry deoxygenated blood from fetus to placenta (paired arteries)
-single umbilical v carries oxygenated blood back to fetus
84
Coagulation changes in pregnancy
Decreased fibrinolysis
Dec anticoagulations -> dec protein C and S
Dec plts (dilutional)
Inc D-dimer
inc thrombin-antithrombin complexes
85
Goldenhar Syndrome
micrognathia, hypoplastici zygomatic arch, facial asymmetry, fascial hypoplasia
mod to severe congenital cardiac defects
resp problems
at risk for C1-2 subluxation
usually intellectually intact (15% not)
**possibility for pseudocholinesterase def*
86
Limb-girdle muscular dystrophy
weakness in shoulders, hips, proximal muscles
-some ppl can have normal life, others severe dx
-likely to have cardiac issues -> arrhythmias, cardiomyopathies
-avoid succ and volatiles anesthetics
87
Effect of dilute epi in bupi for epidural analgesia
causes a more profound motor block -> why is not used frequently
-possible reduction in uterine activity by beta agonism
-dec uterine and SC BF
88
minimum local anesthetic concentration of epidural
measure of the potency of local anesthetics and is the median effective neuraxial conc of local anesthetic solution
89
minimum local anesthetic concentration of epidural effect of adding epi to bupi
lowers it, because epi has some direct agonism in dorsal horn as well
90
MOA of renin
converts angiotensinogen to ATI
91
What triggers renin secretion
Dec in serum NaCl sensed by kidneys
Dec in BF sensed by kidney baroreceptors
activation of beta 1 receptors by NE
92
AT II
acts directly on BV to cause vasoconstriction
acgts on kidneys to stimulate reabsorptin of water and NaCl
stimulates release of aldo from adrenal glands
93
effect of lorazepam on pt satisfaction
NO EFFECT and prolongs extubation time -> why it's not used
94
Fentanyl premedication and postop pain control
-only use if pt has pain porior to surgery
-admin w/o pain -> sensitize pts ot pain -> postop hyperalgesia
95
Concerns for down syndrome and ear tubes
Pt ha sa more narrow external auditory meatus -> procedures will take longer
tilt table instead o neck due to possible atlantoaxial instability
-worth it to put an LMA in b/c lots of issues, want to have hands free
-put the IV in
96
Hepatic extraction ratio
extraction ratio = (mixed hepatic arterial-portal drug conc - hepatic v drug conc)/mixe dhepatic arterial-portal drug conversation
97
How to tell if a drug clearance is dpt on BF or not
If a drug has high intrinsic clearance -> dept on blood flow (b/c more BF, can clear more drug) -> flow dependent
If drug has low intrinsic clearance -> not dpt on blood flow (b/c increased BF wouldn't change anything) -> flow independent
98
Commonly used drugs with high hepatic extraction ratio
FLOW DEPENDENT
Fentanyl
Ketamine
Meperidine
Bupivacaine
Diltiazem
Metoprolol
Morphone
Nifedipine
Propofol
99
Commonly used drugs w/ low hepatic extraction ratio
FLOW INDEPENDENT
Diazepam
Methadone
Rocuronium
Alfentanil
Thiopental
100
Ex of a laser-resistant ETT
dual cuffed tracheal tube
-nonflammable and laser resistance -> stainless steel shaft and 2 indpt cuffs in series
101
How does methylene blue treat Met-Hg
Acts as an electron receptor for NADPH-methemoglobin reductase -> enhances enzyme -> reduction nof MetHg to Hg
102
Oxygen delivery
cardiac output x CaO2
CaO2= (1.34 x Hg x SaO2) + (.0031 x PaO2)
103
Thrombotic thrombocytopenic purpursa
Plt destruction d/o
-Def in vWF-cleaving protease activity (ADAMSTS13 def)
-FFP repeltes enzyme
**plasmapheresis may used to tx the acquired type, to remove antibodies that damages the enzyme
104
Emergent reversal of warfarin
prothrombin compledx concentrate
(FFP if it isn't available, but PCC is better!)
105
Indications for FFP
-Coag d/o once whole body blood volume has been replaced
-Factor def when there isn't isolated factor concentrate
-microvascular bleeding when PT, PTT, and INR elevated (2x normal)
-When giving heparin, but pt has dec ATIII (heparin resistasnce)
-Thrombotic thrombocytopenic purpura
-Urgent reversal of warfarin if PCC isn't available
106
What J do you shock a pt w/ in SVT for synchronixed cardiovesrion
50-100 J
107
Tx of unstable SVT in a pt post heart transplant
synchronized cardioversion
-vagal carotid massage won't work
-phenylephrine won't dec it
-esmolol won't really help in transplanted heart
108
Ion movement during depol at NM
Na in
Ca in
K out
109
Hydrostatic pressure
pressure exerted by blood plasma and interstitial fluid on capillary walls
(force that pushes fluid out of blood)
-hydrostatic P > oncotic pressure-> fluid leaks out into periphery
110
Oncotic pressure
pressure exerted by proteins in blood plasma
(force that pushes fluid into blood)
-oncotic P > hydrostatic pressure -> fluid stakes in bllod
111
Clinical findings of cardiogenic shock
Low cardiac output with JVD
vascular and pulm vascular congestion
peripheral vasoconstriction
cold extremities
poor urine output
AMS
hypoTN
112
Which factor decreased in pregnancy?
Factor XI
113
Factors for inc neuroblastoma survival
Dx < 18 months
extraabd tumors
low INHRG (international neuroblastoma risk group) score
good tumor resectability
primary tumor
no mets
small tumor
favorable tumor biology
114
Dx of neuroblastsoma what lab test?
elevated urinary catecholamines
115
Anesthetic concerns for neuroblastoma removal
-If catecholamine secreting -> alpha and beta blockade prior to surgery
-A line and central line
-euvolemia (pt is dehydrated from chronic symp activation)
-blood available and rapid transfuser
-good BP control esp during tumor manipulation
116
Vaporizer output
1/4 for sevo
1/2 for iso
-If 100 mL/min of O2 inflow through sevo vaporizer -> 1/4 will be sevo -> 25 mL
117
CVP tracing in relation to EKG
118
Guillain-Barre and Na
often accompanied w/ SIADH in 50% of pts -> hypoNa
119
GBS LP
inc protein, normal glucose and cell count
120
Earliest indication of respiratory failure in GBS
spirometry! should be followed throughout hospitalization
-1/3 of pts have respiratory failure
121
Autonomic symp and GBS
autonomic dysfunction
hypoTN, HTN, cardiac dysrhythmias, ileus
122
Cushing syndrome
excess cortisol
-hirsuitism (minimics androgen hormones)
-elevated blood glucose
-inc protein breakdown -> moon facies, buffalo hump, abd weight gain
-mood changes
-thinning of extremities
-HTN
-hypoK
123
signs of extrathoracic airway object
inspiratory stridor, drooling
124
object has migrated to trachea/lower airways signs
asthmatoid wheeze
expiratory wheeze
audible slap w/ expiration
palpable thud over suprasternal notch
125
What fluid at large doses can cause a coagulopathy
Hydroxyethyl startch
126
What type of conversations b/w attorney and physician are privileged
oral, print, or electronic
**as long as only intended for them to be the only parties**
127
13 YOM fever, sore throat, trismus, diff swallowing, normal voice dx? cause?
peritonsillar abscess
Group A beta-hemolytic Strep
abscess more common in older children and adults
128
Anesthesia considerations for peritonsillar abscesses
if trismus:
inhalational induction -> keep breathing
-reassess airway after inhalational induction -> adequate mask vent and can open mouth okay -> give NMB and prop to intubate
if no trismus: RSI to avoid oral airway placement and risk rupture
129
RF for failed neuraxial in OB
fast decision to incision interval
late labor epidural placement
maternal obesity
130
terbutaline lyte changes
hypoK
hyperglycemia
131
If ETT is unable to pass off fiberoptic, most likely cause?
tip impinged on R arytenoid cartilage
132
Assist-control ventilation
has a set TV and RR
if pt not spontaneously breathing -> looks like VCV
if pt initiates -> delivers positive pressure w/ set TV
**be careful in pts w/ rapid resp rate -> auto PEEP and breath stacking
133
Elevated DLCO
DLCO is a function of: diffusion rate and binding capacity
Asthma
Obesity
Cardiac Output
Polycythemia
Pulm vasodilation
L to R shunting
134
Propofol v sevo for airway reflexes
propfol more likely to mitigate laryngospasm
sevo more likely to mitigate cough, spasmodic panting reflex
135
MOCA questions per year
120 -> 30 max per quarter
136
Allodynia
mild sensory stimulations elicit severe pain
-ordinarily non-noxious stimulus perceived as painful
137
anesthesia dolorosa
pain in an area that lacks sensation (usually the face)
feared complication of radiofreq ablation for treatment of trigeminal neuralgia
138
Pacemaker indications
sick sinus syndrome
congenital long QT syndrome
supraventricular tachycardias responsive to pacing and nothing else working
Heart block: Mobitz type II or type III
HF as part of resynchronization therapy
Dilated cardiomyopathy
HOCM
sinus node dysfxn w/ symp bradycardia
139
anxious pt starts getting extremity numbness, cramping, why?
Hyperventilation -> hypocarbia -> resp alk -> functional hypoCa
140
pt w/ placenta previa, what inc risk of PPH?
Prior hx of c/s -> inc risk of placenta accreta
