System Review

Question 1

preeclampsia

Answer 1

neuro: AMS, H/A, visual, cerebral edema, seziure, intracranial hemorrage #1 cause death
cardiac: HTN, elevated SVR, hypovolemia
pulm: airway edema, pulm edema (increase PCWP, decreased CO, excess fluid admin)-low colloid oncotic pressure and increase vascular perm predipose

GI: capsule distention, hemorrage, rupture, HELLP

renal: oliguria (decrease GFR), proteinuria from increase glomerular perm
heme: plt activation <100K, hypocoag, increased fibrinolysis
fetal: IUGR, decreased uteroplacnetal perfusion (placental infarcts), premature, abruption

Question 2

Pregnancy for non-OB surgery

Answer 2

Neuro: decreased MAC and increased sensitivity to LA

cards: aortocaval compression predisposing to hypotension
pulm: difficult airway, low FRC predisposing to desaturation

GI: aspiration risk

Fetal: teratogencity (postnatal changes function or form, weeks 1-6), spontaneous abortion, premature labor, fetal mortality

Heme: thromboembolism

Question 3

Evaluate the nature of cardiac dz

Answer 3

1. FocusedHistory: -known diagnosis, past evaluations/hospitalizations, tests, meds/compliance
   - cardiac sx (past and current): exercise tolerance, CP, SOB, syncope, orrthopnea, palpitations
2. PE: signs for HF -Rhythm, murmurs, S3 gallop, crackles, edema, JVD
   3: Labs: CXR EKG, echo

Question 4

HTN consideration head to toe

perioperative risks,

preop assessment

potential causes

Answer 4

Head to toe

neuro: shift in cerebral autoregulation, stroke, retinopathy
cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys)
renal: overactivity of renin angiotensin-aldosterone system

concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction

Preop:

History:

• cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, pheo, thyroid/parathyroid),
• degree of control, baseline, meds
• end organ effects

PE: signs CHF

Labs: BUN/Cr-renal involement, NA K diruetic effects

EKG for LVH, arrythmia, ischemia, strain

CXR: cardiomegaly, pulm edema

Goal: keep BP within 20% of baseline

Question 5

Concerns for a aneursym repair

Answer 5

Anesthesia

Difficult airway-

compression (airway compression, SVC syndrome edma), DLT

Cross clamp

neuro

Paraplegia- Loss sensory and motor with intact vibration and proprioception (ASA syndrome); epidural hematoma if neuraxial performed

Stroke: emboli, hypotension

CV

Aneurysm: rupture, thrombosis, compression (SVC, AI MI, CHF

Pulm

Post op pulmonary dysfxn from manipulation of diaphragm and lungs

Damage to phrenic or RLN

Heme

Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC

dilution effects of massive transfusion,

Renal

Post op AKI

Question 6

hypotension…what do you do

Answer 6

1. 100% oxygen
2. confirm adequate ventilation and oxygenation (PTX, broncospasm, anaphlaxisis)
3. evaluate monitors
   - EKG: look for ischemia, hyperK, hypoCa, and arrythmia
   - PIP, PEEP, MV, capnography (broncospasm, anaphalaxsis)
4. treat with fluids blood pressors PRN
5. more access/monitors
6. continue to eval cause

Question 7

obesity

Answer 7

o Anesthesia: difficult airway management, patient positioning, altered drug effects (sensitivity), sensitivity to anesthetics, BP cuff

neuro: stroke, obesity hypoventilation syndrome,

CV: difficulty eval cardipulm status 2/2 sedentary lifestyle, HTN, CAD, phtn,

Pulm: rapid desat w apnea (decreased FRC, high v02), OSA/pickwickian, post op apnea, restrictive lung dz, pHTN

GI: nonalcoholic fatty liver, GERD w abdomen pushing belly up, delayed gastric emptying

Endocrine: DM o

Heme: DVT/PE, wound infection

Question 8

Types of apnea

apnea

hypoapnea

obesity hyoventilation syndrome

Answer 8

1. apnea cessation airflow >10 sec w >4% drop sat, >5 per hr
2. hypoapnea >50% cessation in airflow, >4% drop sat, >15/ hr
3. OHS 2/2 obesity/OSA: BMI>30, daytime arterial hypercapnea >45 nocternal hypoxia, polycythemia
4. Pickwickian: severe form OHS chronic hypovent –>pulm HTN and RVF

Question 9

hypothermia

Answer 9

neuro: AMS, delayed awaking

Cardiac;: myocardial depression, vasoconstriction (increased epi/NE levels), shivering (increased O2 consumption,increased PVR

Heme: left shift of hgb-O2 dissociation curve, plt dysfunction, poor wound healing/infection

other: decreased drug metabolism

Question 10

burns

Answer 10

Anesthesia:increase free fraction opioid benzos, 25-30% burns resistance to NDMB at 72 hr, increased binding to alpha 1 glycoprotein, increased fetal Ach R (resistant to NDM

Neuro: head injury

Cards: hypovolemic-leaky capillaries (Parkland)

pulm: inhalational injury–>VQ mismatch, CO posioning (cooximetry) edema

GI: curling ulcer, aspiration risk

Heme: infectionsepsis/ disrupted skin barrier

Question 11

Machine check

Answer 11

1. check for emergeny ventilation equiptment: ambu suction
2. check high pressure system: cylinders (1/2 full: 1000PSIG) and pipeline pressures (50-55 PSIG)
3. check low pressure system: (vaporizers filled and caps tight, flowmeters cant deliver hypoxic mixture and tested through full range, negative pressure test (bulb to common gas outlet >10 sec)
4. check scaavangeing: connection of APL to scavaneging system, NPRV: apl open and O2 flow low should collapse and gausge read 0, PPRV: APL open and and flush O2, bag should distent and read no more than 10 cm H20
5. check breathign system: calibrate O2 monitor to RA and 100% oxyegn, inspect ciruit and CO2 absorber, Postive pressure leak test circuit (>30 10 seconds)
6. check bmanual and automated breathign system: place bag on Y piece and set paremeters for pt, check this under manual and automated ventilation
7. monitors
8. machine final position: APL open, vaporizer off, flow off, manual vent selected

Question 12

Liver disease

Answer 12

o Neuro: 1. Wernicke encephalopathy (ETOH thiamine def) 2. hepatic encephalopathy (production ammonia by intestinal bacteria)

o Pulm: 1. ascites decrease FRC 2. portopulmonary HTN 3. HPS

o GI; increased risk aspiration

o Renal: hepatorenal syndrome

o Heme: 1. SBP 2. plt dysfunction 3. coagulopathy

Question 13

cirrhosis

Answer 13

heapatic necrosis, fibrosis, and nodal regeneration/ leading to portal HTN >10mmHg. causes ETOH, hepatitis, toxins

Anesthesia:

1) paralysis: may need more larger initial dose due to larger VD, decreaed proetin binding larger free fraction may off set this, and impaired metabolism few doses may be needed
2) citrate intoxication more likely w blood
3) psueocholinesterase def

Neuro: encephalopathy AMS, asterxisis, hyperreflexa, wernicke korsakoff (more permeable BBB, ammonia broken down from blood in GI tract or transfusion)

Cards: hyperdynmaic state =high mixed venous(increased CO, low SVR, anemia, systemic shunts), systemic AV shunts

resp: decreased FRC and restrictive dz from ascites, increased AV shunts, plerual effusions, inhibition of HPV (from vasodilating substances - VIP, glucagon)–>hypoxemia, resp alkalosis

GI: Portal HTN

ascities (2/2 portal HTN, hypoalbumin, renal rentention of fluids)

varices/hemorrhids,

aspiration risk, delayed gastric emptying

renal: decrease renal perfusion, sodium retentiom. (increase in total body andvolume but decrease in effective volume, HRS (prerenal oliguria w NA retention, azotemia, and ascites

Heme: thrombocytopenia (splenic sequestration), anemia (bleeding, RBC destruction, malnutritio) SBP

Electrolytes: hyponatremia (dilutional), hypokalemia (diuresis or hyperaldosteronism), hypoalbumin, hypoglycemia

Question 14

esophageal cancer

Answer 14

cardio: often after ETOH and smoker, high risk post op a fib
pulm: smokers often, chronic aspiration–>pulm fibrosis,

GI: nutrional status poor (increased MM), liver fxn, aspiration risk (obstruction, altered motility and spincter dysfunction

chemo: doxorubicin (cardiomyopathy, belomycin lung, radiation (pnumonitis, pericarditis

Question 15

chronic alcoholic

Answer 15

Anesthesia: intoxiciation effect on MAC

neuro: AMS, encephalopathy, wernicke korsaoff (ataxia, confusion, occular issues; tx thiamine), withdrawl (sezizures DT)
cards: acute HTN tachy; cardiomyopathy, arrythmia
resp: smoker?
gi: ulcer, cirrhosis, aspiration risk
heme: pancytopenia

Question 16

RA

Answer 16

CV: pericardial thickening/pericarditis//effusion, myocarditis/fibrosis, vasculitis, AR, CAD from steriods, conduction defects, vasculitis

pulm: pleural effusion, pulm nodules, pulm fibrosis

Heme: anemia, Aspirin induced plt dysfxn, thrombocytopenia,

endocrine: adrenal insufficiency (chronic steriod use), immunesuppression from steriods and antiinflammatory meds

Joint involvement/difficult intubation: cervical spine (alantoaxial subluxation, >5mm alanto odontoid distance), TMJ, cricoarytenoid joint (hoarse voice, small ETT)= difficult intubation

liver and kidney dysfunction

Question 17

Ankylosing spondylosis

Answer 17

neuro: nerve root compression, cauda equina syndrome, uvetitis, parathesia, high block 2/2 smaller epidural space, c spine/TMJ involvement
cards: AI, condution defects,
resp: restrictive lung dz, impossible trach if stuck in neck flexion, difficult airway
gi: UC, crohns

Question 18

SS head to toe

Answer 18

CNS: cerebral thrombosis, painful/vasoocclusive crises, deficits from stoke/seizures

Cardiac: CHFfrom chronic hypoxia, hemochromatosis, MI,

pulm: increased intrapulm shunting, ACS

GI: nonconjugated hyper bili from hemolysis, bile cholelithaisis,

renal: meduallary infarcts leading to isothenuria

Heme: splenic infarcts, aspetic necrosis, osteo, infection (asplenic), aplastic anemia(Parovovirus/folate decreased rbc production+ reduced life span (20 vs 120 days)–>profound anemia), transfusion, anemia

Endocrine: hemachromatosis-DI, hepatomegaly, adrenal insufficiency, hypothyroidism, hypopara

Question 19

risks factors for aspiration

Answer 19

delayed gastric emptying: autonomic neuopathy, acute abdomen, pain, cirrhosis, chronic alcohol abuse,

pregnancy

bowel obstruction

GERD

Question 20

DM

Answer 20

Neuro: peripheral neuropathy, retiniopathy

Cards: autonomic neuropathy: silent MI, resting tachycardia, lack HR varibility w respirations, orthostasis, insensitivity to atropine and propranolol, lack HR response to hypovolemia, impaired vasoconstriction (susceptible to hypothermia), lack sweating, impotence

CAD, HTN, cardiomyopathy, PVD, MI

Resp: difficult intubation stiff join syndrome (TMJ, AO, cervical spine-prayer sign)

GI: gastroparesis (early satiety)

renal: nephropathy
endocrine: hyper/hypoglycemia, DKA, NKHC

Heme: impaired phagocytosis

Question 21

stridor after thyroidectomy

Answer 21

Post extubation airway obstruction/ stridor

Hematoma

Edema

Post intubation croup

Tracheolamacia

laryngospasmm

RLN injury-partial hoarseness, complete-aphonia, aspiration risk b/l partial laryngeal obstruction (abduction of VC)

Hypocalcemia removal of parathyroid 1-3 days later

Residual paralysis (MG common in hyperthyroid pts)

Question 22

ESRD

Answer 22

Anesthesia:

decreased protein binding–>enhanced drug effect: barbs and benzo, etomidate:

active metabolites dependent on renal excretion: keta,ine, morphine, meperidine,

increased BBB permeability and uremic toxins, effects anesthetics may be enhanced

neuro: urremic encephalopathy, peripheral/autonomic neuropathy,

cards: accelerated CAD, fluid overload, CHF, HTN, pericarditis, arrythmias, autonomic neuropathy, conduction blockade
resp: pulm edema, pleural effusion

GI: delayed gastric empyting; bleeding,

endocrine:

• hyper: K, mAg, Po4, uric acid
  hypo: na ca, hypoalbumin,

met acidosis

heme: anemia (low EPO), plt and WBC dysfunction

endocrine; insulin resistance, 2 hyperparathyroidism , high TG

Question 23

delayed emergence

Answer 23

ABCs: hypoxia, hypercarbia, hypotensions

Drugs: opioids, paralysis, benzos

Metabolic: hypoglycemia, hyponatremia, hypermagnesium (OB), hyperosmolarity

Neurologic: stroke (embolic, thrombotic, ischemic), postictal, ongoing ischemia (ICP, vasospasm, herniation) hematoma, edema tension pneumocephalus, hydrocephalus

other: hypothermia

Question 24

How to manage ICP

Answer 24

Eval ABCs and etiology: avoid hypoxia and hypercarbia

Increase venous drainage

elevate head 15-20 degrees if hemodynamically

ensure no venous obstruction (esp if C collar in place)

diureticsadmin mannitol: (reduces ICP by osmotically shifting fluid from brain to intravascular space, decrease production CSF, induce reflex cerebral vasoconstriction 2/2 decreasing blood viscosity(lasts 6 hr)

risktransient increase intravascular volume can increase BP & decrease ICP (increase transmural pressure): hazard to unrupture aneurysm, AVM, expanding hematoma (mod elevated ICP can serve to tamponade the lesions

elderly: rapid diuresis shrink brain and tear bridging veinssubdural hematoma

increase vascular volume poorly tolerated by HF

cerebal edema if BBB not intact

furosemide

keep in mind that in presence of hypovolemia this an lead to hypotension and worsen cerebral ischemia

hypertonic saline

admin barbiturate/propofol (reduced ICP 2/2 cerebral vasoconstriction) and CMR02

risk of hypotension when admin large doses for cerebral protection

hyperventilation to PaC02 25-30 if other methods unsuccessful and ICP elevation was so severe that there was risk of brain stem herniation

too much cerebral vasoconstriction can leadto cerebral injury

effects temporary (6-12 hrs) since Hc02 levels in CSF are adjusted for the change in PaC02

between Pac02 20-80 CBF changes 1ml/100g per 1mmHg change PaC02

If ICP severe requires immediate tx: intraventricular drainremove CSF (no more than 5cc/min).

Too much can cause brainstem herniationHTN/hypotension/bradycardia/tacycardia

if lumbar catheter can cause herniation if obstructive hydrocephalus (obstruction proximal to superior sagittal sinus

steroids if brain tumor for vasogenic edema, decrease CSF production?

if at risk for seizures implement seizure ppx to avoid increases CMR02

change agent (volatile to TIVA)

Question 25

muscular dystrophy

Answer 25

Anesthesia: rhabdo to succ/volatiles, sensitive to resp depressants cards: EKG ab (tachycardia, tall R waves in V1, Q waves in limb leads, inverted T waves), cardiomyopathy, arrthymias, MR resp: ineffective cough/dimished airway refexes (aspiration, infections), macroglossia, GI; delayed gastric emptying

Question 26

Loss of neuromonitoring signals

Answer 26

- alert surgeon - ensure not change in dept of anesthesia (prop, volatile, relaxant) - correct hypoxia, ensure normocarbia, correct hypovolemia, hypotension, anemia, to optimize oxygen delivery - surgical causes- excessive distration - perform wake up test

Question 27

Complications of tumescent lipo max limit lido limit LAST

Answer 27

fluid overload pulm edema, LAST, DVT 35-55 mg/kg 1:1,000,000 epi dilute solution, add epi, limitsurgery to 3L of fat removal, lipid rescue kit IV fluids+ tumscuent solution-UOP givelasix after 2L

Question 28

hypothyroid tx

Answer 28

Hashimoto’s thyroiditis anesthesia: do not give volatiles (myocardial depression), consder ketamine Neuro: AMS, slow reflexes, myxedema coma, hypothermia cards: CHF, pericardial effusion, blunted baroR reflexes, bradycardia (downregulation of Beta R), increased SVR (decreased PP), decreased intravascular volume resp: drug induced resp depression, large tongue intubation, limapired hypoxia and hypercarbia drive, pleural effusion, OSA GI: delayed gastric emptying renal: decreased intravascular volume-leaky capillaries Heme: anaemia, coagulopathy Endocrine: adrenal insufficiency, electrolytes: low Na(increased ADH, impaired renal concentration ability), low glucose myxedema coma: altered mental status, (coma or seizure), hypothermia, bradycardia, hyponatremia, heart failure, hypopnea IV levothyroxine steriods if think adrenal insufficiency

Question 29

MG

Answer 29

Pathophysiology: destruction nicotinic acetylcholine R at post synaptic memebrane Sx: bulbar weakness (diplopia, ptosis, difficulty with speech and swallow, dyspnea), muscle weakness with exertion, thyoma cardiac: HTN, AV block, a fib, myocarditis, cardiomyopathy, dystolic dysfunction endocrine: hyperthyroid, RA, pernicious anemia, SLE, thyoma neonate weakness 2-4 weeks

Question 30

hyperthyroidism

Answer 30

Lab: TSH (low), Free T4 and T3 (high) Neuro: anxiety, agitation, tremors, insomnia, muscle weakness, sweating/heat intolerance, weightloss, fever cards: tachycardia, HTN (increased SV and CO), decreased SVR (increased PP) arrythmia (afib), cardiomegaly, hypovolemia GI: dirrhea renal: activation RAAS arrythmia, hyperdynamic circ, risk hemodynamic instability not able to render euthyroid prior to surgery,no tx: iodide, steriods (decrease peripheral conversion, BB, cholestyramine)

Question 31

canceling for a cold

Answer 31

perioperative respiratory complications: bbroncospasm, larngospasm, desaturation - delay 4-6 weeks if fever \>38.5, malise, productive cough, mucopurulent sputum, pulm involement (wheezing) - mild sx delay 2-4 weeks: sneezing nasal congestion, nonproductive cough +require ETT + additional RF (exposure to smoke, underlying pulm dz (asthma), surgery of airway, age \< 1 year /premature - proceed if mild sx and do no require ETT (mask, LMA, regional)

Question 32

tx for MH

Answer 32

- call for help.ICU 72 hrs - admin drantrolene 2.5g/kg q5-10 min, infusion 1mg/kg q6h for 24-48 hrs - hyperventilate pt w 100% - active cooling: lavage-gastric bladder rectal, peritoneal lavage, CBP, ice packs over major arteries - maintain UOP w lasix fluids, mannitol - monitor K (dextrose insulin) calcium, ABG (acidosis-bicarb), serum CK, liver enzymes, coagulation - monitor for DIC, myoglobinuric renal failure (ATN, obstructive nephropathy), recrudenscence

Question 33

Risks of prematurity

Answer 33

Neuro: IVH, hypothermia, retinopathy of prematurity Resp: post op apnea, RDS, PPHN GI: NEC, impaired liver fxn Renal: imapired renal fxn Endocrine: hypoglycemia (poor glycogen stores) Heme: anemia (transfuse 40-45 if severe cardiopul dz, 30-35 moderate, normal 20-25)

Question 34

Downs

Answer 34

Features Neuro: alanto axial instability: subluxation, Cardiac: bradycardia w/ sevo, 50% endocardial cushion defects (defects involving atrial, ventricular septum, and 1 or both AV valves), VSD, ASD, PDA, TOF Pulm: marcroglossia, micrognathia, subglottic stensosis, hypotonia and redundancy soft tissue, osa gi: duodenal atresia

Question 35

When to get Echo

Answer 35

There is no Class 1 recommendation, all 2a reasonable to evaluate LV function in 1. patients with dyspnea of unknown origin 2. patients with known heart disease with worsening dyspnea or change in clinicsl status 3. clinically stable pt with prior LV dysfunction with no eval in \>12 months

Question 36

RCRI and MACE

Answer 36

Revised Cardiac Index Risk factors are: history of ischemia or heart disease, CHF, CVA, Cr \> 2.0, IDDM, high risk surgery CAD: unstable angina, MI, use nitrate, , active + stress test, path q wave 0-0.4% risk of cardiac complications 1-0.9% risk of cardiac complications 2-7% risk of cardiac complications 3-11% risk of cardiac complications

Question 37

Active cardiac conditions

Answer 37

1. Unstable coronary syndroms: unstable angina (ACS) recent MI (30 days) 2. Decompensated heart failure 3. Significant arrythmia: High grade AV block, Mobitz II AV block, 3rd degree block Symptomatic ventricular arrythmia or sx brady SVR with HR\>100 at rest Newly recognized ventricular tachycardia 4: Severe valvular disease: 1. Severe AS (Mean gradient \>40 mmHg, aortic valve area \<1 cm2, or symptomatic) 2. Symptomatic MS (DOE, exertional presyncope, or heart failure)

Question 38

surgery risk

Answer 38

Low risk \<1%: ambulatory, breast, cataracts, endoscopic, superficial Intermediate risk: 1-5% - carotid endarterectomy, head/neck, - Intraperitoneal/Intrathoracic, orthopedic, prostate High risk: aortic/other major vascular procedures, peripheral vascular surgery \>5%

Question 39

HTN consideration head to toe perioperative risks, preop assessment potential causes

Answer 39

neuro: shift in cerebral autoregulation, stroke, retinopathy cards: LVH, CAD/MI, arrythmia, CHF (diastolic dys) renal: overactivity of renin angiotensin-aldosterone system, CKD concerns : BP instability, arrythmias, MI, stroke, CHF, hypoperfusion/end organ ischemia w reduction Preop: History: - cause (essential, coartation aorta, OSA/obesity renal, endocrine-pheo, hyperaldosterone, cushing, thyroid/parathyroid), - degree of control, baseline, meds - end organ effects PE: signs CHF Labs: BUN/Cr-renal involement, NA K diruetic effects EKG for LVH (S in V1 + R in V5 or V6 ≥ 35 mm), arrythmia, ischemia, strain (ST depression and T-wave inversion) CXR: cardiomegaly, pulm edema Goal: keep BP within 20% of baseline

Question 40

Indication for central cathter or PAC, TEE, a line

Answer 40

CVC 1. monitor CVP/fluid status 2. venous access in pt w poor access, drug/hyperailmetation infusion 3. pacing 4. aspiration of air during venous emboli PAC monitor filling pressures, PAP, PCWP, CO, MV02, SVR, PVR TEE 1. eval global fxn 2. RWA (Most sensitive indicator of ischemia) 3. fluid status 3. estimate preload (filling pressures 4. judge accuracy of cardiac procedures 5. assess unexplained hemodynamic disturbances a line 1. monitor BP on a continuous beat to beat basis, 2. ABG freq sampling 3. CPB (non pulsatile flow)

Question 41

aneursym repair

Answer 41

**Anesthesia** Difficult airway-compression (airway compression, SVC syndrome edma), DLT Cross clamp **neuro** Paraplegia-Loss motor with intact vibration and proprioception, sensory (ASA syndrome) epidural hematoma if neuraxial performed Stroke: emboli, hypotension **CV** Aneurysm: rupture, thrombosis, compression (SVC, AI MI, CHF **Pulm** Post op pulmonary dysfxn from manipulation of diaphragm and lungs Damage to phrenic or RLN **GI**: mesenteric ischemia **Heme** Coagulopathy: activation of coagulation (aneurysm thrombogenic), DIC dilution effects of massive transfusion, **Renal** Post op AKI

Question 42

minimize cord ischemia during cross clamp

Answer 42

-Avoid hypotension MAP\>80, maintain normal Hct and Labs: PaO2, (monitorand maintain adeuwate MAP above and below cord) -Avoid hyperglycemia Monitoring: - Lower ICP w spinal drain (15cc / 15 min max 60cc) ICP 8-10 - Monitor cord with SSEP MEP Careful with vasodilators or high conc on inhalational agents (vasodilation increase ICP which transmitted to cord and lower distal perfusion) Surgical: Min clamp time, use shunt, reattach segmental arteries

Question 43

hypotension at start of CBP

Answer 43

1. hemodilution: decreases SVR (depends on vascular tone and viscosity) from pump priming solution (usually transient as hypotension induced vasoconstricton and endogenous catecholamine increase BP 2. arterial or venous malfunction or malposition: aortic cannula inserted into aortic wall--\>dissection, inserted into inmoninate or carotid (cerebal edema/hemorrhage), venous cannula kinked or malpositioned, 3. switch of venous and aortic cannula \*\*\* aortic cannula in inmoniate would see HTN w R sided a line and hypotension w L sided a line

Question 44

steps of CPB and coming off

Answer 44

HAD2SUE Heparin: Always give prior to bypass. ACT: Always check before going on bypass (450 seconds) Drugs: Do you need anything (Non depolarizing neuromuscular blocker). Drips: Turn off the inotropes etc. Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture. Urine: Account for bypass urine Emboli: Check the Arterial cannula for bubbles. CBP, Cool, Clamp (after Vfib starts ~28C), Cardioplegia WARMVP: warm,, admin midaz Anemia/electrolytes/acidbase Rhythmn: rate ok? need to be paced? defib at 30C Monitors/alarms/rezero lines Ventilation: deair, check compliance/recruit Perfusion: pump flow, cardiac fxn on TEE, admin vasopressors and inotropes

Question 45

coagulopathy after bypass

Answer 45

1. abnormal plt fxn-activation on nonendothealil surfaces-oxygenator, filter, cartiotomy suction, hypothermia, nitro protamine preserve function: autologous blood collection, less use of cartiotomy suction, no bubble oxygenator 2. thrombocytopenia 3. hemodilution of coag factors 4. residual heparin:inadequate neutralizaton, heparin rebound (4-6 hrs after neutralization from dissociation of heparin), residual heparin from scavanged blood 5. fibrinolysis- increase plasmin 2/2 to release of TPA (tissue plasminogen activator) from endothelium during CPB, decrease levels plasminogen activator inhibitor 6. DIC 7. hypothermia

Question 46

AICD WORKUP

Answer 46

Type and model of device, Indication for placement, when placed (\<3 months more likely to be dislodged during central line placement, cardiac surgery, or manipulation of intracardiac catheters) underlying rhythm and rate, Pacer dependent, pacing threshold, recoded arrhythmic events programmed mode, response to magnet (usually disables tachydysrythmia detection therapy), reprogramming needed, Last checked (6 months ICD, 12 months PPM), functioning properly, battery life (should be at least 3 months),alert status on lead or generator( lead could be oversensing),

Question 47

Indications for iCD PPM

Answer 47

- secondary prevention VF VT - primary prevention: MI and EF\<30, HF class 2-3 w/ EF \<35 (intraven conduction delay 120ms cardiac resyn), congenital long QT syndrome, brugada, HCM - Sinus node desyfunction, AV block

Question 48

lung ca considerations

Answer 48

**Signs mass effect** Obstructive PNA SVC syndrome Pancoast tumor tracheal bronchial distortion- mass induced VQ mismatch mass compression of heart and great vessels **Tumor invasion** Hemoptysis, blood stained sputum **Cancer related meds** Bleomycin (interstitial pneumonitis, pulm fibrosis) Cisplatin: peripheral neuropathy, renal failure **Paraneoplastic syndrome** Lambert Eaton SIADH-hyponatremia vs loop diuretic), decreased serum osm, Cushing syndrome-Ectopic ACTH, hypokalemia, HTN, psychosis Parathyroid releasing hormone-hypercalemia-N/V, renal failure, weakness, arrhythmia

Question 49

hypoxia during OLV

Answer 49

100% oxygen Ensure adequate placement by capnography, listening to chest, fiberoptic scope for direct visualization Check BP to ensure adequate perfusion RL shunt from collapsed lung Recruitment breaths CPAP 10 Cm H20 to nondependent lung if surgically acceptable PEEP 5-10 cm H20 to ventilated lung ( in healthy lungs this way result in pressure induced shunting blood to nondependent lung) Reinflate non dependent lung Discuss with surgeon about ligating pulm artery to elim shunt Encourage hypoxic vasoconstriction (remove agents that may blunt this)-volatile, systemic vasodilators, hypocapnia (inhibit HPV nondependent lung and increased vascular resistance in dependent lung

Question 50

CF

Answer 50

cardiac: pulm htn cor pulm pulm: freq muscus plugging, inflammation, infection--\>hypoxia (V/Q mismatch), broncospasm, PTX (bbullae), bronchiestasis, resp failure,post op resp failure, lung infections GI/hepatic: malabs (vit K def + coaggulopathy; electrolyte abnormalities), pseudocholinesterase def endocrine: DM (pancreatic involvement) broncodilators, abx, chest physiotherapy

Question 51

post op dyspnea

Answer 51

Neuro: neuro conditions-MG, pain , nerve (phrenic from blocks) Cardiac: cardiogenic pulm edema, Pulm: atelectasis, aspiration, bronchospasm, bleeding/compression, drugs ,airway edema/NPPE/cardiogenic pulm edema , larnygospasm, PTX, PE, obstruction (OSA)

Question 52

extubation critera

Answer 52

Neuro: Awake and alert; following commands; return of airway reflexes; fully reversed, normothermic Cards: Stable vital signs, hemostasis Resp: (VC \>10-15ml/kg, NIF \>25-30, TV \>5ml/kg) If questionable, PS support trial w/ 5cmH2O and 5cmH2O CPAP on FiO2 0.4 x 30 min ABG: PaO2 \>80, PCO2 35-45, pH 7.35-7.45

Question 53

PTH hyper para, tx

Answer 53

increases Ca: bone resportion, renal tubular absoprtion, synthesis of vit D (intestinal abs Ca and P04) anesthesia: unpredictabe response to muscle relaxants neuro: psychosis, weakness, cards: hypovolemia, HTN, heart block, BBB, bradycrdia resp: gi: PUD, constipation, renal: kidney stones hydration, lasix, correct hypoP04, dialysis, second line -calcitonin, steriods (tx \>15) hypervent

Question 54

hypopara

Answer 54

neuro: seziures, cramps, depression cards: hypotension, CHF, insensitive to B agonist, prolonged QT resp: stridor/apnea