Questions/High-yield Flashcards
1
Q
Causes of Oxy-Hb right shift
A
Inc H+ (dec pH)
Inc CO2
Inc temp
Inc 2,3 -DPG
Pregnancy
Abn Hb (sickle cell)
Dec PaO2
Inhaled anesthetics
Infants/kids
Stopping smoking (dec carboxyHb)
This leads to Hb higher affinity at peripheral tissues = inc unloading of O2
2
Q
Causes of Oxy-Hb left shift
A
Dec H+ (inc pH)
Dec CO2
Dec 2,3-DPB
Dec temp
Fetal Hb/NEWBORNS
Carboxy, meth, sulfHb
High altitude
3
Q
Best predictor of post-op mortality after thoracotomy
A
VO2-Max <12-15ml/kg/min
This = >2 flights of stairs
Other predictors:
ppoDLCO <40%
<20% = unacceptable risk
4
Q
O2 cylinder psi and volume
A
2000psi = 660L
5
Q
N2O cylinder psi and volume
A
750psi = 1590L
75% exhausted = 400L
6
Q
Best Mapleson for spontaneous ventilation
A
A
7
Q
Best Mapleson for controlled ventilation
A
D
8
Q
Safest bellow design
A
ASCENDING
Ascends in expiration
Bellow collapse w/ disconnect
9
Q
EKG lead that detects most ischemia
A
V5 = 75%
II + V5 = 90%
10
Q
Correct BP cuff size
A
Width = 40-50% arm circumference
11
Q
Causes of falsely high BP
A
Cuff too small
Loose cuff
Extremity below heart
12
Q
Causes of a-line over dampening
A
1 = Air
Clot, stopcocks, vasospasm, large catheter size, long, narrow or compliant tubing
13
Q
Myasthenia & NMBDs
A
MORE sensitive to ND-NMBDs
Resistance to SUX
14
Q
LEMS & NMBDs
A
MORE sensitive to BOTH
15
Q
Causes of prolonged SUX blockade
A
- Dec cholinesterase production
- cyclophosphamide, severe chronic liver dz, pregnancy, malnutrition, hypothyroidism - Anti-cholinesterase drug
- echtiophate, neostigmine (phase 1) - Dec pseudocholinesterase - huntington dz
- CCBs
16
Q
Enhancers of ND-NMBDs
A
Volatiles (Des the most)
Aminoglycosides (gent), Clinda, polymyxins, Pen V/G
Magnesium
LAs
Dantrolene
CCBs
Lithium
Acidosis, hypoCa, hypothermia, hypoK
17
Q
Burn patients & NMBDs
A
Inc sens to SUX
Dec sens to ND-NMBDs
18
Q
Stroke & NMBDs
A
Resistance to BOTH on hemiplegic side
19
Q
CP & NMBDs
A
Resistance to ND-NMBDs
Normal response to Sux - NO risk of hyperK
20
Q
SLE & NMBDs
A
Inc sens to both
21
Q
LAs most likely to cause allergic reaction
A
Esters –> PABA
Prilocaine & Benzocaine
22
Q
LA potency
A
lipid solubility
23
Q
LA onset
A
pKa (low = fast)
Acidic tissue = slower onset
24
Q
LA duration
A
Protein binding (high = long)
25
LA systemic absoprtion
IV > tracheal > intercostal > caudal > paracervical > epidural > brachial plexus > sciatic > subq
26
Opioid receptor responsible for resp depression, constipation
Mu-2
27
Turbulent flow proportional to?
DENSITY
28
Laminar flow proportional to?
Viscosity
29
Spinal + bradycardia, hypotension, dysphagia, dysphoria, dyspnea, LOC
Total spinal
- intubate + volume + epi
30
Highest MAC age
1-6months
31
High altitude effect on Desflurane administration
Need higher dial %
lower partial pressure for given dial %
32
Gas metabolized the most and highest Flouride levels
Sevo
33
Things that dec Ach release
Antibiotics (clinda, polymyxin)
Magnesium (antagonizes Ca)
HypoCa
Anticonvulsants
Diuretics
LEMS
Botulinum toxin
34
#1 allergic reaction
NMBDs
35
What % of receptors are blocked with 1/4 TOF, 2/4, 3/4, 4/4?
1/4 = >90%
2/4 = 85%
3/4 = 75%
36
How many receptors are blocked with sustained head lift?
50% or less
Reliable recovery = sustained head lift/handgrip, tongue depressor test
Max insp pressure >40-50cmH2O
37
SE of cholinesterase inhibitors
Unopposed cardiac muscarinic --> brady or asystole
Bronchospasm, secretions, intestinal spasm, inc bladder tone, miosis
SLUDGE-Mi = salivation, lacrimation, urination, defecation, GI upset, emesis, miosis
38
CYP2C9 metabolism drugs
Warfarin
39
CYP3A4 metabolism drugs
Most anesthetics
HIV Protease inhibitors —> inhibit CYP3A4 for several days after stopping —> higher [benzo] and [opioids]
St. John's Wort inducer = Inc metabolism of alfentanil, midazlolam, lidocaine, OCPs, NSAIDs, ARVs
40
CYP2D6 metabolism drugs
Codeine, beta-blockers, dilt, tramadol
poor analgesia w/ codeine, oxycodone, hydrocodone
Rapid metabolizers —> overdose
SSRIs inhibit and slow conversion of hydrocodone = need higher doses
41
Mechanism and SE of HCTZ
Blocks Na/Cl channel in DCT
SE = hyperglycemia, hyperuricemia, hyperlipidemia, hyperCa, hypochloremic metabolic alkalosis
42
Effect of hetastarch on coagulation
Dec GP IIb-IIIa, VIII, vWF
43
Tx dystonic reactions
Anticholinergics (diphenhydramine, benztropine)
Benzos
Propanolol
44
Causes of dec CBF
#1 = hypothermia
Dec PaCO2
Dec MAP <50
45
Type 1 error
incorrectly accepting the alternate hypothesis
46
Supine positioning on FRC and CC
Dec FRC
No change in CC
47
Coronary artery blockage --> complete heart block
RCA --> PDA
48
Volatile metabolized the most
Sevo >> Iso >> Des
49
Sudden PAINLESS vision loss
Ischemic optic neuropathy
50
Risk factors for ischemic optic neuropathy
males
large blood loss
anemia
prone position
large crystalloid resusitation
hypotension
DM, smokers
51
In what case are anterior ischemic optic neuropathy more likely vs. posterior?
Anterior = anterior cardiac surgery
Posterior = prone spine surgery
52
OLV/endobronchial intubation affect on induction speed
SLOW Des the most
53
Effect of CO on induction speed
Afffects ISO the most
- inc CO = slows induction
54
Effect of ventilation on induction speed
Affects ISO the most (soluble agents)
- Inc ventilation = speed induction
55
Effect of intrapulmonary shunt on induction speed
Affects Des the most = SLOWS induction
56
Effect of R --> L intracardiac shunt on IV and inhaled induction speed
Slows inhaled induction
Speeds IV induction
57
Portion of heart supplied by RCA
Inferior and inferoseptal LV
58
Tx for prolonged R time on TEG
FFP
long time to clot formation = low on clotting factors or on heparin, warfarin
59
Tx prolonged K time on TEG
Fibrinogen
60
Landmark for stellate ganglion block
TP of C6 (at level of cricoid)
Best indicator of successful block = temperature change
61
Risk factors and procedures where IE ppx is indicated
Prosthetic valve
Prior IR
Unrepaired congenital heart defect or repaired in 1st 6 mo
Heart transplant + valve disease
Dental extractions
T&A, bronch
Skin or mucosal tissue procedures
62
Mech of nalbuphine
Antagonist at mu
Agonist at kappa
Ceiling effect on resp depression
63
Dx pre-renal AKI
UOsm >500
UNa <10
FENa <1%
BUN:Cr >20
64
Formula for Standard Error
SE = SD / square root of N
65
Formula for arterial O2 content (CaO2)
(Hbg x 1.36 x SaO2) + (0.003 x PaO2)
66
Effect of cholinesterase inhibitors on SUX
Prolonged phase 1 block
67
Hyperparathyroidism & NMBDs
dec dose and titrate up d/t unpredictable response from muscle weakness and hyperCa
68
Which H2 blocker does NOT dec gastric volume?
Ranitidine
Onset ~1hr
69
Mech of buprenorphine
Mu partial agonist
Kappa antagonist (opposite nalbuphine)
25-40x potency of morphine
Ceiling effect on resp depression
Only mild withdrawl symptoms
70
EKG abnormality seen with hypoCa
Prolonged QT
71
Mechanism of glucagon
inc cAMP --> + ionotropic and chronotropic
- resembles epi, norepi and isoproterenol
Inc glycogenolysis and gluconeogenesis
Contraindicated in Pheo = severe HTN and hyperglycemia
Relaxes sphincter or oddi
72
FFP contains which factors?
All!
V
VIII (unstable, resembles vWF)
Highest citrate toxicity
73
NMBDs metabolized to laudanosine
Cisastracurium
Atracurium - higher levels, histamine release
74
0 order elimination
1. Elimination is constant/linear
2. Enzymes are saturated/at capacity
3. THE-PAW: Theophylline, heparin, ethanol, phenytoin, aspirin, warfarin
75
Order of nerve fiber blockade w/ epidural
B-fibers (most sensitive) —> A-fibers —> C-fibers (most resistant)
Blocks sympathetic 1st —> pain, temp, touch —> proprioception —> motor last
76
PaO2 and Oxy-Hb curve with Meth-Hb
Normal PaO2
LEFT shift O2-Hb curve
77
Benzo that undergoes glucuronidation (not hepatic oxidation)
Lorazepam
Also has greatest receptor affinity
78
Vasopressor metabolized partially in the lungs
Norepi
79
Drugs that inc cGMP
SNP
Nitro & NO
80
Signs of CN toxicity and treatment
metabolic acidosis, inc MvO2
Tx = 100% O2 and Bicarb
81
Level of sedation with purposeful response to verbal or tactile stimuli
Moderate sedation
82
Level of sedation with purposeful response to repeated or painful stimuli
Deep sedation
83
What explains the relationship between CO2 dissociation and oxy-Hb?
Haldane effect
CO2 dissociation shifts right when [HbO2] increases
Inc ability for Hb to deliver CO2 in veins
84
What explains the relationship H+ and oxy-Hb dissociation?
Bohr effect
Acidosis shifts curve right = less O2-Hb attraction and ability to transport MORE CO2 to lungs
85
Mechanism of botulism
Inhibits intracellular fusion of Ach vesicles
86
Pathway for the oculocardiac reflex
Trigeminal --> vagus
87
How much fibrinogen is in each unit of Cryo?
200mg/U
88
What factors are in Cryo?
VIII
XIII
Fibrinogen
vWF
89
What are indications for using Cryo
Hemophilia A (VIII deficiency)
vWD
Low fibrinogen
does NOT need to ABO screened
90
Max FiO2 in nasal cannula
4% above room air (21%) for every L = max 44% at 6L
FiO2 dec as MV increases
91
Max FiO2:
Simple facemask
Non-rebreather
Partial rebreather
Simple = 35-50%
NRB = 60-90%
PRB = 40-70%
92
things that inc MvO2
Inc delivery
- Inc CO, inc Hb-saturation, inc amt of Hb
Cirrhosis and sepsis (high CO)
Dobutamine (in CO)
Transfusion
CO, CN, methHb (less O2 transferred to tissues)
L --> R cardiac shunt
93
Describe the Haldane effect
Deoxygenated blood = inc CO2 carrying capacity
94
Things that dec FRC
PANGOS:
Pregnancy
Ascities
Neonate
GA
Obesity
Supine
Females, dec height, upright --> supine = greatest decrease or T-berg >30 degrees
95
Things that INC closing capacity
ACLS-S:
Age
COPD
LV failure
Smoking
Surgery
96
Inc peak and plateau pressure problem
compliance problem
CO2 insufflation, PTX, ARDS, pulm edema, auto-peep, asynchronous w/ vent
97
Inc peak and normal plateau pressure problem
Airway resistance problem
Kinked ETT, aspiration, bronchospasm, mucous plug
Tx = suction airway + bronchodilator
98
What factors improve hypoxic pulmonary vasoconstriction?
1. Inc Insp O2 —> worsened V/Q mismatch —> hypercapnia in COPD patients
2. Correct acidosis
3. Inhaled NO
4. HypOcapnia
99
Dx of obesity hypoventilation syndrome
1. Respiratory acidosis + compensated metabolic alkalosis (HCO3 30 +/- 4), and hypoxemia
- 7.37/58/53/32
1. BMI >30
2. Awake hyperCO2 (PaCO2 >45)
3. No other cause for chronic hypoventilation
4. Abnormal sleep study w/ hypoventilation w/ nocturnal hyperCO2 w or w/o OSA or hypopnea events
5. Usually Males, 50-70, chronic fatigue, mood disorders, headaches, DOW, hypersomnolence
100
Causes of anion-gap metabolic acidosis
1. Lactic acidosis
2. Ketoacidosis
3. Renal failure
4. Toxins - aspirin, ethylene glycol, methanol
MUDPILES: Methanol; uremia; diabetic ketoacidosis (DKA); paraldehyde, phenformin; iron, isoniazid; lactic (ie, carbon monoxide [CO], cyanide); ethylene glycol; salicylates
101
Causes of NON-anion-gap metabolic acidosis
1. RTA
2. Expansion - rapid saline infusion
3. GI HCO3- loss (diarrhea)
4. Drugs —> hyperK
HARD-ASS
102
What happens when you put Iso into a vaporizer for Sevo?
Higher vapor pressure gas = higher concentration delivered
103
What happens when one-way valves are stuck open?
Rebreathing, hypercapnia
104
What happens when expiratory limb valves are stuck open?
Breath stacking and barotrauma
105
CO2 absorbent with greatest CO production
Baralyme
106
How much Des will be delivered with a Des vaporizer at higher altitude?
Lower concentration = dial in higher amount
107
What is Boyle's Law?
P1V1 = P2V2
"Water Boyle's at a constant temp and Prince Charles is under constant pressure"
108
What is Charles' Law?
Volume of a mass of gas = temp at constant pressure
V1/T1 = V2/T2
"Water Boyle's at a constant temp and Prince Charles is under constant pressure"
109
PT tests what factor(s)?
VII
factors I (Fibrinogen), II (Prothrombin), V, VII and X
110
PTT tests what factor(s)?
VIII and IX
intrinsic system (factors VIII, IX, XI, and XII) and the common pathways (factors V and X, prothrombin, and fibrinogen).
111
Name the direct thrombin inhibitors
1. Hirudin
2. Argatroban
3. Dabigatran (Pradaxa)
4. Lepirudin
5. Bivalrudin
112
Name the ADP receptor antagonists
Ticlopidine (longest duration), clopidogrel, ticagelor, plasugrel
113
Name the GP-IIb/IIIa inhibitors
Tirofiban, abciximab, eptifibatide
114
Tx vWD
DDAVP
Factor VIII
115
Febrile NON-hemolytic reaction
Host antibodies bind to donor leukocytes
116
Hemolytic transfusion reaction labs
+ direct antiglobulin test (Coombs)
Inc bilirubin, inc LDH
Dec Haptoglobin (binds Hb)
117
How to reduce TRALI risk
<14d old
No female donors
Apheresis platelets
?Cause - transfused antibodies to recipients leukocytes
Most often with FFP and platelets
118
Calculate allowable blood loss
EBV x (Hct starting - Hct lowest acceptable)/ Hct starting
EBV 65ml/kg
