Master List Flashcards
(155 cards)
1
Q
complications of celiac plexus block
A
Most serious = paralysis: d/t spread of neurolytic agent into spinal or epidural space, or damage to blood supply of spinal cord
MC: postural hypoT
Accidental intravascular injection, retroperitoneal hemorrhage
2
Q
issues seen with obesity
A
- Difficult airway
- Increased risk of aspiration
- Bronchospasm
- Labile BPs
- Hyper/hypoglycemia
- Decreased FRC = rapid desat with apnea
- Undiagnosed OSA, obesity hypoventilation
Other issues for obese pts in general: DM2, HTN, CAD, CVA, DVT/PE, NASH, altered drug effects
3
Q
allowable blood loss equation
A
Allowable blood loss = EBV x (Hi - Hf)/Hi
Preemie: 95 mL/kg; FT neonate: 85 mL/kg; infants: 80 mL/kg
Adult men: 75 mL/kg; adult women: 65 mL/kg
4
Q
most to least systemic absorption of local
A
IV > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > sciatic > subcutaneous
5
Q
Define: variable bypass vaporizer
A
variable amt of gas is directed into a vaporizing chamber where it mixes with volatile, and then returns to mix with the rest of carrier gas that was directed to bypass the chamber
6
Q
What happens if you put iso in sevo vaporizer?
A
overdose: If fill vaporizer with agent having higher vapor pressure (iso in sevo container), delivered concentration is higher than expected
7
Q
Vapor pressure of iso, sevo, des
A
Des (681) > iso (240) > sevo (160)
8
Q
concerns for MRI anes
A
- bringing in magnetic things
- equip malfunction
- issues with implantable devices
- burns
- temp/permanent hearing loss
- kidney damage (nephrogenic systemic fibrosis)
- anxiety
9
Q
interscalene complications
A
Ipsilateral diaphragmatic paralysis (may be bad in someone with severe lung dz)
Horner’s (ipsilat myosis, ptosis, anhidrosis)
LAST
Pneumo
Neuraxial blockade
Nerve injury
Hematoma formation
Severe hypoT/brady: 2/2 Bezold-Jarisch reflex (occurs when decreased venous return to heart => reduced sympathetic tone, enhanced parasympathetic tone)
10
Q
pathophys and s/sx of aspiration pneumonitis
A
Aspiration of gastric material => damage to surfactant-producing cells and pulmonary capillary endothelium => atelectasis, pulm edema, alveolar hemorrhage, pulm HTN (2/2 hypoxic pulmonary vasoC)
s/sx: arterial hypoxemia, tachypnea, wheezing, tachy, coughing, cyanosis, bronchospasm
11
Q
What pathways to these test:
- PTT
- PT
A
PTT = common and intrinsic PT = common and extrinsic
12
Q
Systemic effects of liver dz
A
vasodilated state:
Pulm: intrapulmonary shunts, reduced FRC, restrictive lung dz, pleural effusions, attenuation of hypoxic pulm vasoC
Cerebral: accumulation of ammonia/other toxins => encephalopathy
CV: decreased SVR, increased CO, cardiomyopathy
Heme: thrombocytopenia, clotting factor deficiencies => coagulopathy
Metabolic: dilutional hypoNa, hypoK, hypoglycemia, hypoalbuminemia
Various: portal HTN, varices, delayed gastric emptying, ascites, HRS
13
Q
Presentation of cyanide tox, tx
A
Cyanide toxicity: metabolic acidosis + increased venous O2 content + arrhythmias + tachyphylaxis; risk is minimal if stay below doses 0.5 mg/kg/hr
Treatment: discontinue, 100% FiO2; sodium thiosulfate, amyl nitrate, sodium nitrate, or hydroxycobalamin
14
Q
What happens to nitroprusside?
A
Nitroprusside enters RBC => nonenzymatic rxn releases nitric oxide + forms cyanide ions
Possible routes for cyanide ions:
1) React with methemoglobin => cyanmetHgb
2) React with thiosulfate => thiocyanate
3) Bind to tissue cytochrome oxidase, which impairs normal tissue O2 utilization; this causes cyanide toxicity
15
Q
What leads are best for:
- arrhythmia
- ischemia
A
V5 = ischemia
lead II = arrhythmia
16
Q
Causes of postop vision loss
A
AION = MC with cardiac (anterior part of body)
PION = MC with spine (posterior part of body); normal-appearing optic disc
-both likely 2/2 impaired O2 delivery (hypoxia, hypoT); painless; poor prognosis
CRAO = painful, unilat, 2/2 compression
17
Q
Risk factors for PION, prevention
A
surgery >6.5 hrs
substantial blood loss
spine surg
head in neutral forward position watch BP closely with a-line consider CVP monitoring monitor H/H: goal 9/28% consider staged surg
18
Q
bone cement implantation syndrome
A
Signs/sx: hypoT, hypoxia, dysrhythmias, pulm HTN, decreased CO, possibly arrest
occurs during rodding of femoral shaft while using methyl methacryalte
19
Q
Anaphylaxis vs anaphylactoid
A
clinically identical
anaphylaxis is IgE antibody-mediated, so requires sensitization; anaphylactoid is due to direct antigen-binding
20
Q
tx anaphylaxis
A
epi = key
- alpha: causes vasoC, which improves hypoT
- beta: causes bronchodilation
antihistamines: benadryl, pepcid
albuterol
21
Q
s/sx fat embolism syndrome
A
hypoxia + elevated PA pressures + decr CI + petechiae; in pt with long bone fx
22
Q
vWF purpose
A
- Plt adhesion to subendothelial surface of blood vessels
- Facilitates plt-to-plt aggregation
- carrier protein/stabilizer for factor VIII
23
Q
Actions if can’t ventilate after tubing pt with mediastinal mass
A
- try to advance tip of ETT past obstruction, or rigid bronch
- turn pt lateral or prone
- initiate CPB
24
Q
citrate tox s/sx
A
hypoT
increased CVP, narrow pulse pressure, prolonged QT, flattened T waves, widened QRS, and increased LV end-diastolic pressure
usually after multiple transfusions
25
how to do needle thoracostomy
angiocatheter into 2nd intercostal space at midclavicular line
26
causes of hypoT intra/postop
```
Shock: hemorrhagic, neurogenic, cardiogenic
Hypovolemia
Allergic reaction/anaphylaxis
Vagal response
Tension pneumo
Hypothermia
Tamponade
Too much anes
```
27
s/sx significant hypoNa
n/v, fatigue, confusion, anorexia, restlessness, weakness, mental status changes
Severe (<120): cerebral edema, sz, coma, brain stem herniation, arrest
Hyponatremia < 130 = at risk for cerebral edema
28
c-spine clearance requirements
```
Absence of cervical pain or tenderness
Absence of paresthesias or neuro deficits
Normal mental status
No distracting pain
Age >4 years
```
29
stridor causes
- Laryngospasm
- Mass obstruction from lung ca or hematoma
- Recurrent laryngeal n injury: obstruction d/t unopposed tension of vocal cords by cricothyroid muscle
Others: incomplete reversal, allergic rxn, narcosis, tracheomalacia, airway edema
30
mgmt of intraop desat
```
100% FiO2 and hand-ventilate
Listen
Ensure proper ETT placement
Check airway pressures
Check circuit/machine
Level out if in Trendelenburg
Beta-2 agonist like albuterol
If all else seems fine, would adjust vent settings, try to optimize PEEP
Expiratory wheezing + desat = bronchospasm
```
31
mgmt of intraop desat during OLV
- 100% FiO2, confirm proper placement (capnogram, auscultation, direct confirmation with fiberoptic scope), check a-line/EKG for adequate perfusion
- If due to R-to-L shunting from collapsed lung, can apply CPAP (10 cm H2O) to nonventilated lung after slightly expanding it; if this is OK for surgical field
-If no improvement or not surgically acceptable, apply PEEP to ventilated lung
This could result in pressure-induced shunting of blood to nondependent lung and therefore worsen PaO2
If nothing works, come back on 2-lung ventilation and discuss with surgeon the possibility of ligating PA to eliminate the shunt
32
MC surgeries with intraop awareness
CBP, trauma, obstetric surg
| TIVA
33
mgmt of intraop awareness
Discuss that this is rare and poorly understood, and empathize with patient
Explain what measures we took to make sure that didn’t happen
Arrange counseling if needed
Fully document this incident
34
Fluids used for TURPs
Ideal: nonhemolytic, isotonic, electrically inert, nontoxic, clear for visualization, inexpensive, minimal metabolism/rapid excretion if absorbed
Hypotonic fluids = hemolysis
Balanced solutions (like LR) can interfere with cautery, placing surgeon/pt at risk for burns
Glycine: hyperglycinemia, hyperammonemia, transient blindness
Sorbitol: hyperglycemia
Don’t use distilled water now: hypotonic
35
definition: dibucaine #
used to dx pseudochol deficiency; % that dibucaine inhibits hydrolysis of benzoylcholine by pseudocholinesterase
Dibucaine inhibits pseudocholinesterase activity of normal pts by 80%; higher dibucaine # = more normal pseudochol
Normal = 80%
Heterozygote = 40 - 60%
Homozygote = 20% or less
36
issues caused by hypothermia
Coagulopathy
Dysrhythmias
Poor wound healing, infection
Theoretically mild hypothermia reduces CMRO2 by 7% per deg C below 36, but not proven to help after TBI
37
ddx delayed awakening
Any anes: prolonged NMB, residual anes, acid-base issues, lyte imbalance, hypoglycemia, hypothermia
Neuro: hematoma, tension pneumocephalus, cerebral edema, sz, CVA
Can still have tension pneumocephalus without nitrous use: air is moving over surface of brain and can get trapped in upper cranium
38
risk factors for intraop nerve injury
- Male
- Hosp stay >14 days
- Intraop hypoT
- Hx vasc dz, HTN, DM2, smoking
- Very thin or obese body habitus
39
renal dz systemic fx
CV: HTN, CAD, HF, arrhythmias
Pulm: pulm edema (2/2 volume overload)
GI: delayed gastric emptying, anorexia
Endo: insulin resistance
Neuro: CVD, periph/autonomic neuropathy
Metabolic: hyperK, hyperMg, hypoNa, hypoCa, hypoalbuminemia, uric acid accumulation, metabolic acidosis
Heme: anemia, impaired plt fxn
40
AFOI steps
1) Aspiration ppx: metoclopramide to facilitate gastric emptying, glyco to dry upper airway secretions
2) Place appropriate monitors (including art line)
3) Ensure presence of difficult airway equip
4) Adequate analgesia: nebulized lidocaine, peripheral blockade of superior laryngeal n, recurrent laryngeal n
5) Preoxygenate in 30 deg reverse T
6) Fiberoptic intubation with minimal sedation while pt remains spontaneous
7) Verify ETT placement and then induce
41
RSI steps
Ensure appropriate airway equip available
IV lidocaine and narcotics to blunt sympathetic response, reduce risk of bronchospasm
Reverse trendelenburg (improved resp mechanics, facilitates intubation, reduces risk of passive regurg)
Apply cricoid pressure
Perform RSI with (insert induction agent and paralytic of choice here)
Roc: 1.2 mg/kg IBW is the RSI dose
42
how to do cricothyroidotomy
1) pass needle thru cricothyroid membrane until air aspirated => pass wire thru needle
2) Skin incision next to wire
3) Advance tracheostomy or ETT over wire into airway
4) Confirm ventilation after airway in place
43
mechanism of PEEP
recruits atelectatic, fluid-filled alveoli, which decreases intrapulmonary shunting and possibly increasing compliance
Moves fluid in the lungs to areas where gas exchange is not taking place
44
issues with jet vent
Misalignment of gas jet to glottic inlet = poor ventilation, gastric distention
Transmission of blood, smoke, debris (and virus) to distal airways
Excessive vocal cord vibration
Barotrauma: pneumo, subq emphysema, pneumomediastinum
45
mgmt airway fire
Immediately alert OR, disconnect circuit from airway, remove ETT
If flames persist, flood surgical field with saline
Once fire is out, ventilate with 100% FiO2 and perform DL with rigid bronch to evaluate airway and remove any debris
Consider bronchial lavage and fiberoptic assessment of distal airways
Reintubate and leave intubated for minimum of 24 hrs
Risk of delayed airway edema
CXR, consider brief course of high-dose steroids, pulm consult
46
anes concerns with lithium
Toxicity: muscle weakness, cognitive changes (sedation), ataxia, widened QRS, AV block, hypoT, sz
Avoid drugs that can lead to tox: thiazides, NSAIDs, ACEi
47
how to prep machine for MH
Physically disengage vaporizers, or lock/put tape over them
Replace anes circuit and CO2 absorbent
Flush with 10L/min of O2 for at least 10 mins (newer machines might need longer)
Ensure presence of ice, appropriate monitors, adequate supply of dantrolene
48
MH s/sx
rigidity, tachypnea, BP changes, arrhythmias, incr temp, periph mottling, rhabdo, sweating, cyanosis
If concerned, get ABG: decreased PO2, metabolic and resp acidosis
check for hyperK, hyperCa, myoglobinemia, elevated serum CK
49
MH mgmt
Call for help, MH hotline
Dantrolene 2.5 mg/kg bolus, then continue 1 mg/kg every 6 hrs for 24-48 hrs
Cool pt to goal 38 - 38.5: ice packs, cold IVFs, peritoneal lavage, CPB
Monitor UOP, K, Ca, serum CK, LFTs, coag
Treat hyperK, hyperthermia, acidosis, rhabdo (mannitol), dysrhythmias
Send to ICU for up to 72 hrs to monitor for DIC, myoglobinuric renal failure, relapse
50
intralipid dosing
bolus 1.5 ml/kg of 20% intralipid over 1st minute, followed by 0.25 ml/kg/min infusion
repeat bolus and double infusion rate if sz/arrhythmia persist
51
dantrolene dosing
rapid bolus of 2.5 mg/kg, then continue 1 mg/kg q6h for 24-48 hrs
52
dx pheo
Most reliable = measurement of plasma-free metanephrines
Others: urinary vanillylmandelic acid (VMA)
53
s/sx pheo
HTN - continuous or paroxysmal
HA, palpitations, sweating
Catechol-induced cardiomyopathy or HF (decreased energy)
Stroke, MI, sugar intolerance, acute renal failure
54
drugs to manage pheo
Prazosin or phenoxybenzamine: **alpha-blockade BEFORE beta-blockade**
If you beta-block, you can get unopposed alpha action, which translates to unopposed vasoconstriction => HTNsive crisis, HF
Optimal duration of alpha-blockade before surgery: at least 10-14 days (time to stabilize BP and normalize intravasc vol)
Phenoxybenzamine: Irreversible antagonist of a1>a2 receptors
Phentolamine: reversible antagonist of a1=a2 Rs
Alpha-2 antagonism can cause +inotropic/chronotropic effect
55
drugs to avoid with pheo
Those that directly stimulate tumor cells: metoclopramide, sux, histamine-releasing drugs like morphine, atracurium
Those that cause increased sympathetic activity: atropine, ephedrine, ketamine, pancuronium
Those that sensitize myocardium to catechol (halothane)
Droperidol: assoc w/ significant hypertensive response in pheo pts
56
2 hrs postop, pt develops barking cough + inspiratory stridor = ?
Tx?
post-extubation croup: 2/2 glottic or tracheal edema formation
risk factors: traumatic intubation, too-tight ETT, prolonged intubation, head/neck surg, intraop changes in child’s positioning, small larynx, hx croup, coughing with ETT in place
tx: nebulized racemic epi, IV steroids
57
type and screen vs. type and cross
Type and screen = mixes recipient plasma with panel of commercial RBCs to detect presence of various known antibodies
Advantage: IDs rare antibodies
Type and cross = mixes recipient plasma with donor RBCs to detect incompatibility with specific unit to be given
58
hemolytic transfusion rxn
hematuria + hypoT + tachy shortly after admin of blood; MCC ABO incompatibility (clerical error)
59
neuraxial OK with MS?
yes, but epidural > spinal (also prefer lower conc of local in epidural)
60
pathophys of myasthenia gravis
Autoimmune dz of NMJ; post-synaptic AChRs at endplates of affected muscles are destroyed or inactivated => weakness, easy fatigability
Improves with rest
61
s/sx with myasthenia
ocular involvement (ptosis, diplopia)
dysarthria
difficulty chewing and swallowing inability to effectively clear secretions difficulty breathing, pulm aspiration
tx = anticholinesterase drugs, immunosuppressive drugs, thymectomy
62
Avoid metaclopramide in setting of ______
pheo
| SBO
63
s/sx PE
Dyspnea, tachypnea
HypoT, tachy
Hypoxemia
Others: cough, hemoptysis, fever, accentuated or split 2nd heart sound, pleuritic CP, rales, hypoxemia, JVD, hemodynamic instability, palpitations
EKG changes: new RBBB, ST-T wave changes, peaked P waves, R-axis deviation, T-wave inversion
64
definition: carcinoid syndrome
constellation of sx 2/2 carcinoid tumor releasing excessive amt of circulating hormones like histamine, serotonin, and bradykinin
Flushing, diarrhea, bronchoconstriction, R-sided heart dz (serotonin-induced plaques on valves), HTN
Valve prob = tricuspid regurg > pulm regurg > tricuspid/pulm stenosis)
65
dx carcinoid syndrome
24hr urinary 5-HIAA level
octreoscan, CT/PET scan
66
pre-pneumonectomy eval of pulm fxn
three-legged stool:
1) Resp mechanics, as determined by FEV1 and ppoFEV1
2) Cardio-pulm reserve: VO2 max, stair climbing, or 6 min walk test
3) Lung parenchymal fxn: DLCO
Main thing to look at is ppoFEV1%: <40% means high risk R heart failure following pneumonectomy
Order V/Q scan (helps assess preop contribution of lung to be resected), get echo (at higher risk for RV failure)
67
normal parts of CVP waveform
A wave = atrial contraction; end diastole
C wave = elevation of MV; early systole
X descent = downward displacement of atrium during ventricular ctxn; mid-systole
V wave = venous return against closed mitral valve; late systole
Y descent = decline in atrial pressure as MV opens; early diastole
68
centrifugal vs roller pumps
Roller pump: forward flow produced with partial compression of tubing by 2 roller heads
Not sensitive to preload/afterload, can deliver pulsatile flow, reliably produces certain amt of flow based on pump speed
Cons: more damage to RBCs, keeps going if lots of air entrained, risk of over-pressurization (tubing can sep or rupture), preload occlusion can cause negative pressure-induced cavitation
Centrifugal pump: forward flow produced by rotational force
Less damaging to RBCs
Stop functioning if large amt of air is entrained
Sensitive to changes in preload/afterload
Con: incapable of delivering pulsatile flow
69
____ = only intervention that both reduces myocardial O2 demand, while also increasing myocardial O2 supply
IABP
70
How to position/time IABP
Positioning: tip is at junction of aortic arch and descending aorta
Synchronize with cardiac cycle: use either arterial waveform or electrocardiographic QRS complex
Timed so that balloon inflation occurs with aortic valve closure: occur at start of diastole
71
I would not place a PAC in pt with (what pathology)?
mitral stenosis and tricuspid regurg
inaccurate data associated with this + difficulty of passing catheter thru regurgitant tricuspid
72
____: midsystolic crescendo-decrescendo murmur best heard over R upper sternal border
Aortic stenosis
73
____: midsystolic click and loud systolic ejection murmur
MVP
74
____: rumbling diastolic murmur best heard at apex
MS
75
___: pansystolic murmur best heard at L sternal border
tricuspid regurg
76
Ddx hypoT just after CBP initiation
MCC: hemodilution, sudden decrease in SVR that occurs with injection of priming solution
Others: monitor malfunction, anes-induced decr in vasc tone, pump malfunction, inadequate venous return to pump, aortic dissection, kinking/clamping of arterial cannula
Malpositioning of arterial cannula = unilat face blanching, R-sided mydriasis, chemosis
77
checklist for weaning off CBP
Normothermia
Correct any anemia, lyte/metabolic issues
Turn monitors back on
Check lung compliance and begin ventilation again
Make sure heart is de-aired
Assess cardiac function using TEE/PAC, use inotropes/vasodilators as needed
Make sure pacing device, resuscitation drugs are available
Give benzo/propofol during rewarming to prevent awareness
Check UOP
78
types of protamine rxns
Type I = pharmacologic
Histamine-induced venoD, decr SVR, reduced preload
Type II = immunologic
IIA: anaphylactic (antibody-mediated)
IIB: anaphylactoid (not antibody-mediated)
IIC: delayed anaphylactoid; noncardiogenici pulm edema
Type III = catastrophic pulm HTN d/t TXA2 released by protamine-heparin complex
79
what is Beck's triad (cardiac)?
hypoT + JVD +muffled heart sounds = tamponade
pulsus paradoxus: exaggerated BP variation with resp cycle (BP drops more than usually with inspiration)
80
anes goals for tamponade mgmt
keep spontaneous; keep full, fast, and tight (maintain SVR, BP)
ketamine is good; try to just use local until pressure around heart relieved
81
criteria for severity of AS: severe, critical
Severe: valve area 0.7 - 1, mean transvalv gradient 40 - 50
Critical: valve area <0.7, mean transvalv. gradient >50
82
anes goals with severe AS
slow, full
don't significantly drop SVR (e.g. spinal)
83
What will magnet do to AICD
will NOT turn off automatic pacing fxn of ICD
84
Mgmt of CIED preop
Identify and call person who manages this pt’s device:
Indication for placement
Model and type
Whether pt is pacemaker-dependent
Programmed pacing mode and any special prog
Behavior of device when magneted
Number, types, and ages of leads (more likely to be dislodged if placed <3 months prev)
Battery status
85
Cautery issues with CIED
can cause inhibition of pacing function, reprogramming of ICD, triggering of tachydysrhythmia tx, microshock, internal damage to device
Recommend ultrasonic harmonic scalpel or bipolar electrocautery forceps
keep grounding pad as far away from device as possible
magnet if surgery is not >6" away (below diaphgram)
86
failure to capture
2/2 lead failure or myocardial changes that lengthen refractory period or incr energy needed to achieve depolarization; brady + hypotensive
87
aortic aneurysm types
Debakey:
- Type 1: ascending aorta and extending distally to abd aorta
- Type 2: starting in ascending aorta and don’t extend beyond innominate artery
Stanford:
Type A = all dissections involving ascending aorta
Type B = all dissections not involving asc aorta
BB before nitroprusside: otherwise shear forces might cause rupture
88
mgmt vtach on EKG
If unstable: start chest compressions, cardiovert with biphasic defib
If stable with HR >150: no compressions, still cardiovert and then amiodarone
If stable with HR <150, give amiodarone
89
Ddx if ACT still low post-heparin
```
wrong med/dose
infiltration of IV
ACT machine malfunction
heparin resistance (d/t ATIII deficiency; tx FFP)
```
90
what needs IE abx ppx?
Prosthetic valve
Previous endocarditis hx
Unrepaired congenital cyanotic dz
6 month postop period after repaired congenital heart defect
Repaired congenital heart defect with residual defect
Cardiac transplant pts with cardiac valvulopathy
91
what pathology is seen with HOCM?
LVH, systolic anterior movement of mitral valve (SAM), dynamic LVOT obstruction, decreased LV cavity size, diastolic dysfunction, arrhythmias
EKG changes: LVH, LA enlargement, high QRS voltage, ST- and T-wave changes, abnormal Q waves
92
what makes HOCM worse?
hypovolemia, sympathectomy and/or vasoD, increased contractility, sympathetic stimulation (tachy, incr inotropy), dysrhythmia, too much PPV/PEEP, inadequate L uterine displacement
93
Cushing's triad
HTN
brady
change in resp pattern
94
formula for CPP; normal value
CPP = MAP - ICP (or CVP, whatever is higher)
normal: 70-80
95
ways to decrease ICP
Hyperventilation to EtCO2 25-30
Ensure no venous obstruction, e.g. c-collar too tight
HOB 15-30 degrees (if tolerated)
Mannitol (may worsen cerebral edema if BBB not intact)
Lasix
Barbiturate: reduces ICP (vasoC), reduces CMRO2
Ask surgeon to consider ventriculostomy (drainage of CSF, means of ICP measurement)
If tumor, steroids: stabilizes cap membranes around tumor
96
SIADH vs CSWS
**both = hypoNa**
CSWS = hypovolemic; urine Na >100
SIADH = euvolemic, urine Na usually <100; tx water restriction + diuresis
97
tx cerebral vasospasm
triple H therapy: hypervolemia, HTN, hemodilution
98
mgmt VAE
Immediately have surgeon flood the field with saline
Stop any nitrous if you are using this, give 100% O2
Try to aspirate air thru CVC if one is present
Direct jugular venous compression to incr venous pressure at surgical site
Supportive care with vasoC, inotropes, etc
Tx bronchospasm with beta-2 adrenergic agonists
Reflex bronchospasm can happen with air entry into pulm artery
99
what is diabetes insipidus
affects ~40% of pts after pit surg; marked impairment in renal concentrating ability 2/2 decreased ADH secretion
Lots of urine despite rising serum Na
100
tx DI
fluid replacement
Replace urinary loss of hypo-osmolar, low Na fluids with ½ NS at rate equal to hourly maintenance + ⅔ of previous hour’s UOP
101
(good) mag fx
sz ppx
| may decrease SVR, increase ureteroplacental perfusion
102
safe mag goal
Goal: 4-6 mEq/L
watch for: loss of patellar reflexes, visual changes, muscle weakness, somnolence
Tx for too much = Ca
103
AFE s/sx
Early phase: pulm HTN (2/2 pulm vasospasm), hypoT (RHF), hypoxia (V/Q mismatch), sz, cardiac arrest
Second phase: LV failure, pulm edema, coagulopathy
104
tx postpartum hemorrhage
MCC: uterine atony
Manual compression
Oxytocin, hemabate, methergen: cause contraction of myometrial smooth muscle by increasing intracellular Ca
Hemabate = avoid in asthmatics, can cause bronchospasm; IM
Methergine = avoid in preE/hypertensive pts, can cause HTN; IM
Oxytocin can give as IV bolus, give in dilute solution (20u in 1L); hypoT/tachy
Bacri balloon, B-lynch suture
Ligation of internal iliac a, uterine a, ovarian a
Emergent hyst = ultimate tx
105
blocks for labor
Paracervical - 1st stage
Rarely performed 2/2 high risk of fetal bradycardia, decreased uteroplacental perfusion
Pudendal - 2nd stage
Less common complications: intravasc injxn, retroperitoneal hematoma, retropsoas/subgluteal abscess
Can work for 1st stage if coupled with other means of analgesia
106
s/sx PDPH
```
Fronto-occipital HA
Decreased pain with recumbent position
N/v
Neck stiffness
Photophobia, diplopia
Cranial nerve palsies (d/t stretching)
Hearing loss (hair cell position changes)
Rare = sz (due to cerebral vasospasm)
```
107
tx PDPH
Most effective tx = epidural blood patch; injection of 15-20 mL of her blood into epidural space
However, can’t do this if pt on anticoag
Conservative: hydration, caffeine, placement of abd binder, pain control
Tell her they’re self-limited and almost always resolve within 1 week
108
what happens to PDA after birth?
when ventilation begins, arterial O2 levels increase + pulm vasc resistance drops.
The increased O2 results in functional closure of PDA; permanent closure over a few months
Hypoxic infants: lungs don’t make enough bradykinin to induce closure
109
how to monitor for PDA ligation surg
BP on R arm, SpO2 on R hand + on lower limb
110
risk factors for postop apnea (peds)
<50 weeks postconceptual age
Low birth weight, hx chronic lung dz, hx apnea/brady, multiple congenital anomalies, sepsis, anemia
need to monitor 12-24 hrs
111
criteria indicating staged closure for omphalocele
Intragastric/intravesicular pressure >20
Peak inspiratory pressure >35
EtCO2 >50
112
MC type of TEF
type C: esoph atresia, blind upper pouch, lower segment tracheal fistula
113
cyanotic congenital heart diseases
```
Truncus arteriosis (1 trunk)
Transposition of great vessels (2 great vessels)
Tricuspid atresia (tri = 3)
Tetralogy of Fallot (tetra = 4)
TAPVR (5 letters)
```
114
ToF constellation
VSD
RVOT
Overriding aorta
RVH
115
Why do tet spells happen?
Paroxysmal spells of hypercyanosis due to increased R-to-L shunting
Sudden increase in PVR, dynamic outflow obstruction of RV, or decrease in SVR
116
issues with proceeding w/ surgery with current/recent URI
Risks of proceeding with current/recent URI = increased risk of periop resp complications
Laryngospasm, bronchospasm, desaturation
Risk is higher with severe sx, requirement of GA, requirement of ETT, and other risk factors like asthma/reactive airway dz
117
how to intubate foreign body aspiration (peds)
I would choose to induce and keep spontaneous, vs. RSI for full stomach
PPV can 1) push the foreign body further down, 2) cause hyperinflation or pneumo, and 3) foreign body produces ball-valve effect
Use O2 and sevo
118
causes of neonatal sz
```
ICH
hypoxic-ischemic encephalopathy
cerebral edema
hypoglycemia, hypoCa, hypoMag
benign sz
OB history of TORCH (toxo, rubella, CMV, herpes), sepsis
```
119
omphalocele vs gastroschisis
Omphalocele: gut fails to return to abd cavity during gestation
At base of umbilicus (midline), has memb covering; normally fxn bowel; often IS associated with other congenital defects
Diaphragmatic hernia, trisomy 21, bladder exstrophy, cardiac abnorm
Gastroschisis: occlusion of omphalomesenteric artery
Lateral to umbilicus; exposed viscera/intestines; functionally abnormal bowel; less likely assoc w/ congenital abnormalities
120
mgmt peds SVT
Peds SVT: HR >180, absent/abnormal P waves
Supplemental O2, attempt to convert with vagal maneuver (ice to face)
IV access and give 0.1 mg/kg of adenosine: interrupts any reentry circuit involving the AV node (usual cause of SVT in kids)
IO if can’t get IV quickly
If persistent or recurred: successive doses of 0.2 and 0.4 mg/kg every 1-2 mins as needed
Can’t get IV, HR jumps to 260 and pressure drops
SVT + hemodynamic instability = immediate synchronized cardioversion, starting at 0.5 J/kg and doubling energy dose as required up to 2J/kg
While this is being prepared, secure airway, apply 100% FiO2, try to get IV/IO access
121
tx thyroid storm
Tylenol, cooling measures
Titrate in BB to control tachy (esmolol, propranolol)
Ensure adequate intravasc volume, nml lytes
PTU, sodium iodide, and hydrocortisone = reduce circulating levels of active thyroid hormone
Consider giving catechol-depleting agent, like reserpine
122
MH vs NMS
Thyroid storm vs MH vs NMS: all with tachy, hypertherm, mental status changes
MH and NMS = metabolic acidosis, hypercarbia, musc rigidity
Not seen in thyroid storm
Hard to distinguish between MH and NMS in this pt who has received triggering agent and receiving meds that could lead to dopamine depletion
NMS usually has slower progression to critical temp and multisystem organ failure
Non-depolarizing NMBs will produce flaccid paralysis in NMS, but not in pts with MH
```
If can’t distinguish between MH and NMS: treat with dantrolene, intubate pt (with nontriggering agent), hyperventilate
Consider bromocriptine (often used to tx NMS)
```
123
substances from anterior pit
ACTH stimulates adrenal cortex secretion
Prl: secretion of breast milk, inhibits ovulation
FSH: ovarian follicle growth, spermatogenesis
LH: ovulation in females, testosterone secretion
HGH
TSH
124
substances from posterior pit
ADH: promotes water retention, reg plasma osmolarity
Oxytocin: uterine ctx, ejection of breast milk
125
possible meds to tx pit tumors
Bromocriptine: synthetic dopamine-2 R agonist; inhibits secretion of both growth hormone and prolactin; can cause gastroparesis
Octreotide: somatostatin analogue; inhibits release of growth hormone
126
Dx ARDS
Acute onset
Bilat infiltrates on CXR
PaO2:FiO2 ratio <200
PAOP <18, or no clinical evidence of cardiac cause
127
definition and Dx: DIC
pathologic activation of coagulation cascade associated with several conditions (burns, head trauma, preE); widespread formation of small clots in blood vessels throughout body => consumption of coag factors, thrombocytopenia, hemolysis, diffuse bleeding, thromboembolic phenomena
increased PT/PTT, fibrinogen <100, thrombocytopenia, decreased antithrombin III levels, presence of FDPs and D-dimer
128
complications of TPN
Fatty liver
Venous thrombosis 2/2 fat infusion
Cholecystitis 2/2 inactive GI system
Metabolic issues: hypoK, hypophos, hypomag, hypo/hypergly, acidosis/alkalosis, hypo/hyperCa, hypercarbia
Catheter placement: infxn/sepsis, pneumo, arterial puncture
129
complications of bicarb
Generation of additional CO2 (bicarb + H ions = CO2) => diffuse into cells, causing worsening intracellular acidosis
Left-shift of oxyHgb dissociation curve (impaired tissue delivery)
Hyperosmolar state 2/2 excess sodium load
Hypokalemia 2/2 movement from extracellular => intracellular compartment
130
CRPS types
Type 1 = minor injury; crush, lacs, fx, surgery, sprains, burns
Type 2 = nerve injury; sx not necessarily limited to distribution of that nerve
131
CRPS dx
initiating noxious event, followed by burning pain, allodynia or hyperalgesia out of proportion to degree of injury, edema, cutaneous vasomotor instability, sweating
132
how to do superior laryngeal n block
sensation to the laryngeal structures above the vocal cords; located inferior to the greater cornu of the hyoid bone
needle inserted lateral to hyoid bone, directed toward greater cornu => walk off inferiorly, inject 2cc of 2% lido here
make sure to aspirate (carotid nearby)
133
extubation criteria
```
awake pt with intact airway reflexes
muscle relaxant fully reversed
appropriate Vt and RR on min. settings
adequate oxygenation, normocarbia
HDS
```
VC > 10cc/kg, Vt > 6cc/kg, NIF > 20 cmH20
134
postop jaundice ddx
prehepatic = hemolysis, hematoma breakdown
```
intrahepatic = TPN, hypoxia, ischemia, drugs, new viral hepatitis, sepsis
-drugs = inhaled anes, abx
```
posthepatic = obstruction of biliary tree
-stones, strictures, abd surg trauma
MCC = 1) hematoma breakdown, 2) hemolysis after transfusion
135
Dx VAE
Precordial doppler mill wheel murmur + EtCO2 monitoring drop
-left or right parasternal, between 2nd and 3rd ribs
Most sensitive = TEE
PA pressure will also rise
136
epidural dosing
thoracic: ropi 0.2% or bupi 0.125%, start 4 mL/hr
lumbar: can do a little higher rate
can combine with narcs, esp if concerned with BP
137
Benefits of circle system
Low fresh gas flow requirements
Conservation of heat, humidity, and volatile
Minimal environmental pollution
*shorter, narrower-caliber tubing and Y-pieces help to minimize compliance and dead space in peds circuits*
138
Which mitral pathology is better tolerated in preg?
Mitral regurg > mitral stenosis
Gradient worsens as CO incr; need more time for diastolic filling, so avoid tachy
Would be OK with a controlled epidural; avoid spinal in MS (vasoD => reflex tachy)
139
Pt with mitral stenosis needs c/s, what’s your plan?
Assuming no contraindications to neuraxial, would prefer carefully dosed epidural > GA.
GA is potentially fine if blunt sympathetic stim to laryngoscopy with narcs/lido/BBs. Would have to be deep enough to avoid tachy/HTN, so potentially could use remi instead of higher doses of volatile. Also could use a TEE.
Would think carefully about placing PAC unless she had something like pulm HTN as well as the MS
140
Goal level for c/s
T4
141
Why is 5 lead better than 3?
Better ST monitoring
142
Cancer pain mgmt?
Follow the WHO Analgesic Ladder, initially starts with non-opioid therapies like Tylenol
143
What happens when put magnet on ICD?
Anti-tachyarrhythmia detection is suspended, but not pacing
144
Physiologic changes in preg
```
Increased CO (incr HR, incr SV)
Decr FRC, incr RR and Vt => resp alkalosis
Rightward shift of oxyHgb dissoc curve
50% incr in plasma volume, dilutional anemia
Incr most coag factors = hypercoag state
Incr renal blood flow (incr GFR)
Decr MAC requirements
Incr upper airway edema
```
145
synchronized cardioversion doses
Narrow reg: 50-100J
Narrow irreg: 120-200 biphasic or 200J monophasic
Wide reg: 100J
Wide irreg: unsynchronized reg defib dose
146
defibrillation dose
unsychronized shock at 200J vs 360J
shockable rhythms: pulseless Vtach or Vfib (both wide complex); polymorphic wide complex
147
Issues with brachial art line
Median nerve injury
Ischemia 2/2 lack of collateral flow
All: thrombosis, infection
148
Pros/cons of iso
Pro: minimal cardiac depression
-CO maintained by rise in HR
Con: high blood and lipid solubility = slower onset/emergence
- may produce tachycardia
- risk of coronary steal syndrome
149
Myxedema coma presentation/tx
```
Confusion, lethargy
Loss of DTRs
Hypothermia, hypoventilation
Hyponatremia
Hemodynamic instability
Coma, death
```
Admit to ICU
IV levothyroxine, symptomatic tx
IV hydrocortisone 100 mg, then 25 mg q6h
150
preggo with dyspnea, chest pain; diastolic murmur
EKG with LA enlargement, paroxysmal atrial tach
mitral stenosis
151
Preferred anes for c/s in:
AS
MS
both = epidural (slow titration)
152
```
Hemodynamic goals for each lesion:
AS
AI
MS
MR
```
AS: HR slow/baseline, adequate fluids, normal rhythm; don't drop afterload (depend on this for coronary perfusion)
AI: slight tachy, careful with fluids; mild afterload reduction is good (promotes fwd flow)
MS: HR goal 70-90 (like AS); need adequate preload; fixed lesion so don't drop afterload
MR: slight tachy, mild afterload reduction is good
153
tx negative pressure pulm edema
Supportive resp care, supplemental O2
Trial of CPAP (NPPV)
Reintubate if severe, PEEP
Consider albuterol, diuretics
154
Heparin dosing
ACT goal for bypass
Heparin dose: 3-4 units/kg
ACT goal: >300
155
Protamine dosing
Protamine dose = 1 mg per 100u heparin
