STUDY GUIDE !!! Flashcards
Please continue to add shit. I'm starting at the top of the list and working my way down.
1
Q
- diabetes causes - What causes type 1 diabetes?
A
destruction of the beta cells of the pancreas.
2
Q
- diabetes causes - What causes type 2 diabetes
A
the body is unable to use insulin effectively. the beta cells of the pancreas produce insulin normally when the disease begins, but will eventually tire and not produce as much insulin.
3
Q
- Diabetes and regional - …kind of a vague study suggestion…
A
diabetics are more prone to infection. poorly controlled diabetics experience increased levels of post-op pain. diabetics are also typically dehydrated, so if you’re doing a spinal, they may bottom out faster. (that’s all i could find in the articles regarding regional and diabetes)
4
Q
- diabetics and the reason they can become stiff - What is the reason diabetics become stiff?
A
i don’t remember seeing this in the articles, but the reason is because the excess glucose floating around glycosylates with all of the cells of the body. this glycosylation or “activated glycosylated end-product” (AGE) thickens the cells and makes them stiff. that’s why we check the HbA1C, because the RBCs have become glycosylated over the 3 month period prior. organs typically effected: kidneys, blood vessels, peripheral nerves, and lenses of the eye. (the way i learned it is that glycosylation is a non-enzymatic reaction that simply just occurs if there is too much glucose floating around for too long of a time. craziness.) wikipedia says it’s an enzymatic reaction. whatever…
5
Q
- carcinoid syndrome and the heart - Cardiac involvement has been reported in more than half of the patients with carcinoid syndrome. Cardiac lesions, if present, may result from the secretion of bioactive mediators and most often affect only the ______ side of the heart. What are the mediators and why only one side?
A
Right side of the heart is affected by fibrous thickenng of the endocardium and fixation of the tricuspid valve. The lungs have the ability to clear out the causative agents mediators: 5-HTP (serotonin) and substance P.
6
Q
- carcinoid syndrome and the heart - Serotonin may cause vasoconstriction and vasodilation. Why?
A
At normal concentrations, serotonin does not affect cardiac function; however, the elevated levels seen in carcinoid syndrome may cause both inotropic and chronotropic responses. This action is due in part to an indirect effect from the release of norepinephrine.
7
Q
- carcinoid tumors and medications to use and avoid - Medication used to treat the symptoms of any residual tumor remaining after surgery?
A
octreotide (this is a somatostatin. somatostatins block hormones)
8
Q
- carcinoid tumors and medications to use and avoid - Release of _________ and _________ should be avoided when choosing which medications to use.
A
catecholamines and histamine (propofol and etomidate are good for induction; succs is debatable; don’t use opioids that cause histamine release; only use NDNB that don’t cause histamine release, vec is the best choice because of cardiac stability)
9
Q
- carcinoid tumors and medications to use and avoid - Because these patients often have chronic right ventricular valvular lesions and heart failure, one should avoid anesthetic factors that increase RV work with potential precipitation of acute RV failure. What 3 factors does this include?
A
hypoxemia hypercarbia a light anesthetic plane
10
Q
- carcinoid tumors and medications to use and avoid - What is the drug of choice for treating hypotension perioperatively in carcinoid tumor patients?
A
octreotide (IV boluses up to 1.0mg), along with fluids (hypotension can be a serious problem since the drugs usually used to treat hypotension may make it worse by further stimulating the release of peptides)
11
Q
** For burn injury info, look at the other brainscape cards for burns **
A
…. no reason to rehash it since it was vague on the study guide …
12
Q
- anesthetics for the patient with muscular dystrophy - Duchenne muscular dystrophy and administration of Suc’s, NDNMB and inhaled agents can trigger ?
A
Rhabdo and MH
13
Q
- anesthetics for the patient with muscular dystrophy - Why can rhabdo or MH happen with muscular dystrophy patients? What is happening in the cell?
A
the absence of the dystrophin-glycoprotein complex results in instability and increased permeability of the sarcolemma and increased intracellular calcium levels. exposure of the sarcolemma to the potent inhalational agent (or succ’s) stresses the muscle membrane and further increases the instability and permeability. consequently, intracellular calcium levels increase further and cell contents, such as potassium and CK, leak out. **a compensatory hypermetabolic response occurs in an attempt to reestablish membrane stability and prevent calcium fluxes. (this mechanism may explain the hyperkalemia, hyperthermia, tachycardia, and rhabdo observed in these patients. knowledge!)
14
Q
- anesthetics for the patient with muscular dystrophy - Should you use inhalational agents or do a TIVA for these patients?
A
TIVA (a “trigger-free” anesthetic and a “clean” machine with the inhalational agents flushed out)
15
Q
- anesthetics for the patient with muscular dystrophy - If anesthesia induced rhabdo is suspected, serial potassium levels should be measured and immediately treated if greater than ______ mmol/L. What is the treatment?
A
5.5 mmol/L treatment: IV sodium bicarb, insulin with 10% dextrose, and the patient hyperventilated to produce a respiratory alkalosis.
16
Q
- anesthetics for the patient with muscular dystrophy - If anesthesia induced rhabdo is definitely happening, what additional steps need to be taken to protect the kidneys?
A
IV hydration and mannitol, to maintain the UOP > 1ml/kg/h
17
Q
- anesthetics for the patient with muscular dystrophy - What is the treatment for perioperative hyperkalemic cardiac arrest?
A
IV calcium chloride (to antagonize the myocardial effects of hyperkalemia and help restore a spontaneous rhythm)
18
Q
- Duchennes muscles issues, cardiac changes - Patients with Duchennes suffer from progressive degeneration of what types of muscle?
A
skeletal, cardiac, and smooth muscle (Lack of the dystrophin protein in muscle cells causes them to be fragile and easily damaged)
19
Q
- Duchennes muscles issues, cardiac changes - _______ __________ occurs in over 50% of patients by 15 years of age.
A
dilated cardiomyopathy
20
Q
- SLE confirmation and pulmonary issues/cardiac issues - What is the best diagnostic test for systemic lupus erythematous?
A
the antinuclear antibody (ANA) test (the ANA is positive in significant titer - usually 1:160 or higher)
21
Q
- SLE confirmation and pulmonary issues/cardiac issues - SLE usually begins with one or several of the following features. (11)
A
-unexplained fever, fatigue, and weight loss -photosensitive rash (butterfly rash on face) -arthritis -raynaud phenomenon -serositis (pleuritis, pericarditis, peritonitis) -nephritis or nephrotic syndrome -neurologic symptoms, such as seizures, psychosis or stroke -alopecia -phlebitis -recurrent miscarriage -anemia
22
Q
- SLE confirmation and pulmonary issues/cardiac issues - Which cardiac problem is relatively common with SLE?
A
pericarditis (side-note: verrucous [Libman-Sacks] endocarditis is usually clinically silent but can produce valvular insufficiency and serve as a source of emboli)
23
Q
- SLE confirmation and pulmonary issues/cardiac issues - Do patients with SLE have an increased or decreased risk of coronary artery disease?
A
increased risk
24
Q
- SLE confirmation and pulmonary issues/cardiac issues - What are often considered the first clues either to lung involvement or to SLE itself? (3)
A
pleurisy, coughing, and/or dyspnea
25
- SLE confirmation and pulmonary issues/cardiac issues - What are some lung issues that can occur in SLE? (6)
pleurisy pleural effusion pneumonitis interstitial lung disease pulmonary HTN alveolar hemorrhage
26
- SLE confirmation and pulmonary issues/cardiac issues - What issues would suggest shrinking lung syndrome? (4)
dyspnea episodic pleuritic chest pain progressive decrease in lung volume in the absence of interstitial fibrosis significant pleural disease
27
- SLE confirmation and pulmonary issues/cardiac issues - Pulmonary function tests are often significantly abnormal prior to complaints of dyspnea. Do they show obstructive or restrictive abnormalities?
restrictive
28
Geriatric, pulmonary: By age 70, your alveolar surface available for gas exchange has decreased by how much?
15%
29
Geriatric, pulmonary: Why does your alveolar surface available for gas exchange decrease by 15% by age 70? (2 reasons)
1. Reduction of elastic tissue 2. Increased collagen
30
Geriatric, pulmonary: What happens to PaO2 when the alveolocapillary membrane thickness increases in elderly patients?
It declines
31
Geriatric, pulmonary: What is the age-based formula for PaO2?
PaO2 = 100-(0.4 age [yrs]) mmHg
32
Geriatric, pulmonary: PaO2 on room air at age 20 is 90 mmHg; what is it in the 80 year old?
~70 mmHg (68, if you use the formula)
33
Geriatric, pulmonary: What are the causes for decreased alveolar compliance? (3)
1. V/Q mismatch 2. Increase in physiologic shunt 3. Decreased efficiency of oxygen exchange
34
Geriatric, pulmonary: Name 4 changes in respiratory functional efficiency in the elderly (think PFTs)
1. Decreased FEV1 & FVC 2. Increased closing volumes 3. 10% decrease in TLC by age 70 4. Diminished CNS response to hypoxia & hypercarbia
35
Geriatric, pulmonary: What are 4 airway changes in the elderly population?
1. diminished laryngeal & pharyngeal responses 2. narrowed airway passages 3. edentulous 4. cervical arthritis/OA
36
Geriatric, pulmonary: What are some of the consequences of having diminished laryngeal & pharyngeal responses?
- Decreased airway clearance (cough & swallowing) - Decreased gag reflex - Predisposition to aspiration
37
Geriatric, pulmonary: What are some of the consequences of having narrowed airway passages?
- More turbulent flow - Increased work of breathing - Difficult ventilation
38
Geriatric, pulmonary: What are some of the consequences of being edentulous?
Poor mask seal --\> difficult mask ventilation Loss of upper airway muscle tone
39
Geriatric, pulmonary: What should you focus on during your preoperative assessment?
- Focused exam & history - Smoking hx - PFT for severe lung disease
40
Geriatric, pulmonary: What are some of the risk factors for postop PNA in the elderly?
Diminished ADLs Weight Loss CVA ETOH use Steroid use Lung disease
41
Geriatric, pulmonary: Name two post-op complications re: the pulmonary system, common in the elderly population
1. Post-op hypoxia (20-60%) 2. Post-op PNA (20-30% mortality)
42
Herbal med side effects: Name all of the herbal meds that can potentially cause increased bleeding
Alfalfa Capsicum Chamomile Dong quai Garlic Ginger Ginkgo Ginseng Guarana Echinacea Fish oil Feverfew Horse chestnut Vitamin E Willow bark ? Glucosamine mnemonic: ALF CAPped CHAMal DOwn, while 5 (possibly 6) G-nomes FEVERishly FISHed . wHORes' Vaginas WILL BARK ECHoes
43
Herbal med side effects: Name all of the herbal meds that cause increased CV stimulation
Ephedra (may also ↑ glucose) Ginseng Goldenseal Licorice Yohimbine Things that make me excited! Ephedra (duh), Gin, Gold, Licorice (yuck), YoHIMbine (that's just an exciting name right there)
44
Herbal med side effects: Name the herbal meds that causes decreased CV stimulation
Black Cohosh ....black hogwosh...depressing to my heart
45
Herbal med side effects: Name all of the herbal meds that cause increased CNS stimulation
Ephedra ↑ Ginseng ↑ Goldenseal ↑ Yohimbine ↑ Feverfew ↑ Gotu kola ↑ Guarana ↑ St John’s Wort ↑ (first 4 - all of my hearts favorite things minus licorice PLUS: fevers, worts, guana & cola) my mnemonics are getting worse...
46
Herbal med side effects: Name all of the herbal meds that cause hepatotoxicity.
Aloe Chapparal Echinacea Germander Kava Kava Liferoot St. John’s Wort SCKAGLE (rock! - like fraggle rock...get it? but scanky? idk)
47
Herbal med side effects Name all the herbal meds that cause hypoglycemia
Alfafa Aloe Argimony Artichoke Chromium Coriander Dandelion root Devil’s claw Eucalyptus Fenugreek Garlic Ginseng Grape seed Hoodia Juniper Onions Periwinkle Yellow root Fuck - you're on your own with this one.
48
RA patient risks: Where can nerve entrapment occur? What is a common peripheral neuropathy in RA?
Nerve entrapment may occur at any site where peripheral nerves pass near the inflamed joint. Carpal tunnel syndrome is a common peripheral neuropathy.
49
RA patient risks: What problem can result from the TMJ synovitis experienced by RA patients?
Synovitis in TMJ occurs in 30-70% of RA patients; as the disease progresses, flexion contractures and soft-tissue swelling may lead to a marked limitation in the patient’s ability to open the jaw
50
RA patient risks: What problems does cervical spine involvement pose?
Cervical involvement may be extensive and can lead to limited movement or deformity of the neck and to severe laryngeal deviation. The most common spine synovitis is C1-C2; C1-C2 instability results from erosion and collapse of bone and from destruction of supporting cervical ligaments; symptoms occur when excessive motion between C1-C2 exerts pressure on the spinal cord. Additionally, separation of the atlanto-odontoid articulation may allow the odontoid process of the axis to impinge on the spinal cord, leading to neurologic damage. When this separation is severe, the odontoid process can protrude into the foramen magnum and exert pressure on the spinal cord or impair blood flow through the verterbral arteries.The atlantoaxial subluxation may also exert pressure and impair blood flow through vertebral arteries
51
RA patient risks: What sx does arthritis of the cricoarytenoid joint of the larynx occur? What will you see on DL? And what problems will it pose?
Occurs in 40% of pts w/severe RA. Sx: larynx tenderness, hoarseness, pain on swallowing w/radiation to ear, dypsnea or stridor, or asx May see red, swollen arytenoids on DL. Obstructs airflow & difficult intubation
52
RA patient risks: What problems will the medications for RA cause?
NSAIDs: platelet dyxfxn, liver/kidney Mild anemia: disease process or drug therapy Corticosteroids: HPA suppression, infection susceptibility
53
Thyroidectomy issues/concerns, monitoring: What are three post-op complications after a thyroidecomty? When do each occur? What are their causes? And how do you treat them?
1. Stridor (immediate) -b/l RLN injury -respiratory depression --\> reintubation 2. Hematoma (early in postop period to 6hrs) -acute bleeding compromising airway -remove sutures, call surgeon 3. Hypoparathyroidism (24hrs post op) -unintentional removal of parathyroid glands -hypocalcemia - check calcium levels -s/s: neuromusc excitability, circumoral tingling, tetany, ventricular arrythmias, laryngospasm
54
Thyroidectomy issues/concerns, monitoring: What are some issues you should assess during preop in the hyperthyroid patient undergoing thyroidectomy?
Is patient euthyroid? If goiter present: inquire about duration (tracheomalacia) Positional dyspnea or stridor (CT to eval deviation or compression) Examine neck for tracheal deviation SVC obstruction (distended neck veins that don't change w/respiration) Neck ROM
55
Thyroidectomy issues/concerns, monitoring: What are some intraoperative issues/concerns for a thyroidectomy?
-Monitor CV fxn & temp -Protect eyes -Avoid SNS stimulating meds (Ketamine, ephedrine) -Chronic hypovolemia --\> exaggerated hypoTN w/induction -Get adeq anes depth before DL/incision -NMB w/caution (increased incidence of myopathies & MG)
56
Thyroidectomy issues/concerns, monitoring: Describe thyroid storm (crisis): symptoms onset how it's different than MH in presentation treatment
Severe hypermetabolism Sx: altered LOC, hyperpyrexia, tachycardia, HTN or hTN Onset: 6-24 hr postop but may occur intraop MH-like sx but NO acidosis, muscle rigidity, elevated CK Tx: hydration & cooling; esmolol gtt for HR control, propylthiouracil 250-500 mg Q6H, correct underlying cause
57
Thyroidectomy issues/concerns, monitoring: What are the s/s of tracheomalacia?
stridor, hoarseness, sore throat, feeling of pressure in neck, coughing, dysphagia, dyspnea May need require prolonged intubation or trach Absence of leak around deflated cuff = alert you to possibility of tracheomalacia
58
Thyroidectomy issues/concerns, monitoring: Describe the use of a NIM tube for this procedure
NIM tube has 4 stainless steel wire electrodes (2 pairs) embedded in silicone shaft with short part exposed above cuff. Designed to make contact w/vocal cords for EMG monitoring of RLN. Should show consistent sound signal and action potential tracing. • Red wires for anterior & posterior portions of RIGHT true vocal cords • Blue for anterior & posterior portions of LEFT true vocal cords
59
Pheochromocytoma: What are the 2 portions of the adrenal gland?
Medulla & Cortex
60
Pheochromocytoma: What does the medulla secrete?
Catecholamines: -epi -NE -dopamine
61
Pheochromocytoma: What are the different zones of the cortex? What do they each produce/secrete?
Zona Glomerulosa: Aldosterone Zona Fasiculata: Cortisol (glucocorticoids/mineralocorticoids) Zona Reticularis: Testosterone (androgens), estrogens Valley Review: Remember (GFR-ACT) G - A F - C R - T
62
Pheochromocytoma: What is a pheochromocytoma?
tumor of the chromaffin cells secreting NE, epi, or dopamine
63
Pheochromocytoma: What is the classic triad of pheo?
Headache, sweating, tachycardia w/HTN (HTN = most frequent manifestation)
64
Pheochromocytoma: Why is orthostatic hypotension common?
D/t hypovolemia and impaired venous/arterial vasoconstrictor reflex response
65
Pheochromocytoma: Why must a pheo patient undergo alpha-blockade before beta-blockade?
bc blockade of vasodilatory peripheral beta receptors w/unopposed alpha receptor stimulation can lead to further elevation in BP
66
Pheochromocytoma: Roughly when should alpha and beta blockade be initiated.
10-14 days preop and 2-3 days preop, respectively
67
Pheochromocytoma: Why are patients alpha blocked?
To normalize BP and expand contracted blood volume Also: prevents paroxysmal hypertensive episodes, allows resensitization of adrenergic receptors, and decreases myocardial dysfunction. Alpha-blockade appears to protect myocardial performance and tissue oxygenation from adverse catecholamine effects
68
Pheochromocytoma: When is it recommended to stop alpha blockers and why?
Recommended to stop alpha blockers 24-48 hrs before surgery to avoid vascular unresponsiveness immediately following removal of the tumor; some say give a half dose morning of surgery
69
Pheochromocytoma: What kind of drugs should you avoid in these patients?
Avoid drugs that promote catecholamine release or potentiate catecholamine reactions -histamine releasing drugs: morphine, atracurium -vagolytic or sympathomimetic drugs (sux, atropine, pancuronium)
70
Pheochromocytoma: What should you anticipate once the tumor's blood supply is ligated?
Prepare for sudden decrease in BP after the tumor’s blood supply is ligated: -Volume support -Direct-acting vasopressor, i.e., Phenylephrine
71
Pheochromocytoma: What are the postoperative concerns?
Hypotension = most frequent cause of death in immediate postop period -Vasopressors, IV fluids Hypoglycemia: -Dextrose containing IV fluids -Monitor blood glucose for 24 hrs ICU for 24 hrs: Adequate pain control
72
Pheochromocytoma: What are some of the meds you would expect to have ready or will possibly use intraoperatively to maintain the patient's hemodynamics WNL?
Nipride, Magnesium, Nicardipine, Phentolamine, Esmolol
73
What can occur with long term steroid use?
Corticosteroid withdrawal Use of high-dose steroids for more than a week begins to produce suppression of the patient's adrenal glands because the exogenous glucocorticoids suppress hypothalamic corticotropin-releasing hormone (CRH) and pituitary adrenocorticotropic hormone (ACTH). With prolonged suppression, the adrenal glands atrophy (physically shrink), and can take months to recover full function after discontinuation of the exogenous glucocorticoid. During this recovery time, the patient is vulnerable to adrenal insufficiency during times of stress, such as illness.
74
What is pancreatitis and how does the pancreatic damage occur?
Inflammation of the pancreas. Pancreatic damage occurs when digestive enzymes are activated before they are secreted into the duodenum and begin attacking the pancreas.
75
What are the 2 types of pancreatitis?
Chronic: irreversible Acute: gland can return to normal if the underlying cause is removed
76
What is acute necrotizing pancreatitis?
Severe form of AP where necrosis and subsequent infection result. Inflammation leads to necrosis. Necrotic debris becomes infected, usually by gram-negative organisms from the alimentary tract. The acinar and ductal tissues and the Islets of Langerhans become infected. Vascular injury leads to massive hemorrhage within the pancreas.
77
What is the pathophysiology of acute pancreatitis?
Injury or disruption of pancreatic acinar cells permits leakage of pancreatic enzymes. Activated proteolases and lipases break down tissue and cell membranes causing inflammation, edema, vascular damage, hemorrhage, necrosis, and fibrosis.
78
What are the s/s of acute pancreatitis?
mid-epigastric pain that radiates to the back, n/v, fever, leukocytosis, hypermotility or paralytic ileus, abdominal distention/ascites, tetany (hypocalcemia) hypovolemia, shock, tachypnea, hypoxemia (atelectasis, pulmonary edema, effusions).
79
What is the diagnostic hallmark of acute pancreatitis?
Elevated serum amylase level
80
What is the goal of treatment and interventions for acute pancreatitis?
Goal: to stop process of autodigestion & prevent systemic complications. - Aggressive fluid administration: XL and colloid - Demerol instead of Morphine (\< Sphincter of Oddi spasm) - Bowel rest: NG sxn, NPO - TPN - H2 blockers - Stone removal - Antibiotics if necrotizing - Surgery: ERCP, surgical debridement
81
What are the causes of acute pancreatitis?
GET SMASHED. Gallstones; Ethanol; Trauma; Steroids; Mumps; Autoimmune; Scorpion sting; Hypercalcaemia, hypertriglyceridaemia, hypothermia;
82
What are the causes of chronic pancreatitis?
Irreversible pancreatic damage caused by: -Chronic alcohol abuse -Obstruction from gallstones -Autoimmune disease -Genetic mutations -Smoking -Obesity
83
What is the pathophysiology of chronic pancreatitis?
toxic metabolites and chronic release of inflammatory cytokines contribute to the destruction of acinar cells and islets of Langerhans. Fibrosis, strictures, calcification, ductal obstruction, and pancreatic cysts result.
84
What are the s/s of chronic pancreatitis?
continuous or intermittent abdominal pain, weight loss, steatorrhea, DM.
85
What is the goal of treatment and interventions of chronic pancreatitis?
Prevent disease progression: -Lifestyle modification (abstain from smoking & drinking) -Fat-free diet -Enzyme replacement -Surgical drainage or partial resection
86
What are the anesthetic implications of pancreatitis in general?
Aspiration precautions, consider RSI Glucose monitoring Fluid and electrolyte disturbances Blood product administration Fluid resuscitation Coags Renal function (maintain UOP \>0.5ml/kg/hr) Pulmonary assessment (CXR, ABG)
87
What is hypothyroidism?
Inadequate secretion of thyroid hormone caused by: autoimmune disease (Hashimoto’s thyroiditis), thyroidectomy, radioactive iodine, antithyroid medications, iodine deficiency.
88
What are the s/s of hypothyroidism?
weight gain, cold intolerance, muscle fatigue, lethargy, constipation, hypoactive reflexes, dull facial expression, depression, decreased CO, SV, HR, myocardial contractility. Pleural, abdominal, and pericardial effusions are common.
89
How does myxedema coma occur?
Results from extreme hypothyroidism: impaired mentation, hypoventilation, hypothermia, CHF.
90
Pulmonary agent Phosgene, diphosgene, chloropicrin & chlorine treatment
Steroids, antibiotics for pulmonary infection, theophylline and bronchodilators (albuterol) Latent period of 2-24 hours from initial exposure to possible pulmonary edema depending on exposure
91
Cyanide Agents Hydrogen cyanide and cyanogen chloride treatment
Mild: support circulation w/ crystalloids & vasopressors, correct m.acidosis w/ HCO3, benzo Sig: Na nitrate or amyl nitrate IV ( induces methemoglobin freeing up the Hgb from cyanide. Sodium thiosulfate is given to convert cyanide to thiocyanate (nontoxic)
92
Incapacitating agents BZ & Agent 15 treatment
Cholinesterase inhibitors. Tx hyperthermia and prevent injury from erratic behavior.
93
Vesicant Agents Mustard Gas, Lewisite, Phosgene Oxime treatment
Tx erythema w/ calamine, blisters \<2cm leave alone. Irrigate lg blisters w/ sterile solution & cover w/ antibiotics. P irrigation of eyes, use anticholinergic eye drops w/ topical antibiotic.
94
Nerve Agents Sarin, Tabun, Soman, GF, VX treatment
Initial tx: remove clothing and wash skin . Atropine: comp antagonist @ muscarinic receptor & can blk stim both centrally & peripherally. 1-2 mg IV or up to 6 mg then 2 mg Q5-10 min until secretions have dissipated. Def tx: Pralidoxine cl interferes w/ covalent bond fromed by the NA & ach-esterase aka aging. Oximes wk by removing orangophosphoryl f(x)al group of the NA from ach-esterase= enzyme to regenerate.
95
-Cocaine Abuse and anesthesia- How does cocaine work?
Inhibits presynaptic uptake of sympathomimetic neurotransmitters (e.g. NE, serotonin and dopamine) Produces a powerful euphoria (lasting 5-30 min) as a result of free catecholamines stimulating the sympathoadrenal axis and the prolongation of dopaminergic activity in the limbic system and adrenal cortex
96
-Cocaine Abuse and anesthesia- what does it do to the blood flow?
Blood flow to arteries in areas like the heart and brain may be compromised as these vessels vasoconstrict or vasospasm temporarily, severely compromising oxygenation and supply; this may lead to irreversible brain damage, stroke and myocardial infarction or depression
97
-Cocaine Abuse and anesthesia- what does it do to the heart?
depressed ventricular function and slow electrical conduction. Can cause contract band necrosis and ventricular hypertrophy Rare: Aortic dissection, d/t severe and abrupt catecholamine release and HTN MI and Vent arrhythmia
98
-Cocaine Abuse and anesthesia- what does it do to the lungs?
ranges from asthma -\> pulm hemorrhage
99
-Cocaine Abuse and anesthesia- Misc side effects
infection or perforation of the nasal septum, anxiety, restlessness, irritability, confusion, papillary dilatation, seizures, tachycardia, peripheral blood vessel constriction
100
-Cocaine Abuse and anesthesia- Regional considerations Can induce \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, which is the result of platelet activation due to _________ \_\_\_\_\_\_\_\_\_\_ or part of the ___________ \_\_\_\_\_\_\_\_\_\_.
Cocaine-induced thrombocytopenia can occur, possibly the result of platelet activation due to arterial vasospasm or part of the autoimmune response
101
-Cocaine Abuse and anesthesia- Regional considerations HTN can result d/t what?
peripheral vasoconstriction
102
-Cocaine Abuse and anesthesia- Regional considerations If hypotension occurs what can happen?
Hypotension may occur, which may lead to cardiac dysrhythmias or myocardial dysfunction
103
-Cocaine Abuse and anesthesia- Regional considerations How do you treat hypotension in the coke head?
Ephedrine-resistant hypotension may be encountered – low doses of phenylephrine can usually restore BP
104
-Cocaine Abuse and anesthesia- Regional considerations
Why do these patients have altered pain perception?
Patients may show combative behavior and altered pain perception, perhaps due to changes in m- and k-opioid receptor densities and abnormal endorphin levels
105
-Parkinsons and Medications-
Levodopa..... Do you continue it? Why or why not?
What if your pt gets hypotensive from your descicion to stop levodopa?
The elimination half-time of levodopa and the dopamine it produces is brief, so interruption of drug therapy for more than 6 to 12 hours can result in an abrupt loss of therapeutic effects.
**Abrupt drug withdrawal can also lead to skeletal muscle rigidity, which can interfere with ventilation.**
Therefore, levodopa therapy, including the usual morning dose on the day of surgery, must be continued throughout the perioperative period.
Oral levodopa can be administered approximately 20 minutes before induction of anesthesia, and the dose may be repeated intraoperatively and postoperatively via an orogastric or nasogastric tube as needed
**The possibility of hypotension and cardiac dysrhythmias must be considered, and butyrophenones (e.g., droperidol, haloperidol) must be available to antagonize the effects of dopamine in the basal ganglia. **
106
-Parkinsons and Medications-
What may happen when you give alfentanil?
Acute dystonic reactions following administration of alfentanil might indicate an opioid-induced decrease in central dopaminergic transmission
107
-Parkinsons and Medications-
Ketamine or not to ketamine.....
or as josh says... ketaFUCKINmine
The use of ketamine is controversial because of the possible provocation of exaggerated sympathetic nervous system responses, but ketamine has been administered safely to patients treated with levodopa.
108
-Parkinsons and Medications-
Complications of muscle relaxant
The choice of a muscle relaxant is not influenced by the presence of Parkinson's disease.
109
-Parkinsons and Medications-
What is Neurolepic Malignant Syndrome? (NMS)
NMS is characterized by autonomic instability, altered mental status, rigidity, and fever.
Cn occur with abrupt stoppage of levodopa
110
-Parkinsons and Medications-
Unless the patient is having cardiac dysrhythmias or hypotension, why avoid Droperidol
Haloperidol?
Antagonize the effects of dopamine in the basal ganglia.
Remember parkinson pts have a loss of dopamine-secreting neurons, and the inequality of dopamine and acetylcholine are what cause the s/s. If the pt is hypotensive, and you antagonize the dopamine the acetylcholine can excite the brain/ body to increase the BP. (thats my understanding of this shit)
111
-Parkinsons and Medications-
Synthetic dopamine agonists
Act directly on the postsynaptic dopamine receptors. Side effects from these drugs include visual and auditory hallucinations, hypotension and dyskinesia
112
-Parkinsons and Medications-
Anticholinergic treatment
Blunt the effects of excitatory neurotransmitters acetylcholine, thus correcting the balance between dopamine and acetylcholine. Helps with tremor and salvation control, *but does not effect skeletal muscle rigidity and bradykinesia*
113
-Common Nosocomial Infections-
Can you name all 15 bugs?
1. Acinetobacter
2. Burkholderia cepacia
3. Clostridium difficile
4. Clostridium sordelli
5. Enterobacteriaceae
6. HIV
7. Influenza
8. Klebsiella
9. MRSA
10. Mycobacterium abscessus
11. Norovirus
12. Pseudomonas aeruginosa
13. Staphylococcus aureus
14. Tuberculosis
15. VRE
114
-Common Nosocomial Infections-
What 4 medical equipment/ surgical sites relationship of infection do we care about?
Related to medical devices:
1. Central Line-Associated Blood Stream Infections (CLABSI)
2. Ventilator-Associated Pneumonia (VAP)
3. Catheter-Associated Urinary Tract Infections (CAUTI)
Related to surgical site:
1. Surgical Site Infections (SSI)
115
-Common Nosocomial Infections-
Organisms found on the anesthesia equipment
(A. Streptococcus, Acinetobacter, Staphylococcus aureas, and gram-negative rods)
116
-Sepsis and Flotrac-
this is just a nice flochart to decide what you may need for anesthesia
117
-Sepsis and Flotrac-
Vigileo (aka flotrac) (SVV & SVI)
For use on control ventilated patients
Variation in arterial pulsations caused by volume changes during positive pressure inspiration
\>15% may indicate hypovolemia
118
-Sepsis and Flotrac-
uno mas pictura
119
-Sepsis and Flotrac-
Just another good chart from last year.
120
-Refractory Hypotension-
Sepsis version.....
Sepsis with refractory hypotension despite fluid administration. Septic Shock
**refractory hTN defined as SBP \< 90 mm Hg or MAP \< 60 mm Hg (or drop of ≥ 40 mm Hg from baseline)**
Later, septic shock, is marked by a decline in peripheral vascular resistance and an increase in cardiac output in response to the fall in PVR. This response is the body’s mechanism to maintain adequate perfusion, despite the presence of myocardial depressant activity exerted by TNF-alpha, PAF, IFN-gamma, arachidonic acid metabolites and other endogenous factors. Their effect may decrease ejection fraction to as little as 20%
121
-Refractory Hypotension-
Renal version
Blocking action of angiotension II, a powerful vasoconstrictor
Blocks release of aldosterone and ADH (endogenous vasopressin)
Give fluids: crystalloid or colloid
Vasopressin??
122
-Immune Response-
Anaphylaxis
type 1 hypersensitivity
involves B cells, mast cells and basophils, rhinitis to anaphylaxis
IgE is activated. Systemic reaction. Causes a massive histamine release.
123
-Immune Response-
Trauma
alright.... in his presentation (i watched it AGAIN), all it says is trauma reduces your immunity. But it rebounds.... It maybe related to the triad (Hemodilution, hypothermia and acidosis) just a stab in the dark, stab stab stab
