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in training exam tl > ITE TL Block 4 > Flashcards

ITE TL Block 4 Flashcards

1
Q

inc risk of hypoTN after spinal

A

BP < 120
age > 40
spinal at or above L2-3
concurrent GA
sensory block >T5

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2
Q

Aprepitant

A

neurokinin 1 receptor antagonist
-duration of action: 24 hours
-PONV ppx

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3
Q

Dropierdol

A

PONV ppx antidopaminergic

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4
Q

Glucagon and cardiac effects

A

activates adenylyl cyclase -> inc cAMP -> positive ionotropic and chronotropic (inc HR and contractility)
-how glucagon treats beta blocker overdose
-can be used in pt w/ anaphylaxis on beta blockers (resistant to beta of epi)

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5
Q

opioids and seizures

A

opioids do NOT alter the sz threshold or cause sz
-only exception is in renal failure when toxic metabolites accumulate

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6
Q

In ICU triglyceridemia, lactic acidosis, rhabdo, and acute fatty liver injury

A

Propofol Infusion Syndrome
-inc in TG 1st

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7
Q

if viral pandemic and running out of sedatives best next step

A

scheduled PO opioids through an NG/OG tube

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8
Q

when attempting epidural placement, what changes in vitals/EKG show a positive intravascular catheter placement?

A

HR > 10 bpm
Systolic BP >15-25 mmHg
T wave depression of > 25%
-tinnitus, metallic taste, perioral numbness

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9
Q

hyperthermia, vomiting, rigidity, hyperreflexia and myoclonus w/ antipsychotics and meperidine dx?

A

serotonin syndrome
-SSRI, SNRI, MAOI w/ meperidine
methylene blue
fent, methadone, tramadol, morphine
maprotiline (antidep)
trazodone
buproprion
mirtazapine
buspirone

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10
Q

treatment for serotonin syndrome

A

cyproheptadine

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11
Q

Isocarboxazid

A

MAOi

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12
Q

Tranylcypromine

A

MAOi

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13
Q

Doxepin, desipramine, Clomipramine

A

TCA

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14
Q

mental status change, hyperthermia, rigidity and dysautonomia w/ antipsychotics and meperidine, dx?

A

Neuroleptic Malignant Syndrome
-no hyperreflexia in NMS! how you tell them apart

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15
Q

Drug eluding stent 6 months later wants elective surgery on ticagrelor and ASA, what and when d/c prior to surgery?

A

hold ticagrelor for 5-7 days prior
continue ASA
-allows for spinal anesthesia and still reducing risk of in-stent thrombosis

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16
Q

what is the epidural test dose

A

3 cc of 1.5% lidocaine w/ 1:200,000 epi
45mg lidocaine and 15mcg of epi

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17
Q

bronchospasm

A

FiO2 100% and hand ventilate
deepen anesthetic
albuterol
epi
anti-Ch (glyco, atropine, ipratropium) but take 20-30 minutes
Mg sulfate
steriods (4-6 hrs to work)

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18
Q

How does transcutaneous n stimulation using electricity help pain

A

stimulates A-beta cutaneous mechanoreceptors -> inhibit A-delta and C pain fiber signaling -> inc levels of endorphins

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19
Q

Gabapentin MOA

A

VG Ca channels

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20
Q

MOA of tranexamic acid

A

inhibits conversion of plasminogen to plasmin
-preventing clot breakdown (plasmin essential for breakdown of fibrin clots)
-lysine analog antifibrinolytic

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21
Q

Alteplase MOA

A

fibrinolytic agent
plasminogen activator that converts plasminogen to plasmin -=> breakdown of clots

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22
Q

FDA approval for TXA

A

heavy menstrual bleeding and prevention of bleeding in hemophiliacs in tooth extractions
-use otherwise is off label

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23
Q

Measure of liver synthetic function

A

Factor VII
-1/2 life is four hours

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24
Q

PT and bile acid secretion impairment

A

PT dpts on Vit K consumption and absorption
-so if bile acid secretion impaired (biliary obstruction) -> PT will be prolonged, but hepatic fxn will be normal

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25
Q

Bilirubin measures what in liver

A

excretory function

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26
Q

Fibrinogen 1/2 life

A

4 days
-so measures hepatic synthetic function, but factor VII is faster

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27
Q

16 yo rhinoplasty, mild jaundice post op, t bili 2.5 inc in unconjugated bilirubin, no symptoms.
Dx?

A

Gilbert Syndrome

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28
Q

Gilbert Syndrome enzyme

A

Reduction of UDP-glucuronosyltransferase activity
-leads to a dec in conjugated bili -> inc in indirect bili
-indirect bili elevated but < 3
-benign no tx

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29
Q

Ischemic hepatitis

A

hepatic hypoperfusion usually 2/2 hypoTN -> dec hepatic clearance
-AST and ALT peak 25-250x normal 1-3 days after insult
-takes 3-11 days to return to normal

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30
Q

sudden painless bright red vaginal bleeding after 20 weeks gestation

A

placenta previa

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31
Q

RF for placenta previa

A

previous c/s
previous pregnancy termination
previous uterine surgery
smoking
advanced maternal age
multiple gestation
multiparity
cocaine abuse

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32
Q

sudden painful vaginal bleeding >20 weeks, uterus rigid and tender, fetal distress

A

placental abruption
-premature separation from uterus before delivery

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33
Q

sudden, severe abd pain duringn labor, pause in contractions, fetal distress, hemodynamic instability

A

uterine rupture

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34
Q

sudden painless vaginal bleeding after rupture of membranes

A

vasa previa
-fetal blood vessels overlying the internal cervical os
-can cause fetal exsanguination
-different from placenta previa b/c after water breaks

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35
Q

50 year old man hx of obesity BMI 32, inguinal hernia repair, what preop tests?

A

none indicated
-EKG if cardiac dx, resp dx, type of surgery
-CXR if smoking hx, pulm dx or cardiac dx but routinely not done
-Hg/Hct if liver dx, aneemia, hematologic d/o, type of surgery

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36
Q

What would cause a decreased gradient of O2 partial pressure b/w alveolar gas and serum tension leading to a decreased diffusion capacity? what would inc it?

A

Anemia dec diffusion
polycythemia inc diffusion

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37
Q

Why decreased diffusion capacity of carbon monoxide in pulm hypertension

A

thicken walls of the alveolar-capillary membrane -> dec gas diffusion
-similar to chronic thromboembolic dx

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38
Q

What causes a decreased surface area that will dec DLCO in lungs?

A

small lungs
pulm fibrosis
hx of lung resection
emphysema

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39
Q

What you need to maintain your certification by ABA every 10 years

A

-hold an active, unrestricted medical license in US or Canada
-250 Cat 1 CME credits (125 done by year 5) -> 20 must be ABA-approved for pt safety
-30 MOCA MC questions every quarter -> 120 questions per year
-25 pts in first 5 years and 25 points in 2nd 5 years: given points for clinical practice assessments and systems-based practice such as QI

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40
Q

PFTs diagnostic for COPD

A

FEV1/FVC < 70% incompletely reversed after bronchodilatory therapy

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41
Q

Severity for COPD based on FEV1

A

mild: FEV 1 80% or greater of predicted
moderate: FEV1 50-79%
severe: FEV1 30-49%
very severe FEV1 < 30%
*** < 50% means inc risk of postop pulm complications and likely postop ventilation esp after abd and thoracic procedures

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42
Q

Dx of COPD v severity testing

A

Dx: FEV1/FVC ratio of < 70%
severity is entirely based on FEV1 (<50% severe and at risk for postop complications)

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43
Q

Vapor pressure of des, sevo, iso, nitrous

A

Des 669 w/ BP at 24 -> so at room temp, already a gas, so has a high vapor prssure
Iso 238 w/ BP at 49 -> why when in a sevo vaporizer gives more gas than it should
Sevo 157 w/ BP at 59 -> why when in an iso vaporizer gives less gas than it should
Nitrous 38,770 w/ BP at -88 -> why gas in a cylinder w/ liquid at room temp

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44
Q

Retrobulbar v peribulbar block: which has a faster analgesia onset?

A

Retrobulbar < 5 minutes

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45
Q

Retrobulbar v peribulbar block: results in akinesia of the orbicularis oculi?

A

peribulbar
-b/c larger volume injected, greater distribution
-if doing a retrobulbar block, need a suppl facial n block to get akinesis of orbicularis oculi

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46
Q

Retrobulbar v peribulbar block: more likely to inject into subarachnoid space

A

retrobulbar: longer needle used

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47
Q

Retrobulbar v peribulbar block: increased risk of conjunctival chemosis

A

peribulbar: larger amount of local anesthesia accumulating under conjunctiva

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48
Q

Drops v gel local anesthesia for eye surgeries

A

gels have higher concentrations of local anesthesia and offer superior surface analgesia

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49
Q

Tramadol MOA

A

mu-opioid agonism
SNRI

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50
Q

Carbamazepine and opioid meds effect

A

Carbamazepine is a CYP 3A4 inducer
-tramadol is partially metabolised by CYP 3A4 -> would inc efficacy b/c metabolite is active

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51
Q

Dexmedetomidine SE

A

bradycardia, hypoTN, HTN -> all more likely to occur w/ loading or bolus dose

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52
Q

Bohr effect

A

-hemoglobin has a lower affinity for O2 w/ inc CO2 and dec pH
-Hg has a higher affinity for O2 in alkalosis

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53
Q

Haldane effect

A

deoxygenated Hg’s ability to carry more carbon dioxide than oxygenated blood
-oxygenated blood has a decreased ability to carry CO2 and releases it

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54
Q

Vasopressin receptors and actions

A

V1: systemic, renal, coronary, and splachnic circulations -> vasoconstriction
V2: mobilization of aquaporin channels to collecting duct, and inc vWF release
V3: in pituitary -> release of ACTH

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55
Q

What causes decreased Na reabsorption in CD?

A

ANP
-also causes renal afferent arteriole dilation and efferent constriction -> enhancing water and Na excretion
EXIT = EFFERENT

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56
Q

larygnospasm reflex afferent, efferent

A

afferent: SLN
efferent: RCLN

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57
Q

Acute intermittent porphyria

A

Auto Dom usually women 20-30
mutation in: porphobilinogen deaminase
-accumulation of porphobilinogen and delta-aminolevulinic acid

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58
Q

severe abd pain, numbness, paresthesias, weakness, N/V, psychosis after TMP-S for UTI
dx and tx

A

Acute Intermittent porphyria
tx: glucose and hemin -> dec activity of delta-aminolevulinate synthase and heme production, IVF, lytes, and painn control

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59
Q

What do you use delta-aminolevulinic acid in urine to dx?

A

Acute intermittent porphyria

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60
Q

Anesthesia med triggers for Acute intermittent porphyria?

A

Ketamine
Barbiturates
Ketorolac
Etomidate

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61
Q

Anticonvulsant triggers for Acute intermittent porphyria

A

Phenytoind
Carbamazepine
Valproic Acide

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62
Q

Acute intermittent porphyria med triggers

A

CCB
Amiodarone
Estrogens
Fasting
Surgery, Infxn
Barbs
Ketamine
ETomidate
Ketorolac

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63
Q

Acute Intermittent Porphyria

A

5 P’s
painful abd
polyneuropathy
psych distrubance
port wine-colored urine
precipitated by meds

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64
Q

Platypnea

A

SOB worse when standing/sitting and improves when laying flat
-sign of hepatopulm syndrome

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65
Q

Hepatopulm Syndrome triad

A

liver dysfxn
intrapulm vascular shunting/dilation
unexplained hypoxemia

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66
Q

orthodeoxia

A

hypoxemia in upright position resolves w/ laying down
-sign of hepatopulm syndrome

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67
Q

Alpha-1 antitrypsin def

A

early-onset emphysema, bronchiectasis and cirrhosis

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68
Q

Portopulm HTN

A

pulm HTN in pt w/ portal HTN
1. portal HTN w/ or w/o hepatic dx
2. mean pulm artery pressure of 25 at rest or 30 while exercising
3. mean pulm arterial occlusion pressure < 15
4. elevated pulm vasc resistance > 3 wood units
-screen by TTE
-confirm w/ R heart cath
-tx: Diuresis and vasodilators (prostanoids, PDE inh, and endothelin antagonists)

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69
Q

Formal recognition by a regulatory agency or body that a person possesses the qualifications to practice a specific profession in that state is?

A

Licensing

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70
Q

Process by which an employer confirms that a practitioner has the required education, training and experience to practice w/i their system

A

Credentialing

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71
Q

If you have the particular ability to perform a specific procedure within an institute

A

Privileging

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72
Q

Recognition of the successful completion of requirements for recognition as a specialist w/i a specific specialty of medicine

A

Certification

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73
Q

Serum osmolality

A

(Na*2) + (glucose/18) + (BUN/2.8)

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74
Q

BBB is diff from endothelial cells w/ osmolality changes

A

BBB has tight junctions and aquaporins to limit changes in brain size w/ osmotic changes and do not allow entry of Na, Ca, and Cl into tissues require a channel -> endothelial thinsg move easier

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75
Q

Fluid shifts across intracranial capillaries depend on what pressure

A

hydrostatic and mostly determined by Na

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76
Q

Fluid movement in brain

A

Cerebral capillary fluid shift fxn of hydrostatic and total osmotic forces
-osmolar gradient plays a large role -> primarily determined by Na -> rapid inc or dec in Na -> cerebral desiccation or edema

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77
Q

which neonatal defect is ETT most likely required

A

congenital diaphragmatic hernia
-improves gas exchange and prevent bowel insuff

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78
Q

Assoc w/ congenital diaphgramatic hernia

A

adrenal insuff
congenital heart disease
spina bifida

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79
Q

type I error

A

null hypothesis incorrectly rejected when ther eis no difference

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80
Q

alpha error

A

aka type I error
null hypothesis incorrectly rejected when ther eis no difference

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81
Q

accepting the null hypothesis when it is false

A

beta or type II error

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82
Q

What level should neuraxial go to for TURP?

A

T10 level

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83
Q

spinal levels required for postpartum tubal ligation

A

higher than T8

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84
Q

spinal level required for c/s

A

higher than T6

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85
Q

spinal level for cervical cerclage

A

higher than T10

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86
Q

spinal leel for hip fx, knee replacement, knee arthroscopy, ankle surgery

A

higher than T12

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87
Q

spinal level for inguinal hernia repair, or open appendectomy

A

Higher than T8

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88
Q

Postherpetic neuralgia

A

Pain for a duration of greater than or equal to 3 months at local of herpes zoster eruption
-as many as 34%

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89
Q

RF for postherpetic neuralgia

A

> 60 years of age
greater severity of pain during acute herpes zoster eruption
greater severity of skin lesions
greater severity of prodromal pain
location of eruption (worse on ophthalmic V1 and brachial plexus distribution)
immunosuppresion

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90
Q

Tx of postherptic neuralgia

A

1st line: gapapentin and pregabalin
TCAs
2nd line: opiates
topical tx

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91
Q

Increased R time on TEG
problem and tx?

A

initial clot formation
prob w/ clotting factors
given FFP or coag factor concentrate

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92
Q

Highest risk of seroconversion after a needlestick from pt

A

Hepatitis B

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93
Q

what to do after you get stuck w/ possible HIV

A
  1. post-exposure ppx immediately and continued for 4 weeks
  2. immediately determine the HIV status of pt
  3. PEP should have >3 antiretrovial drugs
  4. F/u includes counseling, HIV testing and monitoring for PEP toxicity
  5. If 4th gen HIV p24 Antigen-HIV antibody test used -> HIV testing can cease after 4 months of exposure if negative, if older test 6 motnhs
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94
Q

Drainage of superior sagittal sinus in brain

A

superior sagital sinus -> confluence of sinuses -> transferse sinuses -> sigmoid sinus -> internal jugular vein

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95
Q

Drainage of inferior sagittal sinus

A

inferior sagittal sinus or cerebral veins -> straight sinus -> confluence of sinuses -> transverse sinus -> sigmoid sinus -> internal jugular vein

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96
Q

Unfractionated heparin ppx dose
time b/w last dose and before catheter placement

A

4-6 hours

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97
Q

Unfractionated heparin ppx dose
time after catheter placement to drug start

A

immediately

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98
Q

UFH ppx dose
time b/w last dose and catheter removal

A

4-6 hours

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99
Q

UFH ppx dose
time after catheter removal to drug start

A

immediately

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100
Q

High dose UFH
time b/w last dose and catheter placement

A

12 hours

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101
Q

High dose UFH
time after catheter placement to drug start

A

1 hour

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102
Q

High dose UFH
time b/w last dose and catheter removal

A

12 hours

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103
Q

High dose UFH
time after catheter removal to drug start

A

1hour

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104
Q

AC and caatheter dosing/time

A
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105
Q

How long to wait before restarting LMWH after neuraxial catheter removed?

A

4 hours

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106
Q

How long after the last dose of LMWH for ppx would be the time in which catheter placement or removal can occur

A

12 hours

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107
Q

Transcutaneous electrical nerve stimulation therapy

A

low freq stimulates mu opiods receptors
high freq stimulates delt receptors
**chronic opioid use may get less relief

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108
Q

hepatopulm syndrome TTE

A

contrast or bubbles w/i LA in 3-6 beats
-due to intrapulm shunting

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109
Q

Diagnostic criteria for hepatopulm syndrome

A

PaO2 < 80 or Alveolar-arterial O2 gradient of at least 15
pulm vascular dilation: TTE contrast or saline
liver dx

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110
Q

hyperthermia, rigidity, dysautonomia

A

Neuroleptic malignant syndrome

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111
Q

muscle rigidity, hyperthermia, tachycardia, hyperreflexia

A

serotonin syndrome

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112
Q

What does lactate in LR get metabolized into?

A

CO2, water, and bicarb

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113
Q

Abdominal compartment syndrome

A

Intraabd pressure > 20 w/ evidence of organ dysfxn, typically renal
-dx: indirect measurement of intra-abd pressures using intravesicular (bladder) P

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114
Q

NSAIDs and pregnancy

A

CI after 32 weeks gestation b/c inc risk of premature closure of ductus arteriosus in fetus

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115
Q

Methotrexate MOA

A

folate analog, suppresses nucleotide synthesis to inhibit cell division

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116
Q

Methotrexate SE

A

myelosuppression
megaloblastic anemia
mucositis
GI inflammation
hepatotoxicity
acute/subacute interstitial pneumonitis

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117
Q

Motor neurons

A

fast-conducting, large diameter myelinated neurons that lose their myelin sheaths as they branch into terminal fibers
-each fiber supplying a muscle fiber
-motor neuron + m fiber it innervates = motor unit
-cell body in ventral horn

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118
Q

What CYP metabolized tramadol into active metabolite

A

CYP 2D6

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119
Q

What CYP metabolizes methadone

A

CYP 2C9 and 2C19

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120
Q

CYP 2D6 inhibitors and inducers

A

inh: SSRIs (so tramadol won’t work)
inducers: rifampin and dexamethasone -> tramadol overdose

121
Q

Pilocarpine and eyes

A

M3 agonist -> pupillary constriction (miosis)

122
Q

Phenylephrine eyes

A

pupillary dilation

123
Q

Corneal reflex afferent, efferent

A

afferent: V1: opthalmic branch of trigeminal nerve
efferent: VII temporal branch of facial n

124
Q

pupillary light reflex, afferent efferent

A

afferent: CN II optic n
efferent: CN III oculomotor -> ciliary sphincter contraction

125
Q

Healthy nonobese pt preoxygenated w/ FiO2 of 100% for 5.5 minutes, how long is the apneic period

A

~8 minutes before desat to < 90%

126
Q

Healthier obese pts safe apneic time w/ adequate preoxygenation

A

~2-3 minutes

127
Q

Which opioid would have reduced analgesia if also taking SSRIs?

A

SSRIs are a CYP 2D6 inhibitors -> codeine and tramadol wouldn’t become an active prodrug
-same thing w/ oxycodone, hydrocodone

128
Q

papilledema is assoc w/ which electrolyte

A

severe hypoCa

129
Q

Which IV anesthetic inc hepatic blood flow

A

Propofol

130
Q

Which lung volumtes increase in pregnancy

A

TV
inspiratory capacity

131
Q

Nalbuphine

A

mixed opioid agonist/antagonist
-reverses opioid-infuced pruritis w/o affecting analgesia of ipioids
It’s now FINE because i’m no longer itchy and i’m still not in pain

132
Q

Recovery of muscles from NMB order

A

diaphragm > laryngeal muscles > corrugator supercilii > rectus abominis > orbicularis oculi > adductor pollicis
-diaphragm also 1st muscle to be blocked b/c i’ts a central muscle so more blood flow also higher conc of nicotinic Ach receptors

133
Q

When arm tucked in surgery, what to monitor for NMB?

A

corrugator supercilii at eyebrow correlates w/ recovery of diaphragm and laryngeal muscles
orbicularis oculi correlates w/ adductor pollicis

134
Q

Baby born to mom w/ myasthenia gravis

A

20% change of showing symptoms: poor feeding, generalized hypotonia, feeble cry, resp distress
-monitor clinical course w/ repeat n stimulation testing and measuring ACh receptor antibodies
-tx supporting AChE therapy can be given if needed
-no sym once Ab clear, usually w/i 2-4 weeks

135
Q

Where does an axillary roll go

A

below the axilla on the chest to precent brachial plexus injury in lateral position

136
Q

How does metochlopramide inc gastric emptying

A

stimulation GI motility
inc tone of GES
relaxing pyloric sphincter and duodenal bulb

137
Q

Which antacid given to pregnant pts

A

Sodium citrate
-neutralize the contents in the stomach

138
Q

When doing an interscalene block what is posterolateral to the nerves

A

middle scalene
-you enter from the lateral direction, penetrating middle scalene before entering interscalene groove

139
Q

interscalene n block whats superficial and meidal

A

SCM

140
Q

Dermatome for medial knee

A

L3

141
Q

Dermatome for anterior knee and medial malleolus

A

L4

142
Q

Dermatome for dorsal surface of the foot, 1st 2nd and 3rd toes

A

L5

143
Q

Dermatome for lateral malleolus

A

S1

144
Q

PPV inspiration effect on preload and afterload

A

preload decreases
afterload decreases (compression on LV reducing force required to eject blood from the LV) and inc in return to LA -> inc in SV

145
Q

Alveolar gas equation

A

PAO2 = FiO2 x (Patm - PH2O) - PaCO2/R

146
Q

Prolonged hypoxia w/ altitude causes longer term changes

A
  1. inc in 23DPG prod to favor O2 offloading
  2. hyperventilation (chemorec stimulation)
  3. inc in mitochondria to inc aerobic eff
  4. inc in RBC mass via EPO
  5. inc in renal elimination of bicarb
147
Q

Dexmedetomidine alpha 2 agonist effects and where it binds on body

A

analgesia: a2 receptors in dorsal horn of spinal cord
sedation and anxiolysis: locus coeruleus of the brainstem
hypoTN and bradycardia: brainstem vasomotor center
suppress shivering: hypothalamus

148
Q

Which carbon dioxide absorbent most likely to result in higher levels of carbon monoxide production

A

KOH > NaOH&raquo_space; Ba(OH)2 and CaOH2
KOH: baralyme
sodalime: less KOH and NaOH
BaOH and Ca are both weak bases -> no real carbon monoxide

149
Q

Innervation of cricothyroid muscle

A

SLN external branch
-if injury loss of VC tension -> higher risk for aspiration

150
Q

Innervation of the stylopharyngeus muscle

A

glossopharyngeal n
-aids in elevation of pharynx for special fxns such as speech and swallowing

151
Q

What is an anechoic space b/w parietal and visceral pleura on lung u/s?

A

pleural effusion

152
Q

Chassaignac tubercle

A

C6 transverse process
-landmark for deep cervical plexus block
goal C2-4

153
Q

where is the posterior tibial nerve blocked

A

injxn behind medial malleolus
-sural n is lateral malleolus

154
Q

where to block the supraorbital nerve

A

palpating the supraorbital notch

155
Q

Dabigatran reversal

A

Idarucizumab

156
Q

No posttenaic twitches present, what dose of sugammadex?

A

16 mg/kg

157
Q

If posttetanic twitches present w/ TOR <1 sugammadex dose

A

4 mg/kg

158
Q

Crouzon syndrome

A

genetic dx that causes premature closure of cranial sutures
hypoplastic midface
bulging eyes
beaked nose
C’s: closure of cranial sutures

159
Q

Klippel-Feil syndrome

A

lack of segmentation of cervical spine -> presents w/ fused cervical spine
-rotation is more reduced than flexion and extension
Klipped and fell, now his cervical spine is together

160
Q

Pierre Robin sequence

A

micrognathia
glossoptosis *tongue falls back into throat)
cleft palate
-easier to intubate w/ age

161
Q

Treacher Collins

A

zygoma and mandibular hypoplasia
ear defomrity
deafness
mental retardation
harder to intubate w/ age
-teacher: mental retardation

162
Q

When you have a pt w/ pyloric stenosis, how do you know their fluid status is okay for surgery?

A

Normalization of Cl is best indicator, greater than 106
-pH and K are not helpful w/ fluid status
-bicarb < 30

163
Q

Tumescent anesthesia

A

Injecting very dilute solution of local anesthesia combined w/ epi and sodium bicarb into tissues until it becomes firm and tense

164
Q

Liposuction concerns

A

-total aspirated content should be to less than 5 liters due to risk of hypervolemia
-don’t use GA -> may mask trauma b/c pt unresponsive, and may require larger volumes of fluid exposing to hypervolemia

165
Q

Complications from Tumescent anesthesia

A

Periop: cannula injuries, hypothermia, volume overload
early postop: infxn, DVT, pulm embolism
Late postop: paresthesias, edema, seroma formation, ecchymosis

166
Q

What causes emergence delirium MC?

A

volatile anes, MC sevo

167
Q

How to diagnose hemolysis in OR

A

low haptoglobin
elevated bili
hematuria
positve Coombs test

168
Q

Hg P50

A

pressure at which Hg is 50% saturated
-so it increases w/ rightward shift and dec w/ L shift

169
Q

Anemia compensation

A

inc cardiac output (inc SV)
redistribution of blood to heart and brain
inc O2 release in tissues (inc 23DPG)

170
Q

Schedule I drug by DEA

A

high abuse potential, cannot be prescribed, no medical use
-cannabis, MDMA, LSD

171
Q

Schedule II meds DEA

A

high abuse potential, only up to 30 day supply
-cocaine topical, morphine, oxycodone, hydrocodone

172
Q

Schedule III meds

A

low to mod physical dpt, telephone orders acceptable, give refills
ketamine, buprenorphine, thiopental, codeine

173
Q

Schedule III meds

A

low to mod physical dpt, telephone orders acceptable, give refills
ketamine, buprenorphine, thiopental, codeine

174
Q

Schedule IV meds, mult refills, telephone ok

A

limited abuse, mult refills, telephone ok
benzos, phenobarbital, tramadol, methohexial

175
Q

Schedule V meds

A

limited psych dpt
prescription not necessary
couhg syrup w/ low dose opioid (codeine)

176
Q

Peds pt w/ moderate sedation how frequently must vitals be checked? minimum

A

10 minutes

177
Q

peds deep sedation and GA minimum requirements

A

every 5 minutes

178
Q

continual v continuous

A

continnual: BP cuff
continuous: pulse ox

179
Q

Transvalvular pressure equation

A

4 x (peak velocity ^2)

180
Q

Auto PEEP

A

occurs w/ PPV if exhalation time inadequate
-MC in COPD pts who require prolonged exhalation
-can lead to dec perfusion of alevoli and worse V/Q mismatch

181
Q

Brain-dead pts for organ transplant tend to have what issues?

A

pulm edema
hyperglycemia
hyperNa (early graft loss)
polyuria (DI)
myocardial dyxfxn
catecholamine storm -> hemodynamic instability, hypovolemia

182
Q

normal cardiac output at rest

A

5-6 L/min for adult men

183
Q

Myedema coma

A

hypoTN, bradycarida, hypothermia, delirium
-if suspect, start treament immediately and do not wait for lab confirmation -> give IVF, inotropic/vasopressor support, thyroid hormone replacement, steroids
**careful high dose T3 can precipitate angina or HF du to high cardiac stimulation

184
Q

Severe aortic stenosis

A

valve area less than 0,8 and transvalvular P > 50

185
Q

Initial tx of trigeminal neuralgia

A

carbamazepine

186
Q

NSAIDS and pain

A

block PG, a sensitizing substance at peripheral nociceptors, and decrease transduction of pain

187
Q

Nociceptive pathway

A

transduction, transmission, modulation, and perception

188
Q

Nociceptive transduction

A

conversion of noxious stimuli to electrical action potential
-what blocks: NSAIDs, antihistamines, opioids

pain path: transduction -> transmission -> modulation -> perception

189
Q

Transmission

A

conduction of action potential through neurons
-blocked by local anesthetic blocks

pain path: transduction -> transmission -> modulation -> perception

190
Q

Modulation

A

alteration of afferent pain transmission along the neural pathway
-NMDA receptors, glutamate, epidural opioids
-responsible for neuroplasticity hyperalgesia

pain path: transduction -> transmission -> modulation -> perception

191
Q

Perception

A

final part of common pain pathway to produce pain perception
inhibited w/ opioids, alpha 2 agonists, and GA

pain path: transduction -> transmission -> modulation -> perception

192
Q

source of heat gloss: electromagnetic ray emission from the skin

A

radiation
** most significant source of heat loss

193
Q

Most significant sources of heat loss

A
  1. Radiation: electromagnetic waves emanating from the body 60%
  2. Evaporation: energy consumption as it vaporizes water cooling the body 20%
194
Q

St Johns Wort effect on intraop awareness

A

it is a cytochrome P450 inducer, metbolizing inhalation agents, opioid sand benzos -> inc risk of intraop awareness

195
Q

oliguira

A

production of abnormally small amount of urine
0.5 cc/kg/hr

196
Q

Whats added to blood sorage

A

Citrate: anticoagulant
Phosphate: cellular fxn and ATP production
Dextrose: nutrition source for glycolysis
Adenine: incorporated for ATP production

197
Q

Pulmonary surfactant changes w/ alveoli size

A

surfactant more effectively red surface tension when concentrated
-so as alveoli shrink, surfactant conc inc -> more effectively red surface tension

198
Q

What gas issue is most likely to cause lasting neurocognitive changes

A

Hypoxia

199
Q

Contraindications to extracorporeal shock wave lithotripsy

A

Untreated bleeding disorders
Active UTI (displacement of bacteria when stone broken)
Pregnancy

200
Q

What type of block has diarrhea as s SE?

A

celiac plexus block (T5-12) -> supplies innervation to intraabd organs

201
Q

Memantine

A

NMDA antagonist that can be used in CRPS

202
Q

w/ turbulent flow what matters for resistance?

A

Resistance increases w/ increasing gas density
-so w/ subglottic stenosis -> heli/ox b/c helium has decreased gas density

203
Q

w/ laminar flow, what determines resistance?

A

Gas viscosity

204
Q

pulm HTN and pregnancy

A

assoc w/ high mobidity and mortality -> pulm HTN is a CI for pregnancy (mortality 30-55%) most deaths early postpartum w/ R heart failure

205
Q

nitrous oxide and pulm vascular resistance

A

inc PVR -> avoid in pts w/ pulm HTN

206
Q

Confusion Assessment Method of ICU screening of delirium

A
  1. Acute mental status changes or fluctuating?
  2. inattentive or easily distracted?
    if yes:
  3. altered LOC or RASS other than 2
  4. Disorganized thinking?
207
Q

Lung protective ventilation in ARDS

A

TV 6 cc/kg predicted body weight
plateau pressures < 30
minimum PEEP of 5

208
Q

ARDS severity

A

PAO2: FiO2 ratio
Mild < 300
mod <200
severe < 100

209
Q

Why is a patient hypoxemic and hypercapneic post opioids and volatiles anesthesia?

A

Impaired carotid body chemoreceptors due to dec in glossopharyngeal afferent n activity
-carotid bodies very sensitive to inhibition by anesthetics
-similar phenomenon in b/l carotid endarterectomy

210
Q

Carotid body

A

chemoreceptors inc ventilation when PaO2 dec
-does this through afferent impulses via glossopharyngeal n to CNS ventilation centers
***impaired by opioids, benzos, volatiles, and b/l carotid endarterectomy

211
Q

What arm should the a line be in for CPB

A

right upper extremity
-incase a surgeon places a L axillary art cannula, would display only that pressure

212
Q

RF for GERD in prengnacy

A

gestationl age
GERD sym prior to pregnancy
multiparity
BMI not a RF

213
Q

following transsphenoidal surgery, hyperNa to 155, osm of 320, 2.4L of UOP dx? tx?

A

central DI
give free water

214
Q

SE of Hetastarch

A

inhibits expression of glycoprotein IIb-IIIa on plts -> plts cant achieve appropriate conformation to bind fibrinogen -> prob w/ plt aggregation

215
Q

SACRAL SPINAL NERVE PHYSIOLOGIC FUNCTIONS

A

sacral = parasympathetic
-internal urethral sphincter relaxation
-internal anal sphincter relaxation
-detrusor muscle contraction
-sigmoid contraction -> promote bowel transit

216
Q

Changes intraop w/ dec temp

A

coag impairment
inc blood loss
inc transfusion req
dec drug metabolism
inc wound infxn
potentiation of NMB
3x inc in morbid myocardial outcomes

** O2 consumption in by shivering and symp activity -> morbid myocardial outcomes*

217
Q

risk of airway fire higher in GA or mAC?

A

MAC
-O2 collects near face, not contained

218
Q

EtCO2 and MAC

A

EtCO2 monitoring is not mandatory -> but must ensure adequate ventilation w/ visualization or end-tidal monitoring

219
Q

Dexmedetomidine effect on CBF

A

Causes a dec in cerebral metabolic rate -> dec in CBF

220
Q

Hydralazine, nicardipine, and NG effect on CBF

A

cause direct cerebral vasodilation w/o dec CMR -> inc CBF and inc in cerebral blood volume

221
Q

propofol and CBF

A

dec CMR -> dec CBF

222
Q

Labetalol and CBF

A

DOES NOT EFFECT CMR or CBF -> useful in neurosurgical pts

223
Q

Combitube

A

esophageal obturator airways = cuffed pharyngeal sealed w/ esophageal cuff
-double-lumen, double-cuff designed for emergency airway
-placed blindly
-ventilation through perforations of pharyngeal lumen
-*ETT annot be placed through it

224
Q

Laryngeal tube

A

single-lumen supraglottic airway
-distal cuff seals the esophagus
-blindly inserted
esophageal obturator airway = cuffed pharyngeal sealer w/ esophageal cuff
-if the correct model, can be intubated through**

225
Q

Which morphine metabolite causes analgesia and which causes adverse effects?

A

morphine-6-glucuronide: causes analGesia (6 is an upside down G) but resp depression, upside down lunG (only in pts w/ renal failure)
morphine 3-glucuronide: looks like brain -> excitability when builds up

226
Q

Celecoxib MOA

A

selective COX-2 inhibitors
1st line for cancer pain w/ nonopioids

227
Q

What temperature measuring device requires a battery

A

Thermistors

228
Q

Thermistors

A

-temp sensitive resistors
-requires a power source to create a current

229
Q

Infrared thermometers

A

devices that collect heat and use calculations to covert to temperature
-non-invasive, used in ear or along forehead

230
Q

Thermocouples

A

junction b/w 2 metal types -> when temp different b/w current produced -> measure current
-do not require power source, inexpensive and accurate

231
Q

Charcot-Marie-Tooth def and effect on NMB

A

hereditary denervation of peripheral NM system -> m weakness and neuropathy
-avoid succ and effects of NDNMB prolonged

232
Q

Friedreich Ataxia

A

auto rec ataxia -> progressive limb ataxia and m weakness
**death from HF from myocardial degeneration
-avoid succ b/c denervation -> negative inotropes avoided b/c cardiac

233
Q

Duchenne Muscular Dystrophy def and NMB

A

X linked rc, MC dystrophy
-m replaced w/ fibrous tissue -> inc intracellular Ca
-avoid succ and inh anesthetics -> rhabdo due to extrajunctional ACh (similar to MH)
-inc risk for blood loss (plt dysfxn)
-avoid hypovolemia b/c relatively fixed cardiac output from noncompliant ventricles
-if NDNMB needed, low dose

234
Q

Becker muscular dystrophy def and NMB

A

-milder version of Duchenne -> rep and cardiac failure seen later
NO INC risk of MH! will have rhabdo and hyperK w/ succ and volatiles so still use TIIVA
-if NDNMB needed, low dose

235
Q

Myotonic Dystrophy

A

-m wasting and weakness -> due to prolonged m contraction after stimulation
-cardiac conduction defects and cardiomyopathy
-restrictive lung dx, OSA, endocrine issues, intellectual impairment
-TRIGGERS: hypothermia, shivering, mechanival and electrical stimulation AVOIOD
-avoid succ, NDNMB should be reversed judiciously, as ACh can precipiate contractions
-NMB do NOT tx myotonic reactions

236
Q

Myotonia Congenita

A

Auto Dom -> dyxfxn Cl channel -> global m hypertrophy and severe contractions
-NO weakness
-NO succ b/c intractable myotnias
-TRIGGERS: hypothermia, shivering, physical manipulation AVOID
-NDNMB unable to relax
-topical local anesthesia and Na channel blockers can break contracturs

237
Q

HyperK periodic paralysis

A

Auto Dom d/o of Na channel -> hyperexcitability followed by inactive wakness
-TRIGGERS: inc serum K, cold, hunger, stresss

-can use lasix preop
-minimize fasting time, and use gluoce containing solutions

238
Q

HypoK periodic paralysis

A

Auto Dom of Ca channel -> muscle parlysis in low K
-LINKED TO MH avoid succ and use NDNMB of short duration
-avoid glucose containg solutions, and alkalosis

239
Q

Congenital diapghramatic hernia

A

peak insp P < 25
permissive hypercapnia
SaO2 b/w 85-95%
spontaneous respirations
delayed surgical repair until stable and NEVER laparoscopic

240
Q

LP in pseudotumor cerebri

A

Reduce ICP and improve assoc neuros ymp incl vision
-risks: PDPH, back pain, bleeding, infxn, n damageq

241
Q

What causes inc in peak insp pressure but plateua pressure unchanged

A

bronchospasm
kinked ETT
airway secretions
mucus plug
**only airway resistance

242
Q

inc in peak pressure and plateau pressure

A

situations w/ inc elastic resistance (or dec compliance)
intrisnic pulm dx, ascites, abd insufflation, PX, trendelenberg
-when you do plateua perssure, theres no lung/air movmeent, so its a function of LUNGS

243
Q

Normal CBF

A

50 cc/100g/min

244
Q

EEG changes based on CBF

A

20 cc/100g/min -> EEG slowly
10-15/100g/min -> isoelectric EEG
6-10: neuronal injury will be temorarily reversible, but death if BF not resored

245
Q

Focal ischemia v global ischemia

A

-focal: BF restricted parts of the brain insuff
-global: hypoTN wide area of brain
-focal more well tolerated b/c some BF through collaterals
-both can have EEEG changes -> just depends on if local area of EEG cahnges v global
-both attenuated by hypothermia
-both have ischemia -> depolar -> influx of extracellular Na -> neuronal edema

246
Q

low grade fever post pRBC transfusioncaused by what?

A

recipient antibodies to donor leukocytes
-1 C inc w/i 4 hours, can last 48 hours

247
Q

When are you more likely to get bactweial contaminationn of blood products

A

higher risk in plts b/c stored at room temp
-fever chills, tachycardia, dyspnea, emesis, shock
-possibility for DIC and acute resp failure

248
Q

Why hyperglycemic in stress

A

inc glucose production (cortisol)
peripheral insulin resistance
insulin released reduced (inh by cortisol, to prevent glucose from being stored, and having it readily available instead)

249
Q

Strong ion difference equation

A

(NA + K + Ca + Mg) - (Cl + lactate)

250
Q

What’s not considered in strong ion difference

A

Total weak acid concentration: do not fully dissociate
-mainly albumin and phosphate
-so if alubmin dec -> metabolic alkalosis

251
Q

Balance of all ions in body

A

Strong ion difference plus total weak acid concentration
-metabolic acidosis: due to inc weak acids (hyperphos in renal failure)
-met alkalosis: due to dec weak acids (hypoalbumin)
-met acidosis (decreased SID, large amount of NS)
-met alk: increased SID (vomiting pt, losing chloride)
SID: (Na + Ca + K + Mg) - 9Cl + lactate)

252
Q

pH and strong ion difference

A

decreased SID = decreased pH (acidosis)

253
Q

PPx for infective endocarditis

A

-prosthetic cardiac valves, prev infective endocarditis, congenital heart dx unrepaired, CHD w/ prosthesis w/i first 6 months of valve issues
PLUS
-dental procedure w/ gingival manipulation, perforation of oral or resp tract (incision, biopsy)
-GI or GU w/ active infxn

254
Q

Where is oxytocin synthesized

A

supraoptic nuclei of hypothalamus
-transported to posterior pituitary gland through infundibular stalk
-released by post pituitary gland

255
Q

whre is vasopressin synthesized

A

paraventricular nuclei of hypothalamus
-transported to posterior pituitary gland through infundibular stalk
-released by post pituitary gland

256
Q

which opioid metabolite causes myoclonus

A

hydromorphone -> it’s metabolite hydromorphone-3-glucuronide (accumulates in renal failure)
meperidine -> metabolite normeperidine -> sz, agitation, and myoclonus (again builds in renal faiilure)

257
Q

which opioid metabolite causes myoclonus

A

hydromorphone -> it’s metabolite hydromorphone-3-glucuronide (accumulates in renal failure)
meperidine -> metabolite normeperidine -> sz, agitation, and myoclonus (again builds in renal failure)

258
Q

sympathetic nervous system cell bodies span which SC levels?

A

T1-L2

259
Q

Parasympathetic NS which spinal n?

A

CN III, VII, IX, X
pelvic: S2-4

260
Q

when is epi used as a NT?

A

postganglinic cell sof SNS at adrenal medulla

261
Q

where does Symp NS use ACh as a NT?

A

b/c pre and post ganglionic cells and ACh terminally at sweat glands

262
Q

When do you need to monitor temp intraop?

A

-GA longer than 30 minutes
-neuraxial longer than 30 minutes

do NOT need for sedation and peripheral n blocks

263
Q

Transfusion-related immunomodulation

A

transient immunosuppression in recipients after blood transfusion -> b/c substances released by donor leukocytes -> immune resp
-inc risk of bacterial infxn, cancer, mortality
**reduced by leukocyte reduction

264
Q

When do you leukocyte reduce blood?

A

to prevent transfusion-related immunomodulation

265
Q

When do you irradiate blood

A

reduce risk of graft v host disease

266
Q

When do you wash blood

A

reduce risk of allergic rxn
-pts w/ IgA def
-and red extracellular K -> useful in HD pts

267
Q

Acute v chronic resp acidosis CO2 and bicarb compensation

A

Acute: inc in HCO3 of 0.2 for each 1 inc in PaCO2 above 40
Chronic: .4 inc in HCO3 for each 1 inc in PaCo2 above 40
Normal bicarb: 24

268
Q

Normal bicarb level

A

24

269
Q

How to calculate GCS

A

EYES: 4
VOCALS: 5
MOTORS: 6

270
Q

Acute epiglottitis, best way to proceed

A

get to OR, maintain spontaneous ventilation (inhalational induction)
avoid muscle relaxation

271
Q

Cardiac output in labor

A

Latent labor inc 15%
active labor inc 30%
expulsive labor inc 45%
-uterine contractions additional inc cardiac output by 10-25%

272
Q

Nociceptive afferent neurons

A

A-delta and C fibers
C fibers unmyelinated
A-delta: medium sized, thinly myelinated
-high-threshold neurons

273
Q

Normal TV and RR, whats the normal minute ventilation

A

~5L/min

274
Q

Normal PFT whas the normal vital capacity

A

~5L

275
Q

When does rebreathing on circuit occur

A

When MV exceeds FGF -> rebreathing -> lower FiO2

276
Q

CRPS I v II

A

CRPS I: occurs in absence of prior n injury
II: occurs after nerve injury (trauma, surgery, ischemia)

277
Q

palpable taut band, exquisite tenderness on palpation, painful limitation to passive full ROM

A

myofascial pain syndrome

278
Q

HypoCa symp

A

paresthesias, tetany
severe cases: sz, laryngospasm

279
Q

Best way to prevent heat loss during first phase of hypothermia in OR

A

forced air warming blanket for 1/2 hour prior to surgery

280
Q

Commingling of forced air warming device

A

connecting one manufacturer’s device (warming hose) to another manufacturer’s warming blanket
-considered a type of MISUSE

281
Q

Type 1 diabetes and airway

A

difficult laryngoscopy can occur
-freq hyperglycemia -> glycosylation of joints and limited mobility
-affects atlantio occipital joint and compromises adequate neck extension

282
Q

What chromosomal issue predisposes to subglottic stenosis

A

Trisomy 21 (Down Syndrome)
-atlantoaxial occipital joint instability, macroglossia, floppy soft palate
-enlarged tonsils/adenoids

283
Q

Pain tx of choice for ankylosing spondylitis

A

Indomethain and other NSAIDs

284
Q

Ankylosing spondylitis

A

chronic inflammation of spin (esp cervical and lumbar), hip joints and shoulders
-progressive ossification -> fusion of the spine
-assoc w/ reactive arthritis, UC, Crohns, and psoriasis
**give NSAIDs (Indomethacin)

285
Q

Hypothyroidism and airway

A

hypothyroid -> myxedema -> swelling in oral cavity, hypopharynx and total body (inappropriate ADH)

286
Q

Sensitivity of a class III or IV mallampati for predicting difficult laryngoscopy or intubation

A

35%

287
Q

Specificity lass III or IV mallampati for predicting difficult laryngoscopy or intubation

A

91%

288
Q

Strongest predictor of difficult intubation

A

prior hx of diff intubation

289
Q

SSEPs v MEPs: which is more favorable in detecting SC ischemia

A

MEPs

290
Q

SSEPs v MEPs: which responses more rapidly to ischemic conditions?

A

MEPs

291
Q

SSEPs v MEPs: which does volatile anesethetics suppress more

A

MEPs

292
Q

What nerve is MC monitored when lookingn for anterior and posterior SC ischemia during aortic surgery?

A

tibial nerve

293
Q

Hemodynamic goals during cardiopulmonary bypass

A

Pump flow 1.6-3 L/min/m^2
arterial BP 50-90
O2 sat in venous cannula of greater than 65%

294
Q

Type 1 diabetes, destruction of what cell

A

pancreatic beta cells

295
Q

How does RhoGAM work

A

destroys fetal erythrocytes before they evoke a maternal immune response

296
Q

Emergency transfusion

A

PRBCs: type O Rh neg
FFP: Type AB (lack of anti-A or anti-B)
plts: type O

297
Q

anesthetic concerns for myotonic disorders

A

NMB do not treat myotonic reactions
TRIGGERS: cold, stress, pain, succ, AChEinh

298
Q

Guillain Barre and MH

A

NO iincreased risk
-but still don’t u se succ -> hyperK

299
Q

Neuromuscular disease w/ inc risk of MH

A

Duchenne and Becker muscular dystrophy
King-Denborough disease
Central core and multiminicore Dx
Nemaline rod myopathy

in training exam tl (11 decks)

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