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Anesthesia Oral Boards > UBP book 2 > Flashcards

UBP book 2 Flashcards

1
Q

Anesthetic concerns with autonomic neuropathy

A

-inc risk for aspiration (gastroparesis)
-inc risk for significant hypotension (impaired peripheral vasoconstriction and baroreceptor fxn)
-silent ischemia
-intraop hypothermia (impaired peripheral vasoconstriction)
-impaired ventilatory response to hypoxia and hypercapnia (inc risk of drug induced resp depression)

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2
Q

Start a beta blocker on day of surgery?

A

No -> inc risk of bradycardia, hypoTN, stroke, total mortality

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3
Q

When to start a beta blocker preop?

A

2-7 days
-if have more than 3 RF: CAD, stroke, CHF, renal insuff, DM

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4
Q

Effects of beach chair position on anesthetized patient

A

-decreased CPP, dec SV, dec cardiac output
no compensatory inc in SVR if under GA -> inc risk of cerebral ischemia

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5
Q

chest tube placement location

A

-4th or 5th intercostal space, just anterior to midaxillary line

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6
Q

how to do a needle decompression for tension PTX

A

14 gauge needle, second intercostal space, midclavicular line

**will still need a chest tube

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7
Q

beach chair, shoulder surgery, interscalene block w/ GA ETT, OSA, GERD, difficult airway, O2 sat falls, diminished breath sounds on L

A

-100% FiO2, hand ventilate
-using a fiberoptic to confirm tube placement is accurate
-if placement adequate -> consider PTX, L phrenic n paralysis)
-consequences of PTX -> do a bedside POCUS looking for lung sliding
-look for tracheal devision, goal w/ spontaneous ventilation (minimize PPV in PTX)

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8
Q

Risks for cerebral ischemia in beach chair

A

-if under GA, cannot compensate w/ inc in SVR
-beach chair position dec SV, cardiac output, and CPP
-if pt has autonomic neuropathy -> further risk of cerebral ischemia

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9
Q

If arterial line at circle of Willis -> what is the goal MAP?

A

80.

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10
Q

cerebral autoregulation maintains BF w/ what pressure?

A

MAP 60-150

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11
Q

Normal CPP

A

70-80
**if chronic HTN -> goals towards 80 due to possible R shift of curve

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12
Q

with aspiration event, how long to monitor?

A

24-48 hours for concern of aspiration pneumonitis

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13
Q

cricoid pressure if actively vomiting?

A

NO -> risk of esophageal ruputure

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14
Q

Pathophysiology of aspiration pneumonitis

A

aspiration of gastric contents w/ low pH => damage to surfactant producing cells and the pulmonary capillary endotheliulm -> atelectasis, pulm edema, bronchospasm, larygospasm
-intense inflammatory response -> ARDS
-if particulate stuck/caught in airways -> abscess formation

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15
Q

symptoms of corneal abrasion

A

-red eye, watery
-foreign body sensation
-photophobia
-exacerbated w/ blinking

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16
Q

steps if concerned for corneal abrasion

A

-evaluate pt -> H&P
-c/s optho
-consider abc ointment

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17
Q

prevent corneal abrasion

A

-taping eyes after induciton, prior to intubation
-avoid direct contact w/ eyes
-apply appropriate eye lubricant

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18
Q

How is pheochromocytoma diagnosed?

A

-history and physical -> symptoms of uncontrolled HTN, dizziness, HA, N/V, orthostasic hypoTN
-free metanephrines in plasma
-urinary catecholamines
-urinary metanephrines
-urinary vanillylmandelic acid (catecholamine metabolite)

confirmatory:
=plasma conc of chromogranin-A
-clonidine suppression test (catecholamines dec if essential HTN, don’t if pheo)

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19
Q

symptoms of pheochromocytoma

A

HTN
diaphoresis
HA
tachycardia
orthostatic hypoTN (chronic vasoconstriction, volume depletion, impaired reflex responses)
flushing
tremors
N/V
weight loss
hyperglycemia
encephalopathy
anxiety
dilated cardiomyopathy -> MI

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20
Q

pre-pheochromocytoma optimization

A

-alpha blockade 7-10 days
-BP < 165/90 for AT LEAAST 48 hours
-no significant orthostatic hypoTN
-HR 60-80: can beta blockade after adequate alpha if needed
-give fluids (likely depleted)
-eval cardiac fxn: EKG, CXR, TTE

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21
Q

Why alpha blockade before beta?

A

want to avoid blocking beta vasodilation if no alpha -> can lead to unopposed vasoconstriction at alpha

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22
Q

why put a foley in

A

-allow for bladder emptying (esp in laproscopy)
-monitor UOP in setting of potential hemodynamic instability

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23
Q

monitors for pheo surgery

A

standard ASA (5 lead EKG)
foley (UOP, bladder decomp)
a line
central line
TEE

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24
Q

fluids pre pheo surgery?

A

-yes if volume depleted to avoid hypoTN w/ induction or pneumoperitoneum
-no if not volume depleted _< avoid CHF exacerbation, and avoid edema w/ steep trendelenberg position
-can use CVP/TEE to guide fluid replacement

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25
Q

can you do a spinal for laparoscopic surgery

A

-avoid -> could not toelrate inc abd pressures from pneumoperitoneum, lead to respiratory compromise
-req NG/OGT placement for stomach decompression -> not tolerlate
-muscle relaxation red risk of serious injury, and prevents coughing/bucking

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26
Q

position for pheo

A

-lateral 60 deg flank position

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27
Q

metochlopramide in pheo?

A

can stimulate secretions of cetecholamine from pheo
-avoid if needing to give aspiration ppx

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28
Q

when not to give metochlopramide for asp ppx

A

-SBO
-pheo (inc catecholamine secretion)

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29
Q

RSI in pregnant smoker, pheo surgery?

A

Yes -> high risk of aspiration
-acknowledge: goal to minimize catecholamine surge (despite inc in catecholamines w/ fasciulations w/ succ and intubating in not deep enough)
-acknolwedge inc risk of bronchospasm if not deep enough
-GOAL: ensure adequate alpha blockade and intravascular voleume replacement, difficult airway equipment available, RT, topical lidocaine and fent (dec symp resp), RSI prop and ROC

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30
Q

Meds to avoid in pheo

A

-ephedrine: inc release of catehcolamines
-ketamine
-succ (stimulate tumor cells to release)
-morphine, atracurium: histamine releasing drugs
-meotchlopramide
-droperidol

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31
Q

laparoscopic case, ABG PaCO2 54, ddx?

A

-normal inc in CO2 w/ pneumoperitoneum (first 15-30 minutes) -> V/Q mismatch from pt position,
-inadequate ventilation
-CO2 emphysema
-capnothorax
-CO2 embolism
-PTX (alveolar rupture)
-aspiration
-MH

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32
Q

inc EtCO2, PaCO2, subq crepitating of head, neck, face

A

subcutaneous emphysema

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33
Q

Capnothorax presentation

A

Inc EtCO2
Dec O2 sat
Inc airway pressure
Dec breath sounds
hyperresonance

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34
Q

CO2 embolism presentation

A

Dec EtCO2
Dec O2 sat
no change in airway pressures
R heart strain EKG
hypoTN
aspiratiory of foamy blood from CVC
inc pulm artery pressure

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35
Q

PTX presentation

A

EtCO2 dec
O2 sat dec
airway pressures inc
hyperresonance
dec breath sounds

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36
Q

laproscopic surgery UOP low, what to do

A

Transient oliguria common w/ laparoscopic surgery: hypercarbia, inc intra-abd pressures (dec CO, catecholamines, ADH)
-give volume cautiously: consider fluid losses and invasive monitoring data (pulse pressure variation, CVP)

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37
Q

what to do if subq emphysema?

A

-consider possibility of PTX or capnothorax: look at EtCO2, PaCO2, auscultate b/l
-if 2/2 insufflation: d/c insufflation, hyperventilate, and w/ improvement of hypercapnia, reinflate w/ lower insufflation pressure
-consider prolonged intubation dept on comorbidities (COPD w/ inc CO2 -> inc postop work of breathing)

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38
Q

pheo surgery, massive inc to 200/100, what to do?

A

-verify BP
-ask surgeon to stop manipulation
-check vitals, look at oxygenation, ventilation, EKG
-Check TEE and CVP
-ensure adequate depth of anesthesia: inc volatiles, consider pain meds
-if no improvement give short acting anti-HTN: nicardipine, clevidipine, nitroglycerin, nitroprusside, phenotalmine

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39
Q

signs/symp of cyanide toxicity 2/2 nitroprusside

A

metabolic acidosis
hypoxemia
confusion
palpitations

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40
Q

Mg sulfate in pheo

A

inhibits catecholamine release from adrenal medulla and peripheral n terminals
direct vasodilator
reduces the sensitivity of the alpha receptors to catecholamines

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41
Q

pheo surgery BP dec to 74/46 after vein ligation to tumor, ddx?

A

-tumor has been adequately isolated, so dec in plasma catecholamines

OTHER
-residual alpha blockade
-hypovolemia
-cardiomyopathy (catecholamine induced)
-CO2 embolism
-PTX
-CHF
-MI
-massive blood loss
-vagal activation

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42
Q

post pheo surgery -> pt has conjunctival edema and subq emphysema, extubate?

A

No -> could be a sign of laryngeal edema possibly 2/2 position or fluid overload
-subq emphysema = hypercapnia = inc WOB after extubation
-goals: optimize fluid status, and ventilation with easly extubation

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43
Q

glucose control post pheo removal

A

common for hypoglycemia
-w/ inc catecholamines: dec insulin,
inc glycogenolysis, and gluconeogenesis
-now dec catecholamines: inc insulin, red gluconeogenesis and glycogenolysis
-after tumor removal, should use dextrose containing solution
-monitor for 24 hours postop

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44
Q

how to minimize PONV in pregnant laproscopic surgery

A

-TIVA prop
-no volatiles or nitrous oxide
-adequate hydration
-scopolamine
-zofran (serotonin antagonist)
-aprepitant (neurokinin-1 receptor antagonist)
-acupressure
-local at port sites to minimize postop opioid needs

**NO NSAIDS IN PREGNANCY -> closure of ductus arteriosus

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45
Q

pheo removal POD, HTN w/ elevate catecholamines, concerned?

A

yes, possible residual pheo
-acknowledge that can have HTN and elevated catecholamines a few days postop due to inc stored catecholamines in peripheral nerves
-less concerned if HTN is sustained (NOT paroxysmal), and if it was lower than pre tumor removal

**HTN could be essential HTN or renal ischemia

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46
Q

signficant bleeding after delivy w/ echongenic mass in uterine cavity dx?

A

uterine inversion

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47
Q

Treatment of uterine inversion

A

-d/c all uterotonics (oxytocin)
-NG to relax uterus (can also use volatiles)
-give fluids and vasopressors tu support

POST reduction: u/s to confirm, idetnify and perofrations, lacerations or retained placenta
-now give uterotonics to minimize additional blood loss

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48
Q

ACA aneurysm, severe headaches, HR 92, BP 140/90, RR 16, temp 36C, inc ICP?

A

Possibility w/ known aneurysm and severe headache
-H&P: HA, papilledema, N/V, AMS
-Cushings triad: HTN, bradycardia, change in resp pattern (or widened pulse pressure)
-unsure: order CT: looking for bleeding, small ventricoles, or midline shift

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49
Q

Airway evaluation

A

-ability to open mouth
-cervical spine mobiltiy
-receding chin
-large tongue
-prominant incisors
-short neck
-thyromental distance (good > 6.5 cm), sternomental (good >12.5)
-mallampati

**obtain prev anesthesia records if available

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50
Q

difficult airway thyromental distance

A

<6.5 cm

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51
Q

monitors for ACA aneurysm clipping open

A

5 lead EKG
foley
a line (preinduction)
central line (vasopressors, fluid status, facilitate rescuctiation, air embolism)
SSEPs or EEG (identify cerebral ischemia)

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52
Q

Periods of significant stimulation in ACA clipping

A

laryngoscopy
endotracheal intubation
head pinning
bone flap creation

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53
Q

Scalp block nerves

A

Supraorbital
Supratrochlear
zygomaticotemporal
auriculotemporal
greater/lesser occipital

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54
Q

what to do if accidentally cannulate carotid artery

A

-cancel the case and c/s vascular surgeon
-keep in place -> concern for bleeding and hematoma formation in neck -> decrease cerebral venous return -> decrease in cerebral perfusion
-possibly compromise airway

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55
Q

complications w/ inadvertent cannulation of the carotid artery

A

-hematoma formation
-airway obstruction
-stroke
-hemothorax
-pseudoaneurysm
-AV fistula
-death

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56
Q

why use a lumbar drain

A

maintain spinal perfusion pressure to avoid SCI in thoracic aortic aneurysm repair

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57
Q

risks assoc w/ accidental carotid cannulation prior to ACA aneurysm repair

A

hematoma formation
airway obstruction
dec cerebral venous return
inc ICP
dec cerebral perfusion

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58
Q

Hunt and Hess classification neuro grade

A

non-traumatic SAH
0: no repture
I: asymptomatic w/ ruptured aneurysm: mild HA, slight nuchal ridigity
II: mod to severe HA, nuchal rigitidy, neuro deficit limited to CN
III; drowsy, confused, mild focal deficit
IV: exhibiting stupor, hemiparesis
V: deep coma, cerebrate

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59
Q

ACA aneurysm repair, would you lower BP prior to clipping?

A

-assuming deliberate hypoTN not absolutely necessary, no -> global dec in cerebral perfusion pressure -> inc ischemia -> vasospasm
-controlled hypoTN showed worsened outcomes and inc incidence of vasospasm
-cardiac concerns for hypoTN

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60
Q

Conditions that worsen cerebral ischemia

A

hyperthermia
hypoxia
hyperglycemia
anemia
hyperventilation (SAH or TBI)

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61
Q

what to do after a temprary clip placed on ACA for aneurysm reapir?

A

increase MAP -> support collateral circulation

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62
Q

cerebral protection while temporary ACA clip in place

A

-give prop/etomidate: goal to dec CRMO2
-maintain higher than normal MAPs
-minimize occlusion time
-brain relaxation: mannitol, furosemide, hypocapnia
-mild hypothermia acceptable

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63
Q

hypothermia with ACA aneurysm clipping

A

-no b/c has not proven to be of benefit, can cause delayed emergence, slow metabolism of anesthestics and muscle relaxants, inc rate of infxn, inc O2 consumption w/ shiviering, MI, coag defects

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64
Q

ACA aneurysm clipping, ST changes, what to do?

A

Look at surgical field about potential rupture (ST depression occurs in presence of SAH)
-ensure adequate ventilation w/ 100% O2
-monitor EKG, a line, pulse ox CVP
-order trops, assess hemodyanmic status

***ST depression often occur in presence of SAH and have not inc morbidity or mortality

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65
Q

ACA aneurysm repair, aneurysm rputured, what to do?

A

-not excessive: correct any conditions that inc ischemia: hypoxia, hypercarbia, hyperthermia, hyperglycemia, mild hypoTN to allow for repair
-excessive: compress carotid arteries, suggest temporary clipping, prepare for aggressive resucitation w/ fluids and blood products -> avoid hypoTN and cerebroprotective agents
-consider CPB

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66
Q

surgen put on a clip on the ACA to control bleeding -> SSEP changes

A

-correct any hypoxia, hyper/hypocarbia, anemia, hypotension, hypovolemia to optimize O2 delivery
-make sure depth of anesthesia has been stable
-consider inc MAP to improve collateral circulation
-consider prop/barbs to provide some ischemic protection

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67
Q

SIMV stands for

A

synchronized intermittent mandatory ventilation

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68
Q

POD #2 post ACA aneurysm repair, AMS, ddx?

A

-vasospasm (#1 M&M)
-delayed cerebral ischemia
-cerebral edema
-hematoma formation (highest 1st 12 hours)
-sz
-electrolyte abnormality

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69
Q

POD #2 post ACA aneurysm repair, AMS, what do you do?

A

evaluate patient, secure airway, ensure adequate ventilation and oxygenation
-check lytes
-EKG, trops, CK
-pain control
-BP
-urgent neuro c/s
-nimodipine for cerebral vasospasm
-transcranial doppler or angiography

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70
Q

Post ACA aneurysm clipping => vasopasm -> tx?

A

secure airway
normovolemia
inc MAP 20-30 above baseline using phenyleprhine, NE
-surgeon: transluminal angioplasty, or intra-arterial CCB

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71
Q

What is Triple H therapy post aneurysm repair?

A

Hypertension
hemodilution
hypervolemia

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72
Q

Neurogenic pulmonary edema

A

can occur after any injury to CNS -> minutes to hours
-massive sympathetic surge by injury CNS -> generalized vasoconstriction -> redistribution of blood volume to pulmonary circulation

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73
Q

tx of neurogenic pulm edema

A

treat CNS injury
reduce ICP
mechanically ventilate w/ TV 5-6 cc/kg
PEEP -> not too high, don’t want to impede cranial venous drainage
-diuretics
-optimal O2 delivery: Hg > 10. adequate cardiac ouput

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74
Q

ACA aneurysm repair, POD3 Na 125, differential?

A

-Cerebral Salt Wasting (UNa > 100, hypovolemia)
-SIADH (UNa < 100, normovolemia, elevated ADH levels)

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75
Q

tx for cerebral salt wasting syndrome

A

fluid and sodium replacement

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76
Q

tx for SIADH

A

water restriction and diuresis

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77
Q

Cystic fibrosis and pneumothorax

A

bullae formation w/ CF -> inc risk of PTX

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78
Q

Other system impact of cystic fibrosis

A

-coagulopathy (hepatic involvement and malabsorption of Vit K)
-diabetes (pancreatic involvement)
-electrolyte abnormalities (malabsorption)

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79
Q

PFTs for cystic fibrosis

A

dec max mid-exp flow rate
-inc RV to TLC’dec FEV1/FVC

80
Q
A
81
Q

Cystic Fibrosis pathophysiology

A

Mutation on a protein that transports chloride and bicarbonate -> impacts sodium transport across plasma membranes -> affects airways, intestines, liver, reproductive organs, sweat glands
-causes thick secretions -> Dec mucociliary cleareance, airway obstruction, bronchiectasis

82
Q

Treatment for CF

A

-breathing/coughing maneuvers -> chest PT
-percussive vests
-inhaled airway clearance agents: Doran’s Alfa, hypertonic saline
-oral azithromycin, inh tobramycin, and inh aztreonam w/ P. Aeration’s a in fxn
-pancreatic enzyme replacement therapy, fat-soluble vitamin supplementation, insulin
-if biliary obstruction: ursodeoxycholic acid

83
Q

Optimize cystic fibrosis patient for emergent surgery

A

-pulm: chest PT, bronchodilators, humidified nebulizers, perioop box
-GI: asp ppx
-adequate fluid resuscitation
-correct any coagulopathy or electrolyte abnormality as time allowed

84
Q

Asthma and nasal polyps with NSAIDs

A

NSAIDs or aspiration can induce bronchospasm

85
Q

Why R mainstem intubation w/ insufflation

A

Cephalad displacement of the diaphragm and carina with inflation of the pneumoperitoneum

86
Q

EtCO2 changes w/ capnothorax, PTX, and CO2 embolism

A

Capnothorax: increase
TPTX: decrease
CO2 embolism: decrease

87
Q

Laproscopic appendectomy, O2 sat Dec to 82%, diminished breath sounds over L lung field, what do you do?

A

-100% FiO2, look at peak pressures
-Look at EtCO2: if unchanged, likely too deep, w/d until b/l breadth sounds, if high possible capnothorax (ask surgeon to deflate, hyperventilate and try again)
-if low concerned for PTX -> ultrasound POCUS look for lung point, or lung pulse
-exhibit TPTX w/ hypoTN: needle thoracostomy or ask surgeon to place chest tube

88
Q

Benefit of thoracic epidural for open procedure

A

-improved pain scores
-greater mobility
-Dec postop pulm complications: Dec pulm splinting -> Dec atelectasis, shunting, improved clearance of pulm secretions
-reduce opioid requirements

89
Q

Coagulopathy and cystic fibrosis

A

Hepatic dysfunction and malabsorption of Vit K: reduced clotting factors II, VII, IX, and X: inc risk of epidural hematoma

90
Q

Emergence ship becomes delirious, thrashing around, pulling at ETT and IV

A

-call for help, secure girl’s arms to prevent from pulling, consider giving a sedating dose of fentanyl, ketamine, propofol, or dexmedetomidine
-acknowledge other causes: pain, hypoxia, hypercarbia, hypotension, hypoglycemia, bladder distention
-ensure adequate oxygenation and ventilation, adequate pain control, correct hypoTN or hypoglycemia, r/o bladder distention w/ bladder scan

91
Q

Limit emergence delirium how?

A

-reduce preop anxiety
-adequate postop pain control
-stress-free environment recovery
-preop midazolam

92
Q

RF for emergence delirium

A

-poorly controlled pain
-preop anxiety
-young age (1-5 highest)
-sevo and does
-pt underlying temperament
-type of surgery: abd and breast
-prolonged surgery time

93
Q

Extra pyramidal symptoms

A

Dyskinesias: repetitive, involuntary, purposeless body or facial movements
Akathisia: extreme restlessness, inability to sit still, jitteriness or shakiness
Dystopia: muscle tension strong muscle contraction

94
Q

Postop shaking ddx

A

-extrapyramidal symptoms (if metochlopramide given/anti-DA)
-shivering
-NMS
-seizure

95
Q

What causes extrapyramidal symptoms?

A
96
Q

Treat extrapyramidal symptoms

A

-diphenhydramine or benztropine
-d/c offending agent (antiemetic, anti-DA)
-give supplemental O2, assess respiration and oxygenation
-explain what occurred

97
Q

Diabetic undergoing outpt surgery

A

-reduce nighttime dose of subs insulin to 2/3 normal dose before bedtime
-hold rapid-acting or short-acting agents the morning of surgery
-check blood glucose level on arrival for surgery
-check glucose hourly during perioperative period
-goal: 120-180

98
Q

Importance of good glucose control

A

-increased wound healing
-decreased rate of infection
-decreased dehydration 2/2 osmotic diuresis
-reduce length of stay
-reduce mortality

GOAL: 120-180

99
Q

What is HgA1c?

A

Hg exposed to glucose -> glycosylated
-% of glycosylated Hg -> tells us glucose control over last 30-90 days

100
Q

Uncontrolled DM can cause

A

-CAD
-autonomic neuropathy
-peripheral neuropathy
-gastroparesis
-retinopathy
-renal insufficiency
-HTN
-PVD

101
Q

Revised Cardiac Risk Index

A

-ischemic heart disease
-heart failure
-cerebral vascular disease
-DM
-Cr of 2 or higher
-intra-thoracic, intra-abd, or supra-inguinal vascular surgery

**assess risk of major cardiac events
“In a Stroke (CVA) of genius, Debbie (diabetes) Created 2 (creatinine of 2, also 2 criteria is increased risk) HeartFelt (heart failure) Schemes (ischemic heart) to find a buff man with abs (chest, abdomen).”
1: 6%, 2: 10%, 3:15%

102
Q

DEX Dual antiplt therapy?

A

6 months! to avoid stent thrombosis
-consider at 3 months if benefit of surgery outweighs risk of stent thrombosis

103
Q

TURP complications w/ glycine solution

A

hyperammonemia -> encephalopathy, sz
visual disturbances
circulatory depression

104
Q

TURP complications w/ sorbitol solution

A

hyperglycemia

105
Q

Concerns with autonomic neuropathy

A

hemodynamic instability, silent MI, hypothermia

106
Q

Benefits of neuraxial for TURP

A

awake patient to communicate CP/SOB, AMS assoc w/ TURP syndrome, pain assoc w/ bladder or prostate perforation

107
Q

Sensory level goal for TURP

A

T10! need hyperbaric bupi for spinal
-above T9 sym/pain assoc w/ bladder perforation will not be felt

108
Q

TURP mannitol solution

A

intravascular volume expansion

109
Q

Distilled water for irrigation in TURP?-

A

Absolutely not -> hypervolemia, hyponatremia, intravascular hemolysis (hypotonic), shock, renal failure

110
Q

20 minutes into TURP pt agitated, HTN, ddx?

A

-inadequate spinal anesthesia
-TURP syndrome (fluid overload, toxicity from solute)-> hyponatremia
-perforated bladder
-perforated prostatic capsule
-MI
-sympathetic response to hypoxia, hypercarbia

111
Q

How does TURP syndrome occur?

A

hypotonic solution absorbed by venous sinuses in prostate -> circulatory overload, hypoNa, and solute toxicity

**inc risk w/ >1 hour surgical resection, bag suspended > 40cm above table (inc fluid hydrostatic pressure), disruption of prostatic capsule

112
Q

TURP syndrome symptoms

A

cardiovascular: HTN, reflex bradycardia, pulm edema
neuro: confusion, restlessness, sz, visual changes (cerebral edema and inc ICP)
resp: pulm edema, hypoxia,
hematology: hemolysis, DIC
renal: metabolites of glycine can lead to renal failure
metabolic: acidosis -> breakdown of glycine

113
Q

Treatment of TURP syndrome

A

-ensure adequate O2
-hemodynamic support
-invasive monitoring if unstsable
-eval blood gasses, lytes, osmolality, glucose
-12 lead EKG
-tx hypoNa: fluid restriction, diuretics, hypertonic saline, anticonvulsants as needed

114
Q

TURP: pt agitated, hypertensive, bradycardic, c/o pain to abd and L shoulder, what to do?

A

-Communicate w/ surgeon possible bladder perforation
-also concerned for MI: 12 lead EKG
-optimize O2 and ventilation, support hemodynamically, ensure adequate analgesia, treat any hemodynamic instability

115
Q

Succ given at beginning of TURP, 40 minutes later pt not breathing spontaneously, ddx?

A

-pseudocholinesterase def
-TURP syndrome
-toxicity from irrigation solution (glycine -> inc ammonia -> encephalopathy)
-hyperglycemia (sorbitol)
-too much narcotics
-stoke (cerebral ischemia, cerebral edema)
-hypothermia
-hypoxia/hypercarbia

116
Q

Post TURP, not initiating respirations, what to do?

A

-ensure adequate oxygenation and ventilation
-assess residual NMB (TOF)
-auscultate the chest (asp, pulm edema, PTX)
-check EKG for signs of ischemia or arryhtmia
-ensure normothermia
-signs of narcosis (miosis)
-check lytes and ABG

117
Q

Fade with TOF means?

A

residual nondep NMB
phase II blockade from depolarizing muscle relaxant (multiple doses, prolonged infusions, or atypical pseudocholinesterase activity)

118
Q

Dibucaine number

A

indirect measure of pseucholinesterase activity

normal: 70s-80s
homozygous: 20s-30s
heterozygous: 50s-60s

119
Q

If given succ and pt has pseudocholinesterase activity, what do you do?

A

continue to sedate and support mechanically ventilate
-consider extubation w/ full return of TOF and once other extubation criteria have been met

120
Q

Difficulty seeing post TURP, ddx?

A

-2/2 glycine toxicity (transient blindness)
-anterior or posterior ischemic optic neuropathy
-acute glaucoma
-retina ischemia
-corneal abrasion

121
Q

severe, diffuse periorbital pain, dry and pale eye, dilated pupil

A

acute glaucoma

122
Q

dilated/nonreactive pupil, normal intraocular pressure, fundus exam, extra-ocular muscle movement after TURP

A

glycine toxicity

123
Q

Anterior ischemic optic neuropathy

A

acute ischemic disorder of the optic nerve head supplied by the posterior ciliary artery
*assoc w/ cardiac surgery
-optic disc edema

124
Q

Posterior ischemic optic neuropathy

A

acute optic neuropathy due to ischemia in the retrobulbar portion of the optic nerve.
*assoc w/ spine surgery
-no optic disc edema

125
Q

Why is postop sepsis assoc w TURP

A

G postive and G neg bacteria into systemic circulation through disrupted prostatic enous sinuses -> bacteremia
-entry of prostatic bacteria into systemic circulation

126
Q

can post TURP septicemia be prevented w/ preop abx?

A

No, abx do not easily penetrate prostate gland => however helpful for reducing incidence of UTI w/ pstop foley

127
Q

Treatment of septic shock

A

-BClx to identify organisms 1st
-broad spectrum antibiotics
-identify source: imaging
-fluid boluses
-vasopressor support as needed (NE 1st line)

128
Q

Risks of starting beta blocker same day as surgery

A

inc risk of morbidity and mortality
-risk of bradycardia, hypoTN, stroke

129
Q

CK v troponin

A

CK: less specific for mycoardial damage, inc 4-6 hrs, max 12-24, baseline 2-3 days

troponin: more specific for myocardial damage
-inc 2-6 hours, max 12-24, baseline 7-10 days

130
Q

Diagnosis of NSTEMI

A

elevated cardiac biomarkers
ST seg depression 2 or more contiguous leads

131
Q

ST depressions on EKG can indicate

A

-non-ST elevation MI
-non-infarction subendocardial ischemia
-hypokalemia

132
Q

contributing factors to MI

A

-supply cannot meet the myocardial demand
-dec supply: hypoTN, tachycardia, anemia, coronary atherosclerosis, hypoxia
-inc demand: tachycardia, LVH, inc afterload

133
Q

pre-CABG wheezing, dec breath sounds LLL, further eval/tests?

A

Yes, could be 2/2 bronchospasm, post MI pleural edema, COPD-PNA
-eval: CXR, PFTs, echo, ABG

-dpt on results: bronchodilators, abx, diuretics

134
Q

CABG, CXR LLL atelectasis, delay case?

A

likely mucous plugging due to COPD/smoking -> mild/mod not interefering w/ O2 or ventilation would proceed with case

-if severe, benefit from short delay to allow for further treatment

135
Q

Atelectasis on CXR, how to optimize preop?

A

bronchodilators
chest PT
incentive spiromety
-post-intubation recreuitment maneuvers

136
Q

Therapeutic level of digoxin

A

0.5-2!!

137
Q

Digoxin toxicity symptosm

A

EKG changes
arrhythmias (heart block, scooped ST segments)
fatigue
hypersalivation
confusion
N/V
visual disturbances

138
Q

What potentiates digoxin toxicity?

A

hypoK
hypoMg
HyperCa

139
Q

R carotid bruit, where to put your central line?

A

-not RIJ -> risk of dislodging clot and causing stroke in artery if accidental carotid puncture
-subclavian approach if actively on heparin cannot be used due to lack of ability to compress
-LIJ ideal -> likely has collateral flow for cerebral perfusion pressure -> minimal in asymptomatic carotid artery dsease

140
Q

pre-CABG on heparin infusion, d/c prior to central line placement?

A

No -> not want to risk further comproising coronary perfusion
-acknoweldge risk of hematoma formation

141
Q

post induction, pre-chest incision, BP drops 80/50 HR 50, ddx?

A

-cardiovascular depression following induction drugs and volatile agents
-autonomic neuropathy 2/2 diabetes
-arrhythmia, cardiac ischemia
-TPTX (recent central line)

142
Q

post induction, pre-chest incision, BP drops 80/50 HR 50, what to do?

A

ensure adequate O2 and ventilation -> 100% FiO2, auscultate chest, verify BP
-TEE
-look at EKG for arrhythmias
-consider small fluid bolus and direct acting vasopressor

143
Q

Decrease in BP w/ initiation of CPB why?

A

-hemodilution 2/2 priming solution
-dec in SVR 2/2 priming solution
-anesthesia induced vasodilation
-inadequate venous return to pump
-kinking, clamping, malpositioning of arterial cannula

144
Q

post CABG cannulation -> unilateral face blanching, R sided mydriasis, chemosis

A

-malpositioning of arterial cannula w/ flows of priming directed to brachiocephalic artery
-can also have increased R rad art line pressures

145
Q

Malposition of arterial cannulation -> proceed?

A

Possibility for cerebral injury -> prefer to delay to allow for resoltuion for cerebral edema or inc ICP
-if surgeon said delay not possible -> take steps to reduce cerebral edema: mannitol, head up positioning -> maintain cerebral perfusion

146
Q

Why glucose control important in CABG

A

-hyperglycemia can exacerbate neuronal injury w/ hypothermia
-infection
-impaired wound healing
-oncotic diuresis

147
Q

Prepare to wean off CPB

A

-normothermia
-check ABG, Hg, lytes -> no anemia or electrolyte derrangements
-check lung compliance and initiate ventilation
-heart de-aired
-ensure adequate cardiac function w/ TEE
-hemodynamically stable
-ensure presence of pacing capabilities and rescucitation drugs

148
Q

Post CABG hypoTN in ICU, bradycardia, PVCs, what do you do?

A

-confirm adequate oxygenation and ventilation
-look at EKG
-ensure proper pacemaker function
-ensure correct infusion concentrations
-look at chest tube drainiage
-check pts volume status, and lytes -> tx accordingly

149
Q

Why might PM fail to capture?

A

MI
lead dislodgement
insufficient energy
PM malfunction
acid-base distrurbances
lyte abnormalities

150
Q

Post CABG BP dropping 70/52 HR in 40s, what to do?

A

Ensure adequate oxygenation and ventilation
attempt transcutaneous or transvenous pacing
-correct any electrolyte or metabolic abnormalities
-if needed give atropine or epi
-check pulse -> might need to start compressions

151
Q

Post CABG first 2 hours, 250 cc out of chest tube, give more protamine?

A

Acknolwedge that inadequate reversal could cause it, however multiple other causes should be evaluated/considered as well
-send ACT
-inadequate surgical hemostasis
-thrombocytopenia
-malfunctioning plts
-hypothermia
-dilution of coagulation factors

152
Q

most likely cause of coagulopathy after CPB?

A

plt dysfunction

(thromboctyopenia, hemodilution of clotting factors, hypothermia, DIC)

153
Q

Post CBG bleeding, how to determine cause?

A

-ACT
-CBC, fibrinogen, PT/PTT
-TEG

**if fails to determine cause -> back to OR

154
Q

Normal SvO2

A

60-80%

155
Q

Extubate if SvO2 is 50s?

A

No -> sign of inadequate tissue perfusion or low cardiac output -> needs to be investigated

156
Q

Postop pt says he was awake during CABG, thoughts?

A

-intraop recall poorly understood
-CBG, trauma, and OB have highest risks
-likely to occur during rewarming (hypothermic potentiation of anesthesia is lost)
-minimize: benzos w/ rewarming or anesthetic dosing of iso

157
Q

What to tell pt and his family if intraop recell?

A

-rare and poorly understood complication
-empathize w/ his experience, pracuations were taken to minimize, goal is to keep him safe and alive, offer counseling/psych eval

158
Q

BMI definition

A

weight in kg/ heigh in meters squared -> identify and classify overweight/obese individuals and theoretically risk of developing associated problems

159
Q

Does liposuction technique matter?

A

YES
-tumescent technique: large volumes diluate anesthetic w/ epi injected into subq tissues -> < 3000 cc
-semitumescent: larger volume of fat removal -> higher risk of fluid overload, pulm edema, LAST, fat emboli
-newer techniques: laser and ultrasonic energy: low complciations

160
Q

Morbid obesity risks w/ anesthesia

A

-difficult airway
-pt position
-pulm abnormalities: OSA, atelectasis, hypoxia, dec FRB, rapid desaturation)
-obesity hypoventilation
-OSA
-DM
-HTN
-CAD
-stroke
-DVT/PE
-fatty liver

161
Q

Possible complications w/ tumescent liposuction

A

periop fluid overload
pulm edema
LAST
systemic epi uptake
cardiac arrhythmias
PE

162
Q

Lidocaine dosing w/ tumescent liposuction

A

35-80 mg/kg -> max 55 mg/kg

163
Q

risk factors that inc risk of LAST

A

extremes of age
cardiac dx
renal or hepatic dysfxn (dec metab)
hypoproteinemia (inc level of free drug)
metabolic/resp acidosis
pregnancy

164
Q

IV fluids w/ tumescent liposuction?

A

-minimize -> large risk of inc intravascular volume w/ procedure (will continue to absorb fluid up to 48 hours postop)
-consider lasix if positive fluid balance

165
Q

Post tumescent liposuction pt wheezing and SOB, ddx?

A

bronchospasm
pulmonary edema
PE
PTX
aspiration pneumonitis
allergic rxn

**suppl O2, auscultate, signs of fluid overload, CXR or POCUS?

166
Q

Cancer pain, severe doses of morphine, N/V/ pain, constipation, treatment modalities would you recommend?

A

-adjuvants: antidepressants, anticonvulants for neuropathic pain
-opioid rotation
-celiac plexus block
-spinal cord stimulator
-acpuncture
-TENS
-psychologicla therapy

167
Q

how to perform a celiac plexus block

A

prone at level of L1 vertebral body
needle 5-7 cm lateral to midline -> advanced under fluoroscopic guidance to be anterior to vertebral body
-test block w/ local anestheticn-> benefit neurolytic block

168
Q

complications of celiac plexus block

A

paralysis (neurolytic agent into spinal or epidural space, artery of adamkiewicz_
postural hypoTN
accidnetal intravascular injxn
treoperitoneal hemorrhage
sexual dysfunction
damage to kidneys or pancreas

169
Q

CPRS I v II

A

definitive n injury present in type II
not in type I
-type I can have an injury, but no DEFINITIVE n inury

170
Q

diffuse burning pain in arm 6 mo after hand injury, fingers cyanotic, ddx?

A

CRPS-I
soft tissue injury
brachial plexus injury
Raynauds
carpal tunnel
peripheral neuropathy

171
Q

Diagnostic criteria for CPRS-I

A

following an incident:
-pain out of proportion to degree and type of injury
-cyanotic changes
-changes in temperature
-stiff and painful joints
-exclusion of other causes for pain/dysfxn

*pain is NEVER limited to a single peripheral nerve

172
Q

CRPS-I v CRPS 2

A

CPRS 2: occurs after definitive n injury -> symptoms are not limited to distribution of that nerve
CRPS I: following an injury, but no n injury

173
Q

Treatment options for CRPS

A

-PT!
-CBT
-gabapentin/lyrica
-antidepressants (amitryptline)
-sympathetic n block
-ketamine IV
-SC stimulator

174
Q

2 YOF fever, stridor, substernal retractions, ddx?

A

epiglottitis
laryngotracheobronchitis
foreign body aspiration
pharyngeal abscess
peritonsillar abscess
pharyngitis

175
Q

2 YOF fever, stridor, substernal retractions, how to determint etiology?

A

H&P
-epiglottis sudden, laryngotracheobronchitis slower onset
-assoc w/ eating: foreign body aspration
drooling: epiglottitis
-previous vaccination status: H influenzae type B (epiglottitis)

-if child was stable, radiographic exam can differentiate

176
Q

how to induce a child w/ MH concerns w/ epiglottitis

A

-cal lahead -> clean setup: no succ, vaporizers removed, flush machine, charcoal filters, change CO2 absorber
-difficult airway equipment and surgeon available
-have parental presence to calm child -> crying will worsen airway obstruction
-monitors on -> 100% FiO2 preoxygentate
-keep child sitting
-give 2-3 mg/kg IM ketamine providing sedation for IV access and spontaneous ventilation
-CPAP
-fluid bolus -> deepen plane of anesthesia to prevent spasm w/ DL
-give glyco to reduce secretions -> gentle DL -> ETT (smaller than normal)
-confirm air leak at 20-25 cm H2O
-consider exchange for nasal?
-BClx and abx
-maintain sedation for transfer -> go to ICU

177
Q

When to extubate epiglottits

A

24-72 hours later when fever, neutrophilia, and epiloglottic swelling have resolved
-swallowing and leak present around ETT
-ensure by flexible fiberoptic that airway edema resolved

178
Q

effects of GH secreting tumor

A

-skeletal and soft tissue overgrwoth: enlaged tongue, tonsils, nose, hands, feet
-HTN
-accelerated atherosclerosis
-OA
-skeletal m weakness
-cardiomyopathy
-VC palsy
-OSA
-insulin resistance
-glottic stenosis

179
Q

When to be concerned about PVCs

A

more than 3 per minute
polymorphin
runs of 3 or more
R on T phenomenon

**VT or VF

180
Q

pituitary tumor, w/ infiltrate of local anesthesia, PVCs, what to do?

A

-ask surgeon to stop injecting
-identify freq of PVCs to see if concerning
-verify oxygenation and ventilation
-other causes: hypoxia, MI, hypoK, sympathetic activation
-ensure presence of defibrilattor
-consider overdrive pacing or amiodarone (antiarrhythmic)

181
Q

PVCs and morbidity

A

5-6 PVCs per minute inc periop morbidity

182
Q

Resp distress after terbutaline for premature labor, crackles b/l, ddx?

A

terbutaline pulm edema
PEC
PE
cardiac condition

183
Q

pregnant lady w/ pulm edema, tx? intubate?

A

tx: identify the cause of the pulm edema H&P -> cardiogenic, PEC -> consider diuretics
-intubate: consider support w/ CPAP 1st, dept on how hemodynamically stable she was and her O2 saturation -> consider intubating

184
Q

How does PEEP help pulm edema?-

A

-redistributes fluid to areas less involved in gas exchange
-recruits collapsed alveoli that are contributing to shunting

185
Q

Post stellate ganglion block -> difficultly speaking, dizziness, difficulty swallowing, SOB, ddx?

A

-LAST
-recurrent larygeal n injury
-accidental epidural/spinal injection
-PTX

186
Q

Progression of LAST toxicity

A

-metallic taste, oral paresthesias, tongue numbness, visual changes, tinnitus, lightheadedness, dizziness
-agitation, shivering, tremors, sz
-resp depression, LOC, coma
-hypoTN, bradycardia, dysrhthmias, asystole

187
Q

LAST, what to you do?

A
  • call for help, put on monitors
    -obtain intralipid
    -support oxygenation and ventilation -> intubate if unable to complete
    -midazolam for sz
    -if progression of neuro or cardiovascular collapse -> give intralipid
    -support hemodynamically
188
Q

Dosing for lipid emulsion therapy

A

Bolus 1.5 cc/kg of 20% lipid solution over 1 min -> continuous infusion of 0.25 cc/kg/min

189
Q

LAST asystole, what to do?

A

-start compressions
-call for help
-intubate -> optimize oxygenation and ventilation
-give intralipid bolus
-attach to monitor -> evaluate rhythm, shock if able
-give epi 1 microg/kg bolus (lower doses in LAST)

190
Q

What affects systemic absorption of local anesthetic

A

-amount of blood flow at site of injection
-dose
-properties of local anesthetic (lipid solubility, protein binding)
-addition of vasoconstrictors

191
Q

Why 2 P waves on EKG post heart transplant

A

1 P wave: native SA node
-other donor SA node

**native SA node, cannot cross suture line to transplanted heart

192
Q

Following CSE, tetanic uterine contraction, FHR dec, why?

A

rapid analgesia -> dec circulating epi w/ uterine hypertonus -> decreased uterine perfusion -> fetal bradycardia

other reasions: maternal hypotension 2/2 sympathetectomy, nuchal cord, aortocavalc compression, possible PEC?

193
Q

Response to fetal bradycardia

A

-L uterine displacement
-assess O2 -> give supplemental
-assess BP -> increase BP
-d/c oxytocin
-consider tocolytic

194
Q

post heart transplant for c/s, preeval?

A

-talk to transplant team: how shes been doing, immunotherapies, steroids
-look at recent echo, EKG, myocardial biopsies
-any SE from antirejection medication: inc cr?
-EKG: inc HR: pregnancy or silent MI?
-eval pacemaker?
-stress dose steroids
-airway exam

195
Q

heart transplant pregnant pt, hypoTN after induction, why?

A

-Dec SVR 2/2 anesthesia induction -> heart cant compensate, preload dpt

-other ddx: allergic rxn, inadequate L uterine displacement, MI, PE, AFE

196
Q

symptoms of allograft rejection of heart

A

usually w/i 1st 6 months
fever, malaise, arrhythmias, SOB, accelerated coronary atherosclerosis, mycardial dysfxn

197
Q

how to reverse NMB in a transplanted heart?

A

-neostigmine can cause bradycardia in transplanted hearts after 6 months -> yes give glyco
-additionally want to block other peripheral muscarinic effects like bronchospasm and inc salivation

Anesthesia Oral Boards (8 decks)

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