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Flashcards in OpenAnesthesia Deck (210):
1

pump flow range

1.6-3 L/min/m2

2

CPB mixed venous goals

SvO2 >65%

3

CPB glucose

aggressive (80-110 mg/dL) management ass with worse outcomes

4

meds to avoid with reproductive assistance, why?

droperidol and metoclopramide; both can increase prolactin levels, which can follicle maturation and corpus function

5

LMWH clearance

renally - prolonged in renal insufficiency, directly proportional to creatinine clearance

6

how to monitor enoxaparin

PTT is not usually monitored, can test anti-Xa activity (peak at 4 hours), therapeutic for tx 0.6-1.0 U/ml and ppx 0.1-0.3 U/ml

7

uterine atony risk factors

oxytocin, multiples, polyhydramnios, chorioamnionitis (NSAIDs irreversibly inhibit platelet function but little affect on uterine tone)

8

TRALI mechanism

GVHD - leukocytes/neutrophils causing flood of neutrophils and inflammatory mediators to lungs causing increased microvasc permeability

9

Haldane effect

Deoxygenated blood can carry increasing amounts of carbon dioxide

10

Bohr effect

an increase of carbon dioxide in the blood and a decrease in pH results in a reduction of the affinity of hemoglobin for oxygen

11

IgA deficiency considerations

blood products need to be washed before administration

12

cryo contains

VIII (100 IU), vWF, XIII, and fibrinogen (250 mg)

13

type

patient's RBCs mixed with serum with known antigens (ABOD)

14

screen

(indirect) put patients serum with RBCs with known antigens

15

crossmatch

patient's serum with donor cells

16

therapeutic hypothermia

32-34 for 24 hours

17

emergent therapy for stroke 2/2 air embolism

hyperbaric O2

18

HBO uses

arterial air embolism, CO poisoning, decompression sickness, severe anemia, hypoperfusion, gas gangrene

19

HBO MAC effects

decrease in MAC because HBO increases partial pressure of volatiles at higher barometric pressure and gas density increases so rotameter flowmeters will read falsely high (2% sevo at 1 atm produces same as 0.66% sevo at 3 atm)

20

1 mm Hg CO2 decrease - CBF?

decreases 3-4%, goal 30-35

21

goal CPP with increased ICP

60-70 mm Hg

22

prevention of contrast nephropathy

periprocedural continuous hemofiltration, oral N-acetylcysteine, bicarbonate infusion

23

predisposition to renal damage with contrast

Cr >1.5, GFR < 60, DM nephropathy, hypovolemia, high dose contrast media, multiple myeloma

24

pierre robin ass syndromes

stickler syndrome, velocardiofacial syndrome, treacher-collins

25

pierre robin characteristics

micrognathia, glossoptosis (prone position may help), airway obstruction --> can cause cor pulmonale, can also see cleft palate, high incidence of central/obstructive apnea

26

congenital lobar emphysema management

inhalational induction, spontaneous ventilation preferred, single lung ventilation, nitrous contraindicated

27

congenital lobar emphysema characteristics

causes hyperinflation of lungs, resp distress in newborn-6 mos, left lung more common, left upper lobe most common,

28

congenital lobar emphysema physical exam

decreased breath sounds, hyper-resonant, hyperinflation on CXR

29

CPB roller pump

roller pump flow is predictable and depends on revolutions per minute of the pump, retrograde flow is not possible, but if there is outflow occlusion, pressure can build and cause tubing rupture or separation

30

CPB centrifugal pump

retrograde flow is possible, flow depends on pressure differential created by the spinning cones --> cause negative pressure that propels fluid forward, flow varies with afterload an preload

31

roller pump vs centrifugal

roller has predictable speed and cost less

32

best echo view for ischemia

transgastric mid-papillary short axis

33

fluconazole active against

candida, Cryptococcus, coccoidioides immitis

34

needed for nitrogen balance calculations

nitrogen intake, 24 hour urine nitrogen, 24 hour change in BUN (very sick usually have negative nitrogen balance)

35

PNA diagnosis from BAL

10,000 colonies, 1,000,000 for endotracheal aspirates, 1,000 for protected brush specimen

36

hyperkalemia treatment

hyperventilation, gluscose/insulin, beta agonist, lasix, dialysis, aldosterone agonist

37

nitroglycerin

much more potent venodilator than arterial dilator

38

hydralazine metabolism

metabolized by acetylation in the liver

39

synchronized cardioversion

shock synchronized with QRS to avoid shock during refractory period (R on T)

40

smoking cessation 48-72 hours

increased secretion, more reactive airway activity, decreased carboxyhgb, improved oxygentation

41

smoking cessation 2-4 weeks? 8 weeks?

decreased secretions, decreased airway reactivity; decreased overall post-op morbidity and mortality

42

MS management

sensitive/insensitive to NMBD, suc may cause hyperkalemia, hyperthermia may cause exacerbations, neuraxial not recommended?, MAC may be reduced

43

MS

autoimmune disease of inflammation, demyelination, and axonal damage to CNS, tx with corticosteroids, methotrexate, azathioprine, glatiramer acetate, interferon-beta

44

autonomic hyperreflexia

HTN followed by profound vagal response (brady), may see vasodilation and flushing above injury (2/2 high afterload)

45

layers for paramedian neuraxial

skin, sub Q fat, paraspinal muscles, ligamentum flavum, dura mater, subdural space, arachnoid mater, subarachnoid space

46

DMD heart changes

dilated CM from fatty infiltration, prominent Q waves, inverted T waves, cardiac involvement seen in 90% patients, can lead to LV failure and sudden death (ACE-I and bb)

47

DMD presentation

most severe MD, 3-5 years start, waddling gait, progressive falls, difficulty with stairs, gower (both hands to get up from seated position)

48

becker's dystrophy

problem with dystrophin results in leaking muscle membranes and elevation of CPK, pseudohypertrophy of muscles from fibrofatty infiltrates

49

LA absorption

ICE-BS intercostal, caudal, epidural, brachial, sciatic/femoral

50

gasserian ganglion

formed from 3 divisions of trigeminal nerve, trigeminal nerve root emerges from here and travels to its nucleus in the pons

51

trigeminal neuralgia cause

irritation of nerve root by blood vessel (superior cerebellar artery), MS, tumor, trauma

52

trigeminal neuralgia treatment

carbamezapine (tegretol), oxycarbemezapine (trileptal), phenytoin, baclofen, gabapentin, microvascular decompress, nerve lesions, motor cortex stim

53

carbamezapine and phenytoin side effects

hyponatremia, agranulocytosis, hepatic toxicity; gingival hyperplasia

54

WHO analgesic ladder

1. non-opioid w/wo adjuvants 2. weak opioids w/wo adj 3. strong opioids w/wo adj

55

acute hemolytic reaction

can occur 3-21 days after transfusion, elevated unconjugated bili, back pain, fever, SOB, chest pain, pain at sight of infusion, HA, change in vitals, pulm edema, bleeding, renal failure

56

febrile transfusion reaction

0.5% RBC transfusions, 30% platelet transfusions, see increase > 1 degree C, HA, chills, back pain, may take 2 hours to develop

57

febrile transfusion reaction treatment

stop transfusion (may be hemolytic), acetaminophen, diphenhydramine, leukoreduced transfusions in the future and premed with acetaminophen

58

LVAD contraindications

PFO/ASD, AI, MS (tends to improve MR)

59

acute hemorrhage and resus, which factor is first to reach critical low

fibrinogen

60

can fibrillating atrium be paced

no

61

Pacemaker

Paced, Sensed, Response to sensed event, Rate modulation, Multisite pacing

62

highest risk for abnormal placentation

placenta previa (increased maternal age, C-sections)

63

bronchial blocker disadvantage

higher cost, not able to add CPAP or suction operative lung

64

missed musculocutaneous on ax block

maintain biceps motor, elbow flexion and supination, sensation to lateral forearm

65

tibial nerve stim

innervates gastroc and soleus muscles of calf - controls plantar flexion of toes and ankle

66

2-chloroprocaine epidural use

associated with decreased efficacy of subsequent epidural opioids because it antagonizes mu and kappa opioid receptors (onset 6-12 min, peak 10-20, duration 30-60 min)

67

2-chloroprocaine epidural use

associated with decreased efficacy of subsequent epidural opioids

68

SC stimulator procedure management

can be extensive dissection and awake has lower fail rate; can use spinal, LA with conscious sedation, thoracic epidural (single shot)

69

spinal cord stim

send pulsed electrical signals to spinal cord to control chronic pain, stim electrodes are placed in epidural space, generator in lower abd or gluteal region, and generator remote

70

spinal cord stim indications

failed back surgery syndrome, refractory angina pectoris, PVD, CRPS I

71

failed back surgery syndrome

40% of patients s/p spinal surgery

72

refractory angina pectoris

angina caused by CAD not controlled with meds, surgery, etc --> treat with SCS decrease chest pain, hospital admission, increase exercise duration, less morbidity than other open procedures for pain

73

SCS for PVD

when PVD is inoperable --> improves quality of life, limb mobility, pain relief

74

AMS differential diagnosis post craniotomy

hemorrhage, tension pneumocephalus, venous/arterial stroke, hydrocephalus, infection, seizures, metabolic, retraction/surgical injury

75

CBF, slowing, flat EEG

50ml/100g/min (15% CO), 20, 12

76

CMRO2

3ml/100g/min

77

PaCO2 and CBF/CBV

decrease CBF 1-1.5 and CBV 0.05

78

cerebral vasospasm treatment

hypertensive euvolemia (HTN, hypervolemia, hemodilution), nimodipine, balloon angioplasty, papaverine/verapamil intraterial injection (vasodilators)

79

cerebral vasospasm presentation and detection

3-10 s/p SAH (think hydrocephalus, seizure, hyponatremia, rebleed), use cerebral angiography, transcranial Doppler (increased arterial velocity

80

vasospasm prevention

nimodipine, remove subarachnoid blood ASAP, instill thrombolytics (urokinase), antinflam (NSAIDs/steroids)

81

AAA repair renal problems

see ATN, decrease chance with good intravascular volume and heart function

82

AAA crossclamp complications (increase)

increased wall motion abn, increased wedge and CVP, increased coronary blood flow, increased mixed venous, increased epi/norepi, renal vasc resistance

83

AAA crossclamp complications (decrease)

decreased CO, EF, RBF, CO2 production, renal cortical blood flow, GFR

84

intralipid dose

1.5ml/kg bolus and 0.25 ml/kg/min infusion

85

bupi cardiac toxicity

binds more strongly to resting/inactive Na channels and dissociates from channels during diastole more slowly

86

methgb with LA

prilocaine (o-toluidine), benzocaine

87

most common arrhythmia with bupi

wide complex ventricular rhythm (vtach)

88

MS and pregnancy

20-30% experience exacerbation post partum 2/2 loss of immune-tolerant pregnancy state

89

most important crossclamp factor

level of clamp - infrarenal least hemodynamic changes

90

CEA neuromonitoring

awake, EEG, SSEP, transcranial Doppler, cerebral oximetry stump pressure

91

hypernatremia and MAC

increases MAC

92

ADH site of action

distal and collecting tubules

93

avoid with HOCM

increasing velocity of blood across LVOT - decreasing SVR, decreasing preload, increasing contractility, increasing HR

94

HOCM treatment

beta blockers, CCB, amiodarone (for afib), diuretics (with caution for diastolic dysfunction)

95

pHTN diagnosis

resting PAP >25, PCWP/LAP 15, PVR >3 (RVH is not required)

96

morphine neonate vs adult differences

increased half life (6-9 hr) until 2-3 months (2-4 hr), more protein bound in adults

97

methadone CV

prolongs QT

98

prostaglandin E1

used for interrupted aortic arch and hypoplastic left heart syndrome (0.1 mcg/kg/min) - maintains ductal patency

99

prostaglandin E2

ductus arteriosus patent in utero

100

prostaglandin E1 se

hypotension, fever, apnea, myoclonus, irritability

101

beta thal minor

microcytic red cells

102

beta thal major (cooleys)

fine at birth because of hgbF, then hemolysis causes severe anemia - pale, jaundice, hepatosplenomegaly, growth retard, skeletal abn

103

beta thal major treatment

regular transfusions of bone marrow transplant

104

CV changes pregnancy

may see cardiomegaly, S3, regurg murmurs (TR-systolic), dilation can cause RAD and RBBB - S4 is pathologic so get it checked

105

coagulation changes pregnancy

hypercoagulable state with increase in factors, decrease in protein S (anticoagulant) and resistance to protein C (anticoagulant), platelet turnover increases

106

pregnancy EKG

heart moved cephalad and laterally - sinus tach, other dysrhythmias, ST depression, T wave flattening, LVH, LAD

107

HAART drug interactions

protease inhibitors inhibit cytochrome p450 metabolism - CCB, macrolide antibiotics, barbs, alprazolam, midazolam, carbamazepine, azole antifungals, phenytoin, rifampin

108

large v waves

MR

109

mitral stenosis

increase preload, decrease HR, maintain SVR, giant a waves, pressure gradient >10 across valve, PCWP reflects LA not LV

110

CMRO2 reduction with anesthetics

barbs and others decrease by 50% (amount responsible for electrical activity)

111

central retinal artery occlusion

associated with external pressure on globe, unilateral most of the time, no improvement in visual acuity over time, see pale retina and cherry red spot on macula

112

morphine peak

1 hour 2/2 very hydrophobic

113

student's t test

compare means of 2 normally distributed populations

114

mann-whitney

compare two populations that are not normally distributed

115

coronary perfusion pressure

aortic diastolic pressure minus LVEDP

116

coronary blood flow

(aortic diastolic pressure - LVEDP)/coronary vascular resistance

117

chattering/fluttering and treatment

of venous cannula when compliant arterial/venous walls collapse against intake cannula opening; treat by increasing blood volume or decreasing siphon pressure

118

mild preeclampsia

BP 140/90, 24 hour urine >300mg (+1 dipstick x 2), after 20 weeks

119

severe preeclampsia

SBP>160 or DBP>110 x 2 (6 hr), 24 hr urine >5g (+3 dipstick x 2), pulm edema/cyanosis, oliguria <400 ml in 24 hr, HA, epigastric pain and/or impaired liver function, thrombocytopenia, oligohydramnios/decreased fetal growth/placental abruption

120

poiseuille's law

Q=(pixPxr^4)/(8xviscosityxlength)

121

preeclampsia increases risk of

postpartum venous thromboembolism, chronic HTN, CV disease; risk of adverse outcomes worse if onset <34 weeks

122

sodium citrate

non-particulate antacid rapidly decreases acidity of gastric contents, duration 1 hour

123

alpha-stat

d/n add bicarb, associated with less post op cognitive dysfunction

124

pH-stat

temperature corrects for pH and pCO2

125

etomidate and ECT

increases seizure duration

126

bicuspid aortic valve significance

increased risk for aortic aneurysm and dissection

127

normal pulm vascular resistance

0.25-1.6 wood units or 20-130 dyne-sec-cm-5 (when equation multiplied by 80)

128

normal SVR

9-20 wood units or 700-1600 dyne-sec-cm-5

129

normal PA SBP

1/8-1/10 systemic SBP

130

transpulmonary gradient

mPAP - PCWP, >14 increased pressure and >16 with elevated right atrial pressure (>20) predictive value for RV failure

131

pulmonary HTN

>1/4 systemic SBP

132

PABA allergy

ester LA

133

AR management goals

"fast and loose" relative tachy (reduces time in diastole for regurg), maintain preload, reduce afterload, maintain contractility

134

decreased lvad effectiveness

Ai will decrease output the most, TR and MS also decrease; PFO increases chance of hypoxemia and paradoxical embolus

135

pyloric stenosis lab abnormality

hypochloremic, hypokalemic metabolic alkalosis with possible aciduria (normalization of chloride signifies resolution of alkalosis)

136

true ventricular aneurysm

at apex, dilated and dyskinetic area with all layers, 90 days after MI (abn remodeling), smooth transition with orifice 0.9-1.0

137

pseudo ventricular aneurysm

saccular/globular at site of chronic ventricular rupture lined with only pericardium after MI, trauma, surgery, infection, abrupt transition with small orifice <0.5, bi-directional flow on doppler

138

affect oxygenation during one lung

degree of HPV (volatiles, hypocapnea, vasodilators), high airway pressures (PEEP, hypervent, high PIP)

139

abd compartment syndrome bladder pressure

>20-25; 25-35 need eventual decompression, >35 immediate decompression

140

abd compartment syndrome bladder pressure

>20-25

141

abd compartment syndrome presentation

sudden intra-ab pressure increase, increased PIP, decreased UOP, hypoxia, hypercarbia, hypotension

142

afib treatment

rate control w/ beta blocker, CCB; cardioversion w/ amiodarone, sotalol, procainamide, synchronized DC (stable/unstable)

143

underestimate LV preload

MS, noncompliant LV, AI, AS

144

nitrous cylinder pressure drops

about 400 L remain

145

temp and CO2 and pH

low temp - low arterial CO2 - high pH

146

pH stat

cooled blood will have high pH, to correct will add CO2, which will cause acidosis which will increase CBF

147

idiopathic Thrombotic Thrombocytopenic Purpura treatment

medical emergency treated urgently with plasma exchange - FFP

148

TRALI diagnosis

new onset acute lung injury symptoms (PaO2/FiO2 300, pulm artery pressure < 19 mm Hg, Edema Fluid/Plasma Protein Ratio >0.75), <0.65 differentiates between a transudate (pulmonary edema) and an exudate (TRALI), greater amount of protein in the edema fluid (larger ratio), more likely exudate

149

stewart approach to acid base

bicarb is not a mathematically independent determinant of pH - pH independent variables are total weak acid concentration, strong ion difference, and pCO2

150

DI lab values

sodium >145, urine osm 310, urine spec gravity <1.005(polyuria, polydipsia)

151

fire triad

oxidizer (O2, nitrous), ignition source (lasers, burrs, drills, fiberoptic scopes, electrosurgical devices), fuel (ETT, sponges/gauzes, drapes, masks) *metal ETT are combustion resistant

152

vit K

IM/oral take 6-8 hours to decrease INR, IV vit k associated with anaphalactoid reaction - hypotension, seizures, death

153

argatroban

reversible direct thrombin inhibitor - does not directly affect platelet function

154

airway fire management

stop the procedure, remove ETT, stop gases, remove flammable material, pour saline into airway, reestablish ventilation, examine ETT, consider bronchoscopy, assess patient status and decide what's next step in patient care

155

finding with epidural >6 hrs

fever

156

disadvantages of stress ulcer prophylaxis

increased incidence of PNA, C. dif, and thrombocytopenia

157

positive intravascular test dose under anesthesia peds

T wave amplitude increase >25%, >10 bpm elevation, increase in SBP >15

158

pHTN definition

resting PAP >25

159

WHO pHTN classifications

class 1 - arterial HTN (includes idiopathic aka primary), class 2 - venous HTN, class 3 - pHTN ass with hypoxemia, class 4 - chronic thromboembolic pHTN, class 5 - miscellaneous

160

severe HF managment

difficulty with increased/reduced preload, d/n tolerate pHTN, increased SVR will decrease SV, brady/tachy poorly tolerated, keep 80-90 bpm

161

prolongs QT

sevo, iso, thiopental

162

PONV children

rare, 3 yo risk is 40% and increases until puberty, increased with T&A, strabismus, hernia, orchipexy, penile surgery

163

Eberhart's PONV classification in children

personal/family history of PONV, duration of anesthesia >30 min, age >3 yo, strabismus surgery (10, 30, 55, 70% risk)

164

ASDs

40% of all CHD, 2-3 x more common in women, ostium secundum 70%, ostium primum 20%, sinous VSD 10%

165

Ostium secundum

70%, ass with mitral valve prolapse

166

ostium primum (endocardial cushion defect/AV septal defect)

20%, ass with cleft of anterior leaflet of mitral valve that causes MR (downs)

167

sinous vsd

10%, ass with anomalous venous return

168

lmwh 2x daily dose

not recommended with epidural no matter the dose

169

lmwh and epidural

placement 12 hours after prophylaxis, placement 24 hours after treatment, removal 10-12 hours after last dose, after removal next dose should be delayed at least 2 hours

170

ECG and mechanics of heart

end of PR mitral closes, R wave starts isovolumic contraction, S wave aortic valve opens, near end of ST aortic valve closes - isovolumic relaxation, end of T wave mitral opens and diastole starts

171

liver blood supply

1/3 hepatic artery - 50% O2, 2/3 portal vein - 50% O2

172

bicuspid AV

most common congen CV anom, more men, ass with coarctation of aorta, often leads to AS, also at risk for AI and endocarditis

173

independent stress ulcer risks

coagulopathy and mechanical ventilation for 48 hrs

174

TEF cause and ass

failure of foregut to separate from larynx, ass with VACTERL (veterbral anom, anal atresia, CV anom, TEF, esophageal atresia, renal/radial anom, limb defects)

175

TEF cardiac anom

35% ASD, VSD, AV canal, TOF, coarctation of aorta

176

altitude effects

higher sea level/higher altitude - decreased partial pressure of gas = lighter anesthetic depth

177

Desflurane vaporizer

heated vaporizer (not variable bypass) so at different altitudes % set is % produced

178

first line for delirium

haloperidol D2 agonist with warning for fatal ventricular arrhythmias

179

TEF renal anom

renal agenesis, reflux, renal failure

180

diffusion constant of gas

directly proportional to solubility and inversely proportional to square root of molecular weight

181

classic vs modified classic sciatic nerve block

PSIS and greater trochanter vs PSIS, greater trochanter, and line from sacral hiatus to greater trochanter (Labat vs Winnie)

182

pKa lido, bupi, ropi, tetra, chorpro

7.8, 8.1, 8.2, 8.5, 9

183

IABP inflation and deflation

inflate after AV closes (dicrotic notch), deflate fully before AV opens

184

bactericidal

cephalosporins, vancomycin, aminoglycosides, FQs, daptomycin, metronidazole

185

bacteriostatic

macrolides, tetracycline, trimethoprim, sulfonamides

186

neuraxial block drugs to avoid

avoid with thrombolytics - even though half-life is a few hours, fibrinogen and plasminogen are decreased for 27 hours

187

ascending aortic aneurysm ass

hoarseness from compression of L RLN, dyspnea from compression of trachea, left mainstem bronchus or pulmonary artery, SVC syndrome, venous HTN

188

increased AFE risk

multiparity, placenta previa, placental abruption, cervical lacerations, uterine rupture, operative vaginal delivery

189

SIRS criteria

T >38/90, RR >22 or pCO2 12,000 or >10% bands

190

renal failure with immunosuppression

calcineurin inhibitors, tacrolimus, and cyclosporine

191

immune suppression stages

induction, maintenance, and anti-rejection if needed

192

chemo stages

induction, consolidation, maintenance (then CNS prophylaxis for ALL)

193

types of shock

distributive (neurogenic, sepsis), hypovolemic, cardiogenic, obstructive (tamponade, PE, pneumo)

194

papillary muscle blood supply

posterior pap - post descending artery (most vulnerable to ischemia), anterior pap - LAD and circumflex coronary artery

195

ECT contraindications

pheo (absolute); Relative = increased ICP/brain tumor with no mass effect, recent stoke CV conduction defects, high risk pregnancy, aortic/cerebral aneurysms, asthma/COPD (theophylline can cause status epilepticus)

196

dural sac termination

birth to 1 year S3, by 1 yo S2

197

ANOVA

simultaneously compares the differences among population means of more than two independent groups for a one-factor experiment

198

chi-square

test for categorical variables determines whether there is a difference in the population proportions between two or more groups.

199

unpaired t-test

compares the population means between two independent (and normally distributed) groups

200

paired t-test

examines repeated measurements obtained from the same set of individuals

201

PABA

metabolite of esters

202

Dipyridamole

phosphodiesterase inhibitor, increases cyclic AMP which blocks the uptake of adenosine, reducing adenosine at the platelet vascular interface or via direct stimulation of prostacyclin release from the endothelium

203

HCTZ electrolytes

Low Na, low K, low Mag, increase Ca and cholesterol labs

204

Only abductor of vocal cords? Innervated by?

posterior cricoarytenoid muscle innervated by RLN

205

Risk factors for post herpetic neuralgia

Age >60, female, severe acute pain

206

Neurotransmitter preganglionic

sympathetic and parasympathetic PREganglionic neurons are cholinergic (release acetylcholine)

207

Neurotransmitter postganglionic sympathetic

POSTganglionic sympathetic neurons are adrenergic and release norepinephrine

208

Neurotransmitter postganglionic parasympathetic

POSTganglionic parasympathetic neurons are and thus release acetylcholine

209

Anterolateral pap muscle

LAD and left circumflex

210

Posteromedial pap muscle

Right coronary - at risk with inferior MI (see MR)