Flashcards in TrueLearn ITE Deck (225):
1. What does Bupivacaine do to the heart?
a. Blocks sodium-gated channels which leads to delayed repolarization and arrhythmias
2. What is the effect of tobacco use on the oxyhemoblogin curve?
a. Shift left (decrease oxygen perfusion)
3. What is most effective treatment for neuraxial opioid-induced pruritus?
What causes persistent fetal circulation in neonate?
Acidosis and hypoxia which cause increased pulmonary vascular resistance and pulmonary hypertension and persistence of right to left shunt.
What is Milrinone's effect?
Increased inotropy and cardiac output while also decreasing pulmonary and systemic vascular resistance.
What is preferred pharmacologic treatment for atropine resistant bradycardia?
What is second line pressor in septic shock, after Norepinephrine?
A dot on the left of a MIGET graph represents what?
What is key feature of MIGET graph for COPD/asthma?
No pure shunt
In bilateral carotid endarterectomy care must be taken with opioids, why?
Because carotid body denervation can happen. If it does central chemoreceptors solely respond to hypoxia and acidosis. Opioids blunt this and severe respiratory depression can occur.
How should bronchospasm be initially treated?
Hand ventilation with 100% FiO2 and deepening of anesthesia
What is mechanism of action of terbutaline? Effect?
Beta 2 agonist. Causes bronchial smooth muscle relaxation and bronchodilation
What is the primary effect of furosemide in the acute CHF?
Decreases venous resistance thereby decreasing mean systemic pressure
Redistribution of most anesthetic drugs occurs to where?
What does hypothermia decrease?
Oxygen consumption, CO, respiratory effort, drug clearance, insulin secretion, clotting/platelet function, immune response, P50
How do you treat seizures in LAST (local anesthetic systemic toxicity)?
What is the hepatic arterial buffer response?
Hepatic artery vasodilation in response to reduced portal venous flow
What can happen after large bolus of dexmedetomidine?
A sharp rightward deflection of spirometry at end of pressure-volume loop is indicative of what?
What two lung parameters are unchanged in obesity?
Closing capacity (volume at which small airways begin to close) and residual volume
What is the key unique physiology in patients with hypoplastic left heart palliated with the Fontan procedure?
Passive pulmonary blood flow
What are the 5 primary causes of hypoxemia?
Decreased PO2. Hypoventilation. V/Q mismatch. Impaired diffusion. Right to left shunt.
What are three reasons for increased incidence of aspiration pneumonitis in obstetric patients?
1. high incidence difficult airway 2. Lower gastric fluid pH 3. Increased intraabdominal pressure
Name 4 drugs with low hepatic extraction ratio
Diazepam. Methadone. Rocuronium. Thiopental.
What is the respiratory quotient?
Ratio of CO2 produced to O2 consumed during metabolism
What is the affect of Sch on lower esophageal sphincter tone in pregnancy?
It increased to tone and decreases risk of aspiration
What is the venous admixture equation? ("shunt equation")
Up until what post-conceptual age is it prudent to monitor a neonate overnight after general anesthesia?
Three requirements to prevent rebreathing in traditional circle circuit system?
1. A unidirectional valve must be positioned between the patient and both the inspiratory and expiratory limbs
2. Fresh gas flow cannot come into the circle system between the patient and the expiratory valve
3. The APL valve cannot be positioned between the patient and the inspiratory valve
What is the shortcut for calculating the volume of liquid volatile anesthetic consumed in one hour?
ml/hr=3*FGF(L/min)* % anesthetic vapor
What is the distance relationship between arterial line transducers and blood pressure?
10 cm change results in 7.5 mmHg change
What is Henry's Law?
Henry: Concentration of gas dissolved in a solution is directly proportional to the partial pressure
Dalton: The total pressure of a gas is equal to the sum of the partial pressures of individual gasses.
What's the quick way to approximate the volume remaining in an O2 tank?
3:1 rule. So if full, 2000 psi then about 625 L
At what serum levels does hypermagnesemia cause respiratory depression?
At what levels will QRS become widened?
(cardiac): 5-10 mg/dL
What are the effect of PEEP on hemodynamics? In systolic HF?
Increases Intrathoracic pressure thereby increasing right ventricular afterload. This decreases preload which can lead to hypotension in normovolemic without heart failure.
In heart failure preload is excessive. So PEEP improves CO and decreases LVEDP.
What are two side effects of Oxytocin?
Hypotension (vasodilation) and hyponatremia (hyponatremia 2/2 antidiuretic effect)
What is the most common complication of hyperbaric oxygen therapy?
Middle ear pressure equalization. (Pain, edema, bleeding, rupture)
What induction agent should be avoided in patients with history PONV?
What type of ETT with most likely prevent airway fire?
Why should paralytics be avoided in patients with anterior mediastinal mass?
Relaxation of skeletal muscle could lead to airway collapse.
Describe respiratory changes in pregnancy. Increase/decrease?
Decrease: TLC, FRC. VC unchanged. RR unchanged. All else (capacities and ventilation (ie: MV)) increased.
Patient with mitral regurg and pulmonary edema following inferior MI. First line treatment?
Sodium nitroprusside. As an arterial vasodilator it will decrease afterload and reduce regurgitant flow. Milrinone may also be a good choice.
Describe cardiovascular effects in NORMOTENSIVE morbidly obese patient
increased blood volume leading to increased CO and DECREASED SVR.
Note: eventually increase Angiotensin-Renin and sympathetic nervous system will lead in increase BP.
List risk factors for difficult bag-mask ventilation
BMI > 26
Age > 55
Also Mallampati III-IV, limited mandibular protrusion, mouth opening < 3cm, TM distance < 6 cm
Vent settings for utilizing PPV
Controlled ventilation, TV > 7-8 ml/kg, no PEEP
In an adult what anesthetic is most common cause of perioperative anaphylaxis?
Rocuronium (neuromuscular blocking agents)
What factors decrease evoked potentials in neuromonitoring?
volatile anesthetics, nitrous oxide, anemia, ischemia, hypoxia
How is MH transmitted genetically? What is the diagnostic test?
CHCT. Caffeine/halothane contracture test. Muscle biopsy exposed to ryanodine receptor agonists (caffeine and halothane) and strength of contracture measured.
When should Metformin be discontinued preoperatively?
Acute renal failure or when acute renal insufficiency is high risk (contrast dye)
How does CO change during labor?
Increases 15% in latent labor, 30% in active labor, and 45% in expulsive phase.
Additional 10-25% increase with contractions
In a patient with emergency surgery and significant risk factors for aspiration, which medication (class and two examples) can be given for prophylaxis?
H2 receptor antagonists.
What two factors cause shedding of endothelial glycocalyx?
ANP and hypervolemia
What physical characteristics affect respiration in neonates?
Pliable rib cage causing retractions
Lower lung compliance but increased chest wall compliance
Immature intercostal musculature
Less type 1 muscle in diaphragm
What are the 4 T's of the HIT scoring system?
2. Timing of reduced platelet count
4. oTher causes ruled out
In kids, what is the premedication dose of IM Ketamine?
What is the mechanism of action of Enoxaparin?
LMWH, inhibits Fator Xa
Which neuromuscular blocking agent is primarily eliminated by the kidney?
What is the initial treatment for symptomatic sever hypermagnesemia? (hypotension)
Calcium gluconate or calcium chloride
What is treatment for SVT in WPW?
What class of medication must be avoided in pheochromocytoma?
Beta specific Beta-blockers (Metoprolol), Because unopposed alpha agonism will worsen hypertension
What are the side effects of Gabapentin?
What is induction agent of choice in acute intermittent porphyria?
What are the 5 goals of anesthetic management of HCOM?
1. Reduce myocardial contractility
2. Maintain or increase SVR
3. Increase preload and CO
4. Maintain low-normal heart rate
5. Treat arrhythmia
What EKG change is characteristic for hypocalcemia?
What is mechanism of action of isoproterenol?
What blood product carries the lowest risk of TRALI?
What are the two groups of local anesthetics? How to remember this?
Aminoamides and aminoesters.
Aminoamides have two "I's":
Bupivacaine, Lidocaine, Mepivacaine
What is Lithium's effect of NDNBD's?
Potentiates paralytics by interfering with prejunctional neuron action potential transmission
What are three ways to manage intraoperative pulmonary hypertension?
Nitroglycerine (vasodilators), PDE-3 inhibitors, Nitrous Oxide
What is most commonly used epidural test dose?
3 ml of 1.5% Lidocaine with 1:200,000 epinephrine
A complete injury to unilateral recurrent laryngeal nerve would result in what vocal cord position?
Paramedian position of affected side (both adductor and abductor segments of nerve injured)
What are the ACC/AHA guidelines for days to wait for nonurgent surgery after stent placement?
PCA: 14 days
BMS: 30 days
DES: 365 days
What 6 parameters comprise the Revised Cardiac Risk Index (RCRI)?
1. Procedural Risk
2. Hx of CVA
3. Hx ischemic heart disease
4. Insulin dependent DM
5. CKD with Cr > 2.0
6. Hx of CHF
A disc herniation at L4-L5 affects what nerve?
What are 5 common characteristics associated with hypoplastic left heart syndrome?
2. Stenoic or atretic mitral and aortic valves
3. Hypoplastic left ventricle
4. hypoplastic ascending aorta
Hypoxic pulmonary vasoconstriction (HPV) is attenuated by what? (6 drugs)
1. Inhaled volatiles
5. PDE inhibitors
What elements make up VACTERL association?
Congenital heart disease
ESRD on dialysis, why is surgical hemostasis difficult?
Impaired platelet aggregation 2/2 uremia
What statistical term represents the accuracy with which a sample represents the population?
Standard error of the mean
What anesthetic agents must be avoided in carcinoid syndrome?
Agents that release Histamine (Succs, Mivacurium, Atracurium, Tubocurarine)
How does altitude affect volatile anesthetic delivery/
Delivered concentration is increased
Partial pressure is unchanged
What color nail polish is least likely to affect pulse ox?
Volatile anesthetics attenuate what cerebral blood flow response most?
Perfusion pressure (autoregulation)
How much does cerebral metabolic rate decrease per decrease in temperature?
6-7% reduction per degree C reduction
What are general platelet cutoffs for surgery?
50,000 for general surgery
100,000 for neurosurgery
In patient with peripartum cardiomyopathy, what is general recommendation for delivery and anesthesia?
Vaginal delivery with epidural anesthesia
Postoperative pulmonary complications are likely to be reduced after smoking cessation of what duration?
What is ratio of TOF to % receptors blocked?
1 twitch indicates >90% suppression.
2 twitches indicate 80-90% suppression.
3 twitches indicate 70-80% suppression.
4 twitches indicate 65-75% suppression.
What T4:T1 TOF ratio is considered sufficient?
How is Rocuronium cleared?
30% renally. Clearned primarily by hepatic metabolism.
What is initial treatment of hemodynamically unstable or symptomatic SVT?
What anesthetic considerations are associated with hypothyroidism?
Hyponatremia and hypoglycemia
One unit of cryoprecipitate contains how much fibrinogen?
Name two ophthalmic blocks. Which one is better but more dangerous?
Retrobulbar and peribulbar.
What class of medication is milrinone?
PDE III inhibitor
What are the pharmacokinetic and dynamic changes of vecuronium in the elderly?
Same potency. Longer duration of action
What congenital cardiac abnormality is associated with pectus excavatum?
What are three neuro effects of propofol?
1. Decrease cerebral metabolic rate
2. Decreases cerebral O2 consumption
3. Decreases ICP
What are the axis for the oxygen hemoglobin dissociation curve?
What are three ASA recommendations for reducing risk of airway fire?
1. Laser resistant tube
2. Low FiO2 as possible
3. Fill cuff with saline and methylene blue when feasible
What medication should be avoided in Thyroid storm?
What info do you need to know how much NO remains in an E-cylinder?
Weight and tare weight
Which nerve is spared with a brachial plexus block?
What nerve and muscle pairing is responsible for vocal cord abduction?
Recurrent laryngeal nerve, posterior cricoarytenoid muscle
Name three unique considerations when using neuromuscular blockade in children?
1. Succs not routinely used except RSI
2. They require higher than normal weight-based doses
3. Hepatic or renally cleared drugs circulate longer in neonates
What anesthetic should be theoretically avoided in pancreatitis?
What is chronic phenytoin use's effect on NMBA?
Duration of block is significantly shorter
What perioperative test is best at predicting acute renal failure in setting of suprarenal aortic cross clamping?
Meralgia parethetica is injury to what nerve?
Lateral femoral cutaneous
What muscle is the attachment point of the tongue to the mandible?
What is magnesiums affect on NMBA?
Describe metabolism of Etomidate. 3 points
1. Metabolized to inactive metabolites in liver
2. Excreted primarily by kidneys
3. Highly protein bound
What is statistical test to use to compare normally distributed data from more than two groups?
Analysis of variance
Why can clonidine be added to local anesthetic?
Increase duration of action
What is the reason for Fentanyl's quick onset and shorter duration of action as compared to Morphine?
More lipid soluble
Describe proper placement of an axillary roll
Oriented anterior-posterior and placed caudad to axilla
What would cause both a decrease in O2 demand and an increase in O2 delivery?
Decreased Heart Rate
What 5 elements are contained in cryoprecipitate?
Given prophylactically in patient with what hemophilia?
Which aspiration prophylaxis medication has the longest duration of action and what is its class?
Proton pump inhibitor
What is the ideal block for surgeries involving hand, wrist, and forearm?
Of the "isomolar crystalloids" which has the highest osmolality and sodium concentration?
What is the sodium concentration?
How does acetazolaminde treat acute mountain sickness?
Shifts to CO2-ventilatory response curve left
What four hormones does Somatostatin inhibit the release of?
FGF must be equal to what in a Mapleson A circuit to prevent rebreathing during spontaneous ventilation?
What factors decrease statistical power? (4)
1. Increasing sample size
2. Increasing effect size
3. increasing alpha (p-value)
4. Reducing population variability
What is the triad of hepatopulmonary syndrome?
1. Intrapulmonary vascular dilation
2. Increased A-a gradient
3. Hepatic failure
What is increased in a closed circuit anesthetic technique?
IN awake patient with no mention of hemorrhage what is first line treatment for uterine relaxation for surgery on retained placenta?
What is the formula to calculate the amount of Bicarb needed to correct acidosis?
What s treatment of choice for prophylactic bleeding risk in patient with type 1 vXD
Ongoing bleeding after cardiopulmonary bypass despite adequate reversal with Protamine is managed with what?
What adjuvant medication is contraindicated in neuraxial anesthesia in obstetric patients due to risk of hypotension and sedation?
Decreased MA on TEG (thromboelatography) is indicative of what?
What are three goals of treatment of acute right heart failure?
1. Improving inotropy
2. Increasing pulmonary vasodilation
What are 5 absolute contraindication to TEE probe placement?
2. Esophageal stricture
5. Active bleeding
What classes of medication should be avoided in patients with glaucoma? 3
Meds that cause mydriasis (dilation).
3. Corticosteroids (increase IOP)
What is the mechanism of local anesthetic toxicity?
Delayed repolarization of via action potential inhibition with binding of voltage-gated sodium channels.
In hypotensive trauma with TBI what are two acceptable fluids for resuscitation?
What increases your risk of myalgia following succs?
Female. Not being very muscular. Being an adult, not pregnant, not at extremes of age.
What 4electrolyte abnormalities are manifest in Addison's?
What anesthetic principle should be remembered for patients on Amiodarone?
Use as low FiO2 as possible to reduce risk of pulmonary fibrosis
Which is Glutamates role in the transmission of pain?
It is a stimulator
What is the correct pacemaker mode for patient s/p AV node ablation?
What are indications for hyperbaric Oxygen therapy following CO exposure? (6)
3. Change in mental status
6. CO level over 40%
What is the strongest predictor of postoperative mortality following liver transplant?
Hypoxemia (PaO2 <50)
What is the normal physiologic response to ECT?
Tonic clonic seizure leading to increase CBF with resultant parasympathetic response with bradycardia followed then by sympathetic surge with hypertension and tachycardia.
What is the cause of "fade" on TOF?
Binding of NMBD's to presynaptic receptors preventing reuptake of ACh resulting in depleted stored of ACh in the presynaptic motor nerve ending
How much negative pressure is required to expand fluid filled alveoli in a neonate and how long after life until FRC is normal?
How is amniotic embolism characterized? (Two stages, two events each stage and one other thing)
Maternal pulmonary vasospasm with right heart strain/failure
Pulmonary edema with left heart failure.
Also maternal coagulopathy (consumptive)
What are two EKG characteristics of MAT (multifocal atrial tachycardia) and what disease processes is it associate with?
HR > 100
3+ different P-wave morphologies
Associated with pulmonary and cardiac pathologies especially those resulting in atrial distension and pulmonary HTN
What is the most appropriate use for a statistical t-test?
Comparing the means between two groups
What is the only opioid that has increased clearance in neonates as compared to older children and adults?
Neuraxial anesthesia and it's affect on:
1. Second stage of labor
2. Mortality and morbidity
3. Rate of C-section
2. No change
3. No change
What is the leading cause of perioperative mortality in the morbidly obese patient?
What is correct maintenance choice in patient with prolonged QT?
What is the half-life of plasma albumin?
How many time constraints is required for the concentration of a drug to decrease by 95%?
Why may nitrous be a bad idea in laparoscopic surgery?
Decreased surgical visualization
What are two effect of epinephrine additive to lidocaine in epidural anesthesia?
Increased density and duration of block.
Describe three characteristics of nocioceptive afferent nerve fibers
1. high threshold
2. A delta and C fibers
Rheumatoid arthritis causes instability to what joint by weakening what two ligaments?
1. Atlantoaxial joint
2. Transverse and alar ligaments
What is normal mixed venous oxygen tension?
Sustained intraabdominal pressures greater than what define abdominal compartment syndrome?
What blood pressure medication is associated with oligohydramnios and should be avoided in pregnancy?
What EKG change is associated with hypocalcemia?
What is treatment for organophosphate poisoning?
Which medication is useful for aspiration prophylaxis in emergencies due to its immediate onset?
Citric acid and sodium citrate
What is bolus dosing of Dantrolene in MH?
What is the mechanism of action of Metocloprmide in aspiration prophylaxias?
Increase LES tone and gastric emptying
What is one of the earliest signs of diabetic neuropathy?
Decreased HR variability and resting tachycardia
What are indications for platelet transfusion in MTP?
If ongoing bleeding less than 75K, if no bleeding if less than 50K.
What are the FDA approved indications for Dexmedetomidine ?
Sedation of non-intubated patients prior to and/or during surgical and other procedures
What two muscles are used as landmarks for placement of central line IJ?
Clavicular and sternal heads sternocleidomastoid muscle
Which electrolyte abnormality can precipitate Digoxin toxicity?
What are the signs of propofol infusion syndrome? (8)
1. Metabolic lactic acidosis
2. Cardiac failure
3. Renal failure
How do you approximate a patient's blood volume?
What is treatment for Thyroid storm?
Propylthiouracil then iodide
Arrythmia treated with Beta blocker +/- Digoxin
What is nerve block of choice for post op pain in ACL repair?
Femoral nerve block
Vasopressin secretion is inhibited by what?
What are risk factors for cauda equine syndrome? (4)
2. High local anesthetic concentration
3. Directing tip in dependent direction
4. Slow and low pressure injection
What is anticoagulation substitute in patient with HIT type II
Which muscle relaxant should be avoided in hyperthyroidism, why?
Pancuronium. May stimulate the sympathetic nervous system
Describe what products are mixed:
1. ABO typing
3. Antibody screen
1. Recipient RBCs with commercial serum
2. Recipient serum with donor RBC
3. Recipient serum with commercial RBC
CNS depression secondary to anticholinergic meds can be reversed with what and why?
Physostigmine. It is an anticholinesterase that can cross the blood-brain barrier
What is the preferred cannulation technique for cardiopulmonary bypass?
In acute tubular necrosis, what is the expected FENa and UNa?
UNa > 40
Nitric oxide is used to treat what, how, and what is it's hematologic side effect?
Pulmonary HTN, pulmonary vasodilator, methemoglobinemia
Name indicated product in heparin resistance and TTP.
Name the three diagnoistic criteria for sepsis and what distinguishes septic shock?
1. RR greater than 22
3. Systolic BP less than 100
If volume resuscitated and still requiring pressors to keep MAP above 65 or lactate is greater than 2 they are in septic shock.
What antibody test is used to diagnose HIT?
Platelet factor 4
What are two most important factors in determining spread of spinal anesthesia when using isobaric solution?
Site of injection and total dose
What are common physiologic changes in brain dead organ donors? (6)
1. Myocardial dysfunction
2. Catecholamine storm
3. Pulmonary edema
5. Pulmonary edema
Why does propofol cause hypotension (4)?
1. Decrease preload
2. Decrease afterload
3. Decrease cardiac function
4. Impair baroreceptor reflex
What two colloids are associated with coagulopathy?
What is opioid's affect on seizure threshold?
What is the single best test for difficult intubation?
Upper lip bite test
At rest what is true of autonaumic nervous system differences between elderly and young patients?
At rest elderly have higher sympathetic tones and lower parasympathetic tones
Initital management of drowning, asphyxiation, choking
A-B-C. Start with breaths
How is blood flow to the urterus regulation
There is no autoregulation. It is all pressure dependent.
Local anesthetics block peripheral nerves by what mechanism?
Reversible binding the intracellular voltage-gated sodium channels.
Opioids are dosed based on what?
What is average vital capacity in 70 kg male?
Labetolol: Metabolism, lipid solubility, elimination half life
1. In Liver by oxidation and glucuronidation
2. Poorly lipid soluble (safe in pregnancy)
3. Half life is 6 hours
Awareness under anesthesia is more common in three types of procedure. What are the three?
Ischemia reperfusion injury is thought to be caused by what?
Disruption of the sodium-potassium pumps secondary to decreased ATP and glycogen
What are the 4 elements of the Berlin criteria in the diagnosis of ARDS?
1. Timing: Acute, within one week
2. Bilateral opacities on CXR
3. Edema origin: Respiratory failure not fully explained by cardiac failure or fluid overload
4. Oxygenation: (Mild) PaO2:FiO2 ratio less than 300 (and goes down from there)
What is PCXP in TRALI?
What is common radiographic finding in croup (laringotraceobronchitis)?
Steeple sign (subglottic narrowing)
What is the best indicator of liver transplant graft function?
Labor epidural anesthesia prolongs what stage of labor?
What is hepatorenal syndrome type I?
Acute onset renal failure with doubling of baseline creatinine in the setting of cirrhosis and an inciting event (spontaneous bacterial peritonitis, sepsis, surgery)
In which space is CSF in the spine?
Subarachnoid. Between arachnoid and pia mater
Spinal anesthesia may be an option for what age neonates?
Former premies at less than 60 weeks postconceptual age.
What is the general relationship between PaCO2 and EtCO2?
PaCO2 is generally 2-5 mmHg higher due to dead space
In local anesthetics, what is the affect of each of these:
1. Higher protein binding?
2. More lipid soluble?
3. Adding sodium bicarb
1. Longer duration of action
2. More potent
3. Quicker onset
What happens to CO in sepsis? In PE?
What is the effect ton blood lines in polycythemia vera. Bonus, what is the mutation?
What receptor is bound by ipratropium to cause bronchodilation?
Name three (random) conditions associated with MH
1. Central core disease
2. multi-minicore disease
3. Ken-Denborough syndrome
What is the order of local anesthetic potency?
What fluids should be avoided in neurosurgery?
Fluids containing glucose
Name 3 classes of meds that antagonize NDNBDs
What happens to blood gas acid/base status in pregnancy?
Slight respiratory alkalosis due to increase MV. This also slightly increase PO2. Also some metabolic acidosis compensation (decreased bicarb)
Where does the sciatic nerve lie in the popliteal fossa and what are its two division?