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Valley Review Book Flashcards

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1
Q

How much body water is in the ECF? ICF?

A

TBW = 42L
ECF (1/3)= 14L
ICF (2/3)= 28L

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2
Q

Components of phospholipids in the phospholipid bilayer

A 
Hydrophobic head (+ charge)
Hydrophilic tail
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3
Q

Major Intercellular Ions

A

K, Mg, PO4

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4
Q

Major extracellular ions

A

Na, Cl, Ca, HCO3

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5
Q

Examples of ligand gated ION channels

A

5-HT3, GABA(A), Glutamate

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6
Q

Examples of GPCR

A

Muscarinic ACh receptors & most adrenergic receptors

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7
Q

Function of Na-K ATPase (pump)

A

3 Na OUT and 2 K IN

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8
Q

Example of something that stimulates the Na-K Pump

A

Insulin and Beta-2 agonists (aka ritodrine, terbutaline)

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9
Q

The 4 major categories of receptors

A
  • Ligand gated ion Channels
  • GPCR
  • Calalytic
  • nuclear receptors
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10
Q

Effect of increased cAMP in cardiac muscle

A

Increases contractility (d/t inc Ca) (Beta-1)

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11
Q

Effect of increased cAMP in bronchial muscle

A

relaxes bronchial smooth muscle(d/t dec Ca) (Bronchodilation) (Beta 2)

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12
Q

What kind of receptors are beta adrenergic receptors

A

Gs: stimulate increased cAMP

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13
Q

Subunits of the GPCR

A

heterotrimeric:
Gamma
Beta
Alpha

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14
Q

List the common second messengers

A 
cAMP
cGMP
Ca
Calmodulin
Inositol Phosphate (IP3)
Diacylglycerol (DAG)
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15
Q

Metabolizes cAMP into AMP

A

PDE

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16
Q

cAMP simulates

A

Protein Kinase A

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17
Q

Activates cGMP

A

NO, NTG, Nitroprusside, Nitric Oxide Donors

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18
Q

Function of phospholipase C

A

create IP3

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19
Q

Normal serum osmolality

A

300 mOsm/kg (270-310)

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20
Q

Most electrolytes are reabsorbed in what part of the nephron?

A

Proximal Tubule

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21
Q

Site of action of carbonic anhydrase inhibitors

A

Proximal Tubule

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22
Q

Function of the descending loop of henle

A

Reabsorbs H2O (Impervious to Na)

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23
Q

Site of action of loop diuretics

A

Ascending Thick LOH

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24
Q

Function of Ascending Thick LOH

A

NA/K-Cl Pump

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25
Site of action of ADH
Collecting Ducts
26
MOA of ADH
Inserts Aquaporins (V2) into the collecting duct to facilitate reabsorption of H2O
27
The site of action of aldosterone
collecting duct (primarily) and Late Distal Tubule
28
MOA of aldosterone
Facilitates Na (therefore H2O) reabsorption and K+ excretion
29
Site of action of hydrochlorothiazide (HCTZ)
Early Distal Tubule
30
Site of action of Spironolactone (K sparing)
Late Distal Tubule
31
The peritubular capillaries of the LOH
Vasa Recta
32
Components of the nephron found in the cortex
Glomeruli, proximal tubules, distal tubules
33
Components of the nephron found in the medulla
LOH and Collecting Ducts
34
CO delivered to kidneys
1.25L/min (25%)
35
What establishes the osmotic gradient in the medulla of the nephron?
Loop of Henle
36
Where is glucose reabsorbed in the nephron
Proximal Tubule
37
Where is vasopressin synthesizes? Released?
Synthesized in the paraventricular and supraoptic nuclei of the hypothalamus Released from the posterior pituitary (Neurohypophysis)
38
What stimulates ADH release?
Increase plasma osmolarity (also Stress, hypotension Pain, CPAP, PEEP, VA)
39
Normal urine osmolarity
1200-1500 mOsm (AVP level low 0.5mg/kg/hr)
40
Urine osmolarity seen with high levels of AVP/ADH/Vasopressin
50-100 mOsm (AVP level 2-25 mg/kg/hr)
41
Causes of SIADH
Intracranial Tumor, Hypothyroidism, Porphyria, small Oats cell carcinoma of the lung
42
the major determinant fo extracellular fluid volume
Sodium content
43
Most important HORMONE for regulation of extracellular fluid volume
Aldosterone
44
Things that increase Na excretion
increased GFR, increased ANP, decreased aldosterone
45
Things that decrease Na excretion
decreased GFR, increased aldosterone, decreased ANP
46
Where is aldosterone produced
Zona Glomerulosa of the adrenal cortex
47
Where in the nephron is most of the sodium reabsorbed
proximal tubule (active process requiring energy)
48
Where in the nephron is most of the potassium reabsorbed?
Proximal Tubule 60%; Ascending LOH 25%
49
What factors increase K+ excretion?
- Aldosterone secretion - Increased Distal Tubular flow rate: Increased flow rate seen with Lasix - BiCarbonate Concentration in Tubular Fluid: increase urine alkalinity increases K+ excretion
50
List some loop diuretics
``` (ide) furosemide bumetanide Torsemide Ethacrynic acid ```
51
What is the target for loop diuretics?
Inhibition of the Na-K-2Cl symporter: inhibit the reabsorption of these ions (located in the Thick Ascending LOH)
52
Side effects of loop diuretics
Hypokalemia, Fluid volume deficit, Otho Hypo, reversible deafness
53
MOA of thiazide diuretics
Inhibit Na reabsorption in the early distal tubule
54
Examples of Thiazide diuretics
Chlorothiazide, Hydrochlorothiazide, Chlorthalidone, Metolazone
55
MOA of potassium-Sparing Diuretics
Decrease Na reabsorption form the late distal tubule and collecting duct
56
MOA of Spironolactone
Competitively inhibits aldosterone: | - therefore inhibits sodium reabsorption in the late distal tubule and collecting duct
57
Side effects of thiazide diuretics
Hypokalemia due to increased K+ secretion
58
Side effects of potassium-sparing diuretics
Hyperkalemia
59
MOA of carbonic anhydrase inhibitor
Inhibits the enzyme carbonic anhydrase in the proximal tubule which inhibits bicarb reabsorption
60
Example of carbonic anhydrase inhibitor
Acetazolamide
61
Actions of carbonic anhydrase inhibitors
Dec Bicarb reabsorption Dec sodium reabsorption -> these cause diuresis -> hyperchloremic metabolic acidosis
62
One of the principal therapeutic uses of acetazolamide
Decrease IOP by decreasing formation of aqueous humor
63
Side effects from osmotic diuretics
Hypokalemia (K+ secretion is increased secondary to flow through the distal tubule and collecting duct)
64
Prerenal causes of perioperative oliguria
Decreased RBF Hypovolemia Decreased CO
65
Renal causes of perioperative oliguria
Renal Tubular Damage (acute tubular necrosis) Renal Ischemia Nephrotoxic Drugs Release of HgB or Myoglobin
66
Postrenal causes of perioperative oliguria
Obstruction Bilateral ureteral obstruction Extravasation due to bladder rupture
67
Tests to differentiate prerenal from renal failure
``` Renal failure (Aka acute tubular necrosis, ATN)) has high fractional excretion of sodium (FENa) > 0.03 (3%) Prerenal failure FENa < 0.01 (1%) ```
68
Normal GFR
125 ml/min
69
GFR for renal insufficiency
12-50 mL/min
70
Pathophysiology of CKD
``` Chronic anemia Pruritus Coagulopathies Hyperkalemia Hypocalcemia Hypermagnesemia HTN Pericardial Dz Metabolic acidosis ```
71
Treatment options for hyperkalemia
``` give Ca Give HCO3 Hyperventilate Loop Diuretics Give insulin-glucose Administer B2 agonist (terbutaline) Kayexelate Dialysis ```
72
Where is most of the HCO3 absorbed?
In the proximal Tubule (90%)
73
Formula for anion Gap
([Na]+[K])-([Cl]+[HCO3])
74
Normal anion gap
12mM
75
What is the definition of anion gap?
total of unmeasured anions (-) such as Proteins, HPO4, & SO4
76
Ion responsible for RMP in nerve? Depolarization? REpolarization?
``` RMP = K Depolarization= Na INTO cell Reploarization = K OUT of cell ```
77
Motor neurons are what kind of nerve fiber?
A-alpha fibers (Large, myelinated, fast conduction velocity)
78
Receptors found in the motor end plate
Nm (nicotinic ACh receptors)
79
What affect does ACh binding to PREsynaptic Nicotinic receptors in the NMJ have?
Positive feedback: increases release of ACh | This accounts for fade seen with NDMB and phase II blocks with succ
80
Ions that diffuse across NMJ as a result of ACh binding to nicotinic receptors
``` Ca and Na IN K OUT (Hyperkalemia with succ) ```
81
What subunit does ACh (and succ) bind to on the Nicotinic receptor in the NMJ
2 Alpha subunits (one ACh to each)
82
MOA of NDMB
Competitive inhibition of ACh- binding sites (Alpha subunits) in the NMJ
83
How long after succ does myalgia occur?
24-48 hours
84
Characteristics of NDMBs
``` aka Phase II Block: Competitive inhibition Fade after high frequency stimulation Exhibits post-tetatinc facilitation Antagonized by anticholinesterases NO fasciculations ```
85
Metabolism of succinylcholine
Plasma cholinesterase ( false, pseudo, non-specific, or type-II)
86
Characteristics of depolarizing muscle blockers
AKA Phase I Block: - decreased single twitch hight - response to high frequency stimulation is maintained - minimal or No fade after TOF - Antagonized by non depolarizers - potentiated by anticholinesterase - Fasciculations precede block
87
Intermediate action NMBs
``` (30-45min) (CAR-V) Cisatracurium Atracurium Rocuronium Vecuronium ```
88
Define DOA of NMBs
The time from injection to return of 25% twitch height
89
The amino steroid NMB
"curonium" Rocuronium Vecuronium Pancuronium
90
The benzylisoquinoline NMB
"curium" Atracurium Cisatracurium Mivacurium
91
What are some properties of NMBs?
100% ionized at physiologic pH VERY highly protein bound Do NOT cross BBB/Placenta (d/t ionization) excreted in urine (d/t ionization)
92
NMB with primarily biliary excretion
Vec and Roc
93
Metabolism is the primary route of elimination for which NMBs
Succ, atracurium, Cis, mivacurium | the "curiums" + Succ
94
NMB which is metabolized by hofmann elimination
Cisatricurium | Atracurium ( and ester hydrolysis by non-specific esterase's)
95
NMB's that elicit the release of histamine
Succ, Miv, atra ...
96
Why does succinylcholine elicit bradycardia
Mimics the action of ACh at muscarinic receptors in the SA node
97
NMB that is a direct vagolytic
Pancuronium ( aka antimuscarinic actions)
98
Potassium changes seen with succinylcholine
Increases plasma K by 0.5 mEq/L in healthy | 5-10 mEq/L in Burn, trauma or head injury
99
Why is the twitch response greater on the paralyzed size of a hemiplegic patient?
Due to up-regulation of ACh receptors
100
Signs of malignant hyperthermia
Increased EtCO2, Pyrexia, Tachycardia, Cyanosis, Rigidity, or master spasm (trismus)
101
Serum abnormalities seen in MH
increased H, K, Ca, and CO2 | Decreased O2
102
What defect is present that causes MH
Mutation in ryanodine receptor (RyR1)
103
One of the earliest, most sensitive and specific signs of MH
Elevation in EtCO2
104
Antibiotics that increase the degree of blockade with NDNMBs
Neomycin, streptomycin
105
LAs that increase the degree of blockade with NDNMBs
Amides (dec dose by 1/3 to 1/2)
106
Effect of VAA on degree of blockade from NDNMBs
increased blockade
107
Lithiums effect on NMBlockade
increases degree of block
108
Effect of myasthenia graves on succinylcholine
block DECREASED
109
Clinical response to 75-80% blockade
TV > 5mg/kg; single twitch as strong as baseline
110
Clinical response for 90% blockade
ABD relaxation adequate for most and surgeries (1 twitch on TOF)
111
Clinical response for 70-75% Blockade
No palpable fade, sustained tetany for 5 seconds, VC at least 20 mL/kg ( reliable indicator for recovery)
112
Clinical response for 50% blockade
Neg insp test -40cm H2O, Head Lift for 5 seconds, sustained strong hand grip, SUSTAINED BITE, (reliable indicator of recovery
113
When does a phase II block occur with succinylcholine
Treatment with higher doses, and/or prolonged exposure (this is diagnosed by the presence of FADE)
114
The predominant neurotransmitter in the periphery
ACh
115
Where is NE released in the periphery
From all sympathetic POST-ganglionic nerves (the exception is sweat glands)
116
The adrenal medulla is innervated by
Sympathetic Preganglionic Neurons that release ACh
117
Where are muscarinic receptors found
peripherally in tissues innervated by parasympathetic postganglionic neurons
118
List the nerve fiber types and their transmitted sensation
``` A-alpha: Muscle contraction & proprioception A-beta: Proprioception, touch, pressure A-gamma: Skeletal muscle tone A-delta: Pain, Temperature, Touch B-Fibers: Autonomic sC-Fibers: Autonomic dC-Fibers: Pain, Temperature, Touch ```
119
Origin of the sympathetic nervous system
Thoracolumbar: T1-L2 or T1-L3
120
Origin of cardiac accelerators
T1-T4
121
Origin of the stellate ganglion
Inferior cervical and first thoracic ganglia
122
Signs and symptoms of Horner Syndrome
``` (Stellate ganglion block) Ipsilateral Miosis Ptosis Enophthalamos Flushing Increased Skin Temp Anhydrosis Nasal Congestion ```
123
All sympathetic preganglionic fibers pass through the _______
White Ramus located from T1-L2
124
Function of grey rami
Allow for coordinated mass discharge of the SNS
125
What is the function of presynaptic Alpha 2 receptors
Negative feedback for the release of NE
126
Pathway for the synthesis of NE
Tyrosine-> L-Dopa-> Dopamine (DA) -> NE -> Epi
127
What is the % of NE and Epinephrine in the adrenal medulla?
20% NE; 80% Epi
128
What metabolizes NE
MAO in the nerve terminal; COMT in the plasma | 80% of NE is not metabolized but undergoes reuptake from the synaptic cleft
129
Drugs to avoid in patients taking MAOI's
Indirect acting sympathomimetics (ephedrine) and Meperidine: They may lead to hypertensive crisis Meperidine > ephedrine
130
Effect of Beta 1 stimulation on the heart
Increased HR(SA node) , Contractility (muscle fibers), and conduction speed (AV node)
131
Effect of Beta 2 stimulation on the lungs
increased secretions and bronchodilation
132
Beta receptor of the kidney
Beta 1: increases renin release -> Increase BP
133
Beta receptor of the liver
Beta 2: Gluconeogenesis and glycogenolysis
134
Effect of Beta stimulation on the uterus
Beta 2: relaxation (Ritodrine)
135
Resting BP is controlled mainly by _______
Renin (85%)
136
Where is renin released
Juxtaglomerular cells of the AFFERENT arteriole
137
Function of Renin
Converts angiotensinogen to Angiotensin I
138
Where is ACE found
On the endothelial surface of capillaries especially in the PULMONARY Capillaries (this is why it causes cough)
139
The two most important stimuli for aldosterone release
Angiotensin II and High serum potassium
140
Function of aldosterone
Increase potassium excretion and sodium reabsorption (Promotes volume expansion)
141
What causes Renin release
Dec RBF | Inc SNS stimulation or [Cl-]
142
Why do we see a decrease in MAP and Diastolic BP with low dose EPI
Beta 2 mediated vasodilation (decreased SVR)
143
Anatomical landmark for T4
Nipple
144
What are some side effects of ritodrine?
Hyperglycemia, Hypokalemia, tachycardia
145
Origin of the parasympathetic nervous system
Craniosacral Cranial Nerves: oculomotor CN III, facial CN VII, glossopharyngeal CN IX, and Vagus CN X Sacral nerves S2-S4
146
Drug that can cause cholinergic crisis
Physostigmine (i.e. excess acetylcholine)
147
Symptoms of cholinergic crisis
``` DUMBBELL STPD (accessive AcH) Diarrhea, Urination, Miosis, Bradycardia, Bronchoconstriction, Emesis, Lacrimation, Lethargy, Salivation, & Seizures. Treatment Atropine, Pralidoxamine, and Diazepam ```
148
Which antimuscarinic least crosses the BBB
Glycopyrolate (d/t charged ammonium group)
149
Signs of anticholinergic syndrome
delirium, dry mouth, flushed skin, blurred vision, tachycardia, rash, hypotension (mad as a hatter, Dry as a bone, Red as a beet, Blind as a bat....)
150
Treatment for anticholinergic syndrome
Physostigmine
151
Bronchodilation is promoted by stimulation of which receptor
Beta 2 Adrenergic
152
MOA of leukotriene antagonists?
competitive antagonists of leukotriene
153
What is the function of the reticular activating system (RAS)
functions to maintain alert/awake state
154
What is the purpose of SSEP monitoring
Monitor for posterior chord ischemia or brain ischemia
155
Site of SSEP stimulation at the ankle
Tibial Nerve
156
Indicators of damage in nerve being monitored surging SSEP
DECREASE in amplitude | INCREASE in latency
157
Motor evoked potentials are used to monitor for
Ischemia to the anterior (ventral) cord
158
BAEP monitor the integrity of
CN VIII
159
VEPs monitor the integrity of
The optic nerve CN II
160
Order the evoked potentials according to their sensitivity to anesthetic agents
VEP (Very) SSEP (Somewhat) BAEP (Barely)
161
Where is the substantial gelatinous located
In Lamina II & III of the dorsal horn
162
Major neurotransmitter of A-delta fibers
Glutamate which binds to AMPA and NMDA
163
Major neurotransmitter for C Fibers
Substance P which binds to NK-1 receptors
164
What is the function of the dorsolateral tract
(descending tract) modulates pain
165
What is the function of the lateral spinothalamic tract?
Carry pain and temperature
166
What is the function of the ventral spinothalamic tract
crude touch and pressure
167
Root associated with clavicle dermatome
C4
168
Root associated with nipple dermatome
T4
169
Root associated with xiphoid dermatome
T6
170
Root associated with umbilicus dermatome
T10
171
Root associated with tibia dermatome
L4-L5
172
Root associated with perineum dermatome
S2-S5
173
What decreases the release of substance P from C-Fibers
Enkephalin (Modulates Pain)
174
Spinal opioid analgesia is mediated through what receptor
Mu-2 primarily (S in Spinal looks like 2)
175
Name the hydrophilic opioids
Morphine
176
Name the lipophilic opioids
fentanyl, alfentanil, sufentanil
177
Site of action of IV opioids? Intrathecal/Epidural?
- IV: Periventricular/periaqueductal grey | - Spinal/Epidural: Substantia Gelatinosa
178
Supraspinal analgesia is mediated by
Mu-1 (primarily), Delta, and Kappa receptors
179
Side effects from Mu-1 receptors
Bradycardia and Euphoria
180
Opioid receptor responsible for physical dependence and respiratory dependence
Mu-2
181
Kappa receptors are responsible for
sedation and dysphoria
182
Competitive opioid antagonist
Naloxone (narcan) Naltrexone (trexate) Nalmefene
183
White rami carry _______
myelinated sympathetic preganglionci neurons
184
List the Cranial Nerves
``` Oh Oh Oh To Touch And Feel A Girls Vagina Ahh Heaven Olfactory Optic Oculomotor Tochlear Trigeminal Abducens Facial Acoustic (Vestibulococclear) Glossopharyngeal Vagus Accessory Hypoglossal ```
185
Site of formation of CSF
Choroid Plexus of the Lateral, Third, and Fourth ventricles
186
Site of reabsorption of CSF
Arachnoid Villi and arachnoid granulations (both are part of the arachnoid membrane
187
List the flow of CSF in the brain
Choroid plexus -> Lateral Vent -> Foramina of Munro -> Third Ventricle -> Aqueduct of Sylvius -> Fourth vent -> Foramina of Lusaka & Magendie -> Subarachnoid Space -> Brain -> Arachnoid Villi
188
Major vessels that supply the circle of willis
Internal Carotid arteries and the basilar artery
189
What is stump pressure
measures the pressure transmitted through the circle of willie back to the carotid artery
190
Desired stump pressure
>40 mmHg
191
Effects of VAA on CBF? CMRO2
Dec CMRO2 | Increased CBF
192
Effects of IV anesthetics in CBF & CMRO2?
Decrease both (Except ketamine which increases both)
193
Arterial blood supply to the spinal cord
(1) one anterior spinal artery (2) two posterior spinal arteries (3) small segmental spinal arteries
194
Major source of blood to the spinal cord
75% via the anterior spinal arteries
195
Origin of the artery of adamkiewicz
From the left side in the lower thoracic (T8-T12 75%) or upper lumbar region (L1-L2 10%)
196
Decorticate rigidity is cause by
Damage to the brain above the cerebellum and brainstem aka supratentorial (upper ext flexion lower ext extension with feet turned medial)
197
Decerebrate rigidity is caused by
Extensive damage to the brainstem or cerebral lesions that compress the thalamus and brainstem
198
Mechanical ventilation is required for which form of rigidity
Decerebrate d/t damaged brainstem which contains vital responses centers
199
What is the normal ICP?
< 15 mmHg
200
Components of Cushing's triad
Increased BP (MAP) Decrease in HR Irregular respiration
201
Cushing's triad is the result of
increased intracranial pressure
202
What is the correct placement of the single orifice catheter
3. 0 cm ABOVE the junction of the SVC and atrium | 2. 0cm Below for MULTI orifice catheters
203
At what age does the anterior fontanelle close
18 months
204
Which fontanelle closes last
Posterolateral
205
The P wave correlates with what cardiac event
Atrial depolarization
206
The PR Interval correlates with what cardiac event
Atrial systole & AV nodal delay
207
The QRS Complex correlates with what cardiac event
Ventricular Depolarization (and atrial repolarization)
208
The QT interval correlates with what cardiac event
Ventricular systole
209
The T wave correlates with what cardiac event
Ventricular depolarization
210
Phases in the SA node action potential
Phase 4: Diastole (K+ OUT & some Na IN) (Ca is in the last 1/3) Phase 0: Slow depolarization (Ca & Na INTO cell) Phase 3: Depolarization (K+ OUT of the cell) Phase 4: Diastole (Na/K Pump restores Na and K lvls)
211
On what phase for the nodal action potential do CCB work?
They slow the rate of Phase 4 depolarization
212
On what phase of the cardiac action potential do CCB work?
The work on Phase 2 (Plateau)
213
RMP of cardiac ventricular cells
-90 mV
214
What happens when gates Na channels are inactivated?
Cell enters the absolute refractory period
215
Diagnosis of RBBB on the ECG
Look at leads V1 & V6 V1 = rSR' (broad R' wave) V6= qRS
216
Diagnosis of LBBB on the ECG
Look at leads V1 & V6 V1= Loss of R wave V6= Wide R wave with a notch
217
Diagnosis of 1st degree heart block
PR interval > 0.20 seconds
218
Diagnosis of 2nd degree AV block Type I
Progressive increase in PR interval until a beat is skipped
219
Diagnosis of 2nd degree AV block Type II
Appearance of a NON-CONDUCTED P-wave (No progressive prolongation of PR)
220
Diagnosis of 3rd Degree AV block
Independent P-wave (atrial) and QRS wave (Ventricular) activity
221
What is the cause of Heart rate increase from Right atrial stretching
Bainbridge Reflex
222
Indication of myocardial ischemia on ECG
Subendocardial ischemia = ST depression > 1mm | Transmural Injury = ST elevation > 1mm
223
What part of the ventricular action potential correlates with the QRS complex?
Phase 0
224
What part of the ventricular action potential correlates with the T wave?
Phase 3
225
What part of the ventricular action potential correlates with the QT Interval?
Phase 2
226
EKG changes for hyperkalemia
Peaked or tented T waves
227
EKG changes for hypokalemia
U waves
228
HR for paroxysmal atrial tachycardia (PAT)
HR 150-250 bpm
229
Diagnostic criteria for WPW
Presence of Delta wave | can induce V-Fib
230
Leads indicating obstruction to posterior descending artery
V1-V2 (posterior)
231
Leads indicating obstruction to RCA
II, III, aVF (Inferior walls)
232
Leads indicating obstruction to LAD
I, aVL, V1-V4
233
Leads indicating obstruction to circumflex artery
I, aVL, V5-V6
234
Best leads for monitoring for ST depression or elevation
V3-V5, III, aVF (In that order)
235
Best lead to monitor narrow QRS complex rhythms
Lead II (arrhythmia)
236
Mnemonic for where in the adrenal cortex hormones are produced?
Glomerulosa / Aldosterone (mineralcorti) Fasciculata / Cortisone (Glucocorticoid) Reticularis / Testosterone (GFR) / (ACT)
237
Things that determine Stroke Volume
preload, afterload, and contractility
238
Preload is determined by what 3 factors
intravascular volume, venous tone, and ventricular compliance
239
The major determinant of intravascular volume
Sodium (Na) in the body
240
What represents preload and afterload in the frank starling law
``` Preload = force Afterload= Tension ```
241
What causes concentric hypertrophy
Chronic untreated HTN Chronic AS Coarctation of the aorta
242
What causes eccentric hypertrophy
Chronic AR Chronic MR Morbid obesity
243
Where does systole begin/end on the PV loop?
Begins at Point B (Bottom RT) and ends Point D (top LT)
244
When does Diastole begin/end on the PV Loop?
Begins at point D (top LT) and ends Point B (bottom RT)
245
What provides evidence if increased EDV?
Increased PCWP
246
How does AS affect the PV Loop?
PV loop shifts upwards (higher pressures)
247
How does MS affect PV loop?
Shorter and narrower and shifted to the left (lower EDV)
248
What does the area under the arterial pressure curve represent?
Area/time = MAP
249
How does pressure change as you move into the periphery?
Increases as you move distally (greatest at the dorsalis pedis)
250
Most accurate reading of arterial pressure
Use the area under the AORTIC pressure curve
251
Examples of direct acting vasodilators
Hydralazine, Diazoxide, NTG, Nitroprusside (arterial and venous)
252
Effect of PDEi's
Block breakdown of cAMP leading to increased myocardial contractility, and decreased SVR
253
What is adenosine used for?
To treat paroxysmal supra-ventricular Tachycardia (example: WPW)
254
What is SAM seen on ECHO
Systolic Anterior Motion (SAM) of the mitral valve leading to LVOT obstruction (normally seen with hypertrophic Cardiomyopathy)
255
What are the signs and symptoms of AS?
Angina , syncope, and dyspnea
256
Indicator of hypertrophic cardiomyopathy
Bisferiens pulse (an aortic waveform with two peaks per cardiac cycle, a small one followed by a strong and broad one)
257
What is the drug of choice for treatment of hypotension in patients with hypertrophic cardiomyopathy?
Phenylephrine (does not increase contractility)
258
The most common genetic CV disease of all ages
Hypertrophic cardiomyopathy
259
Management of Aortic Regurgitation
Fast: Increase HR Full: volume (increase preload) Forward: decrease afterload
260
Things that cause AR
Aortic annulus dilation: Syphilis, ankylosing spondylosis, RA, & psoriatic arthritis Also infective endocarditis, trauma, or aortic dissection
261
When is AR considered severe?
Severe regurgitant volume is >60% of SV Moderate 30-60% Mild <30%
262
Manifestation of Chronic AR
``` Diastolic murmur at Lt sternal border WIDENED pulse pressure Decrease diastolic pressure Bounding peripheral pulses MR ```
263
When is MR considered Mild, Moderate, or Severe?
MR RULE OF 1/3 Severe regurgitant volume is >60% of SV Moderate 30-60% Mild <30%
264
Murmur heard with MR
Blowing HOLOSYSTOLIC murmur best heard at the APEX
265
Most common valvular lesion in the US
Aortic Stenosis
266
Most common cause of LVOT
AS
267
Normal Aortic valvular area
2.3-3.5 cm2
268
Valve area for severe and critical AS?
Severe 0.8-1.0 cm2 | Critical 0.5-0.8 cm2 and a transvalvular gradient of 50 mmHg
269
Murmur for aortic stenosis
Systolic murmur at the right second intercostal space with transmission into the neck
270
Drugs to AVOID in patients with AS
KETAMINE
271
Valve area for symptomatic MS
s/s begin at area of 1.5cm2 or less (normal is 4-6cm2)
272
Adhesion of platelets to damaged vascular wall requires
Von Willenbrand Factor (VIII:vWF); functions as an anchor
273
Activation of platelets requires
Thrombin (Factor IIa)
274
Aggregation of platelets requires
ADP & Thromboxane a2 (TxA2) which uncover fibrinogen (Factor I) receptors
275
What is required for the production of fibrin
Extrinsic, intrinsic, and final common pathway
276
Steps involved in primary hemostasis
Platelet adhesion Activation of platelets Aggregation of platelets Production of fibrin
277
Average lifespan of platelets
8-12 days
278
Where is vWF produced and released?
in the endothelial cells
279
The most common inherited coagulation defect
Von Willebrands disease
280
First line treatment for Von Willebrands disease
Desmopressin (DDAVP) 0.3 mcg/kg IV over 10-20 min | (second line treatment is cryoprecipitate or purified factor VIII
281
Problem with treatment of Type 2B Von Willebrands disease with DDAVP
Causes thrombocytopenia
282
What does cryoprecipitate contain
Factor VIII, Factor I (fibrinogen) & Facto XIII (fibrin Stabalizing factor) 1,8,13
283
ADP receptor antagonist
Clopidrogel Prasurgel Ticagrelor
284
GPIIb/IIIa receptor antagonist
Block fibrinogen receptor: Eptifibatide (d/c 24 hours b4 sx) Abciximab (d/c 72 hours b4 sx) Tirofiban (d/c 24hours b4 sx)
285
Vitamin K dependent clotting factors
``` Prothrombin (II) Proconvertin (VII) Christmas factor (IX) Factor (X) (also protein C & S) ```
286
Cross-linking fibrin strands requires
factor XIIIa (fibrin stabilizing factor)
287
Clotting Factors of the Extrinsic pathway
Factor III (TF) activates factor VII which activates factor X (along with cofactor IV i.e calcium) 3 , 7, 10
288
Clotting Factors of the Intrinsic pathway
(XII, XI, IX, VIII) (Remember 12 + 11.98) | XII -> XI -> IX also VIII;Ca
289
Clotting Factors of the Final Common pathway
(XIII, I, II, V, X) (5 and Dime for I or II dollars on the XIII) X activated + V activated -> activate factor II -> activates factor XIII -> stabilized fibrin
290
What measures the intrinsic pathway?
aPTT (LONG pathway) | ACT
291
What measures the extrinsic pathway?
PT (SHORT pathway) | INR
292
Factor 10 inhibitors
``` Drugs with AN "X": FundaparinuX RivoraXaban ApiXaban AndeXXa LMWH ```
293
Factor II inhibitors
Dabigatron Argatroban Bivalirudin
294
What is hemophilia A and how is it treated?
- Factor VIII:C deficiency - Second most common inherited disorder - Treated with FFP & Cryo but preferred is Factor VIII Concentrate
295
What is hemophilia B and how is it treated?
Factor IX Deficiency (Christmas Factor) | Treated with Factor IX
296
Most important clue to bleeding disorder?
patient history
297
What procoagulants are missing in FFP?
Platelets
298
How does one unit of pRBC affect Hgb?
Increases HgB 1g/dL | Increases Hct 3-4%
299
How does one unit of platelets affect platelet count?
increases by 5,000-10,000/mm3
300
How does heparin work?
By increasing effectiveness of antithrombin by 1,000x
301
How does antithrombin work?
Binds mostly factor II and X therefore neutralizing the final common pathway
302
Patients with antithrombin deficiency
Liver Dz | Nephrotic syndrome
303
Normal bleeding time
3-10 seconds
304
Normal PT
12-14 seconds
305
Normal PTT
25-35 seconds
306
Normal ACT
80-150 seconds
307
Indicates adequate heparinization
>400-450 Seconds
308
Function of plasmin
Breakdown fibrin
309
Where is tPA produced
by endothelial cells (Stimulated by thrombin and venous stasis)
310
Fibrinolytic produced by B-Hemolytic streptococci
Streptokinase
311
MOA of Amicar
Plasmin inhibitors (also Aprotinin)
312
Lab findings in DIC
``` Low PLT (<50,000) Low Fibrinogen (<150) Low Prothrombin Decrease levels of factor V, VIII, and XIII Increased fibrin split products ```
313
Most common cause of an isolated high PT
Liver disease
314
Observation when there is B/L RLN damage
Both cords are floppy and in an intermediate position. Can cause respiratory distress and intubation is needed (Aphonia, and airway Obstruction) (Hoarsness Unilateral & Stridor Bilateral)
315
What is the normal P50 on the oxyhemoglobin dissociation curve?
26-28 mmHg
316
An SpO2 of 70, 80, & 90% correlate with what PaO2?
``` 70% = 40 mmHg 80% = 50 mmHg 90% = 60 mmHg ```
317
What does the Steep portion of the oxyhemoglobin dissociation curve represent?
The unloading of oxygen at tissues
318
Things that cause a leftward shift in the oxyhemoglobin dissociation curve?
``` (Left =Love) Dec P50 Decrease temp, Dec PCO2 Dec 2,3 DPG Dec [H+] (Inc pH/Alkalosis) HbF Carboxyhemoglobin Methemoglobin ```
319
Things that cause a Rightward shift in the oxyhemoglobin dissociation curve?
``` (Right = Release) Inc P50 Inc temp Inc PCO2 Inc 2,3 DPG Inc [H+] (Dec pH/Acidosis) Maternal Hb Sickle cell (HbS) ```
320
How to calculate dissolved O2 in the blood?
0.003 x PaO2
321
What is the Haldane effect?
Describes how changes in there PP of O2 in the blood influences the CO2 dissociation curve
322
How does PO2 affect the CO2 dissociation curve?
Inc in PO2 shifts it down and to the right | Dec in PO2 shifts it up and to the left
323
How is CO2 carried in the blood?
HCO3 (~90%) | also dissolved or chemically bound to proteins
324
What converts CO2 into HCO3?
Carbonic anhydrase
325
What is a Chloride shift?
The exchange of HCO3 for Cl (aka the Hamburger Shift)
326
What is the biggest driver for ventilation?
[CO2] but [O2] is the Strongest driver aka hypoxic drive
327
The heiring-breur reflex is most active in what population?
Neonates
328
The central chemoreceptors are stimulated by
Increase H+
329
Carries sensory input from the carotid bodies
Glossopharyngeal nerve
330
The respiratory pacemaker of the medulla
DRG
331
The function of the VRG
both inspiration and expiration
332
What is the function of the pneumotaxic center (PnC)?
Shuts OFF inspiration
333
What is the function of the Apneustic center (ApC)
Promotes a pattern of maximal lung inflation with brief expiratory gasps
334
Convert 1 atm into mmHg and cm H2O
1 atm = 760 mmHg = 1,033 cmH2O
335
What is the Normal V/Q?
V/Q= MV/CO = 4/5 = 0.8 L/min
336
What happens in the patient in the lateral position when they are awake vs anesthetized?
Awake= Non-dependent lung DEC vent/DEC perfusion Dependent lung INC vent/INC perfusion Anesthetized= Nondependent Lung INC vent/DEC perfusion; Dependent Lung DEC volume/INC perfusion
337
V/Q that indicates a shunt? deadspace?
``` Shunt = V/Q < 0.8 Deadspace = V/Q > 0.8 ```
338
How to determine if there is a V/Q mismatch?
there will be an increases A-a O2 gradient
339
Normal A-a O2 Gradient
5-15 mmHg
340
Normal a-A CO2 gradient
2-10 mmHg
341
Ventilation strategies for one lung ventilation
CPAP the Non-Dependent Lung (Most affective) | PEEP the Dependent Lung
342
What happens in each of the West Lung Zones?
Zone 1 = PA>Pa>Pv = Collapse (Deadspace) Zone 2 = Pa>PA>Pv= Waterfall (matched vent and perf) Zone 3= Pa>Pv>PA= Distention (Shunt) Zone 4= Pa>Pisp>Pv>PA=Inc Interstitial pressure
343
Where is the PA catheter placed?
Zone 3
344
Why do we preoxygenated?
To fill FRC with O2 and increase apnea time
345
PFT results that indicate Obstructive disease
Decreased FEV1/FVC (i.e < 0.7)
346
Lung volumes not directly measured by spirometric readings
FRC, RV, TLC
347
Ratio that is useful in differentiating between restrictive vs obstructive disease
FEV1/FVC
348
The best test for small airway disease
FEF25-75
349
Examples of obstructive pulmonary disease
Asthma, COPD, chronic bronchitis, emphysema
350
Examples of restrictive pulmonary disease
Pulmonary fibrosis, Pneumothorax, Chest wall Dz(scoliosis), Neuromuscular disease (ALS, Myasthenia Gravis)
351
Normal FEV1/FVC ratio
>0.7
352
PFT that indicated restrictive disease
Low FEV1 (<80%) and FVC (<80%) with FEV1/FVC > 0.7
353
When does FRC equal CC?
Upright 66 y/o | Supine 44 y/o
354
What is Zero Order Kinetics?
A constant AMOUNT of drug is eliminated per unit time | aka drug EXCEEDS enzyme metabolizing capacity
355
What is First Order Kinetics?
A constant FRACTION of drug is eliminated per unit time
356
Most drugs undergo what type of kinetics?
First Order
357
The alpha phase of first order kinetics represents? Beta phase?
Alpha Phase: Distribution | Beta Phase: Elimination
358
List the Types of Phase I metabolic reactions
Oxidation Reduction Methylation Hydrolysis
359
What is responsible for phase I reactions?
CYP 450 system
360
List the Types of Phase II metabolic reactions
``` (Conjugation reactions) Glucuronidation Glutathione Conjugation Sulfation Acetylation ```
361
What are phase II metabolic reactions?
Conjugation reactions
362
What are Phase III metabolic reactions?
Elimination
363
What indicates a drugs time-to-onset of action?
pKa
364
What indicates a drugs potency?
Lipid solubility
365
What indicates a drugs DOA?
Protein binding is the most important (But also lipid solubility)
366
What is the level of a sympathetic blockade relative to a sensory block with spinal anesthesia?
2-6 dermatomes HIGHER | 4-8 Dermatomes higher than MOTOR
367
What is the level of motor blockade relative to a sensory block with spinal anesthesia?
2 dermatomes LOWER
368
How many nodes must be blocked by LA to stope nerve conduction?
2-3 Nodes of Ranvier
369
What is the key target of LA?
Voltage-Gates Sodium Channels
370
The degree of nerve blockade with LA depends on what?
Drug Concentration and Volume
371
What drug to avoid for seizures with LAST if CV instability is present?
Propofol (use benzos instead)
372
What is a normal Dibucaine number?
70-85%
373
What is the diagnostic criteria Atypical homozygous pseudocholinesterase?
dibucaine number of 20%
374
What is the diagnostic criteria Atypical heterozygous pseudocholinesterase?
Dibucaine number of 30-70%
375
What happens in patients with atypical pseudocholinesterase?
Do not metabolize amide LA and also succ
376
What is Methemoglobin?
Iron in the FERRIC state (Fe3+)
377
Iron in normal HgB is in what state?
FERROUS (Fe2+)
378
What is the pKa of Procaine, tetracaine, Bupi, Ropi, Chloroprocaine, Lidocaine, Etidocaine, mepivacaine
``` Procaine 8.9 Tetracaine 8.6 Bupi/Ropi 8.1 Chloroprocaine 8.7 Lidocaine 7.7-7.9 Etidocaine 7.7 Mepivacaine 7.6 ```
379
How is MAC related to potency?
Inverse relationship
380
List the Oil:Gas partition coefficient for the VAA
N2O 1.4 Des 18.7 Sevo 55 Iso 98
381
List the MAC for the VAA
N2O: 104% Des 6.6% Sevo 1.8% Iso 1.17%
382
How do changes in temperature influence the solubility of a gas in a liquid?
More soluble in cold temperatures (This is known as LeChatelier Principle)
383
List the Blood:Gas Solubility coefficient of the VAA
``` HE IS Doing Nothing (Greatest to Least mnemonic) Halothane: 2.54 Iso: 1.46 Sevo: 0.69 Des: 0.42 N2O: 0.46 ```
384
Law that explains diffusion hypoxia
Ficks Law
385
MOA of barbiturates
GABA-A Agonists
386
Sulfur containing barbs
Thiopental
387
In what population should you avoid thiopental
Severe asthmatics (Histamine release) Sulfa allergy Porphyria
388
In what patients should ketamine be avoided?
Cardiac Patients Glaucoma Pt with elevated ICP
389
Why does diazepam have such long DOA?
it is 98-99% protein bound
390
The termination of CNS effects of IV anesthetics is primarily due to what process?
Redistribution
391
Order the synthetic opioids by potency
Alfentanil < Fentanyl/Remifentanil < Sufentanil
392
List the Vapor Pressures of the VAA
Sevo 157 mmHg (157 -170) Iso 240 mmHg Des 669 mmHg
393
What is the Partial Pressure of saturated water vapor?
47 mmHg
394
When Bourdon Gauge reads "0" what is the pressure inside the cylinder?
1 atm
395
Flow is directly proportional to
- radius to the 4th power | - hydrostatic pressure
396
Flow is inversely proportional to
fluid viscosity, length of the tube
397
Law that explains flow through vessels
Poiseuille's law
398
What does henry's law state?
That the amount of gas that dissolves in a liquid is proportional to the PP of the gas in the gas phase
399
What remains constant in Boyles Law?
``` Constant Temp (inverse relationship of P & V) P1xV1=P2xV2 ```
400
What remains constant in Charles Ideal gas Law?
``` Constant Pressure (Directly relationship of V & T) V1/T1=V2/T2 ```
401
What remains constant in Gay-Lussac's Ideal gas law?
``` Constant Volume ( Direct relationship of P & T) P1/T1=P2/T2 ```
402
Triangle for gas laws
B P V G T C Big Gas Cars/ PhoToVoltaic
403
What does Daltons law state?
The total pressure in a mixture of gases is equal to the sum of the pressures of the individual gases
404
The temperature above which a substance can not be liquified
Critical temperature
405
Explains why a cylinder cools when it is opened
Joule-Thompson Effect ("Joule Is Cool")
406
Diffusion rate is directly proportional to what?
PP gradient Membrane surface area Solubility of gas in membrane
407
Diffusion rate is inversely proportional to what?
Membrane thickness | Molecular weight
408
What are some applications of Fick's Law
Concentration Effect Second Gas effect Diffusion Hypoxia
409
What law explains why smaller substances diffuse in greater quantities?
Grahams Law (as well as Ficks)
410
Which law is the basis of Pulse Oximetry?
Beer-Lambert Law
411
What are the Routes of heat loss?
Radiation (60%): most significant source of heat loss Convection (15-30%) Evaporation (20%) Conduction (<5%)
412
Who establishes requirements for the design, construction, testing, etc... of compressed gas cylinders?
The DOT
413
Who sets basic performance and safety requirements for components of the anesthesia machine and ET tubes?
The American National Standards Institute (ANSI)
414
Who promulgates standards for medical devices and gases?
The FDA
415
Who develops purity specifications for medical gases?
Pharmacopeia of the US
416
What is the most fragile part of the cylinder?
The Cylinder Valve
417
PISS index system for gases
Air 1-5 O2 2-5 N2O 3-5
418
What prevents a full cylinder from emptying into and empty cylinder?
The Hanger Yoke Valve
419
At what flow rate does the O2 Flush Valve deliver oxygen? What PSI?
``` Flow rate 35-75 L/min PSI 50 (intermediate pressure) ```
420
What triggers the closure of the Oxygen failure cutoff Valve (aka Fail safe system)?
O2 pressure drops below 25 PSI
421
What is the pressure of the flowmeters?
16 PSI (low pressure system)
422
What are the 5 roles of oxygen?
``` Delivery of O2 to patient Power O2 flush valve Activate fail-safe system (If < 25 PSI) Activate O2 Low Pressure alarm Driving gas for the ventilator ```
423
What prevents reversal of flow through the vaporizer?
The Check Valve
424
Properties of Injection vaporizers
Tec 6 (Des) Dual Circuit (Not Split) Heated to 39 C Pressurized
425
Properties of variable bypass vaporizers
Gas Split Flow over automatic temp compensation
426
What are the components of the Low pressure system?
``` (16 PSI) Flow Meter tubes Vaporizers Check Valves Common Gas Outlet (CGO) ```
427
What are the components of the Intermediate pressure system?
``` (40-50 PSI) Ventilator power inlet Pipeline inlets, Check Valves, Pressure gauges Flow Meter VALVES O2 pressure-failure device O2 Second stage regulator Flush Valve ```
428
What are the components of the High pressure system?
Hanger Yolk Yoke Block Cylinder pressure gauge Cylinder pressure regulator
429
Properties of Open Breathing Systems
NO RESERVOIR no rebreathing no absorbent no dead space
430
What are some examples of Open Breathing Systems?
Open drop either NC Simple FM Insufflation
431
Properties of Semi-Open Breathing Systems
NO REBREATHING Reservoir Causes room pollution Req high Gas flow
432
Properties of Semi-Closed Breathing Systems
PARTIAL REBREATHING Reservoir Most common in US
433
Properties of Closed Breathing Systems
Reservoir COMPLETE REBREATHING FGF=O2 consumption
434
What is the best Mapleson system for spontaneously breathing
Mapleson A
435
Order of Mapelson stystem for controlled ventilation
DFE>BC>A
436
Max cuff pressure for LMA
60 PSI
437
Most common adverse effect of using an LMA
Sore Throat ( incidence 10%)
438
ETT that can be accommodated by the FasTrach LMA
8.5 ETT
439
What is evidence of an incompetent expiratory valve?
No return to baseline ('0") | Prolong inspiratory Limb (Beta Angle)
440
List the BIS values for each level of anesthesia
``` Light/Mod Anesthesia: 90-70 Deep Sedation: 60-70 GA: 60-40 Deep Hypnotic State: 40-10 Flat Line EEG: 10-0 **** ```
441
Red light absorbs what wavelength? IR light?
``` Red = 660nm deoxyhgb IR= 940nm OxyHgb ```
442
Identify the components of the CVP waveform?
- A wave: atrial contraction (end Diastole) - C wave: Tricuspid elevation during early vent systole (early systole) - V Wave: Venous return against a closed tricuspid valve (Late systolic filling of the atrium) - X descent: Atrial relaxation (Mid Systole) - Y Descent: Early Vent. Filling (Early Diastole)
443
What is the depth to the Right Atrium based on insertion site of the catheter?
``` Subclavian 15cm Right IJ 20cm Left IJ 25cm Right AC 40cm Left AC 45cm Femoral 50cm ```
444
Depth from RA to RV? How about to the PA?
RA to RV is 10 cm RV to PA is 15 cm (RA to PA is 25 cm)
445
What is the normal PCWP?
6-12 mmHg
446
What is the maximum wedge time?
15 seconds
447
What are some complications from PA catheters?
Pneumothorax | Air Embolism
448
What is the normal RVEDP?
0-8 mmHg
449
What is the normal PA systolic? PA Diastolic?
PA systolic 15-25 mmHg | PA Diastolic 8-15 mmHg
450
What portion of the ECG correlates with the Dicrotic Notch on the arterial waveform?
Occurs at the end of the T wave
451
How much higher is invasive BP versus noninvasive BP?
20 mmHg
452
Karotkoff sounds identify __________
The onset of systole
453
How many vertebrae are there?
33 Vertebrae - 7 cervical - 12 Thoracic - 5 Lumbar - 5 Fused Sacral - 4 Fused Coccygeal
454
The high points of the vertebral column
C3 & L3
455
The Low points of the vertebral column
T6 & S2
456
Where is the epidural space widest?
L2 (5-6 mm)
457
Where is the epidural space is narrowest ?
C5 (1.0-1.5 mm)
458
The spinal cord extends from the __________ to the _________
Foramen Magnum | extends to L1 (L3 in newborn)
459
The spinal cord terminates at the ____________
Conus Medullaris
460
How many spinal nerves are there
31 paired spinal nerves
461
Where does the Arachnoid matter end?
Ends at S2
462
What are the factors that play a role in the spread of spinal blockade?
``` Density of the drug solution Site of Injection Dose Position Baricity ```
463
Treatment options for bradycardia that result from spinal anesthesia
Prophylactic ondansetron (5-HT3 antagonists) Atropine 0.4-0.6 mg ephedrine 5-25 mg Epinephrine (if severe bradycardia)
464
What is the best means for treating hypotension during spinal anesthesia?
Physiologic, give IV fluids if hypovolemic
465
When can you restart heparin after epidural removal?
1 hour after removal (or 1 hour after placement)
466
When is it safe to remove catheter after stopping a heparin?
4-6 hours after the last dose
467
Guidelines for unfractionated heparin and neuraxial blockade
Daily dose < 20,000 Units: 12 hours after sub-Q heparin Daily Dose > 20,000 Units: 24 hours after Sub Q heparin (ALWAYS CHECK LABS)
468
At what INR is it safe to provide neuraxial anesthesia in a patient on warfarin?
INR < 1.5
469
Guidelines for fibrinolytic or thrombolytic drug therapy and neruaxial anesthesia
D/c for 10 days before
470
Guidelines for LMWH with neuraxial anesthesia
Delay 12-24 hours | remove all catheters 2 hours before first LMWH dose
471
The inferior border of the scapula correlates with what spinal level
T7
472
What Dermatome is covered by nerve roots L2-L3?
The Knee and below
473
The perineal dermatome correlates with which spinal levels
S2-S5
474
Absolute contraindications for spinal anesthesia
Infection at Injection Site Coagulopathy Hemodynamic Stability Patient Refusal
475
What 2 structures are avoided with a lateral approach to spinal anesthesia?
Supraspinous Ligament | Interspinous Ligament
476
Most common causative agent of epidural abscess
Staph Aureus
477
Most common complication of neuraxial anesthesia
Back Ache
478
What is the angle of the bevel on the Tuohy needle?
30 degrees
479
The order of nerve fiber blockade after epidural?
B > C/A-delta > A-gamma > A-beta >A-alpha
480
What is the distance from the skin to the epidural space?
Adult 4-6 cm Obese up to 8 cm Thin 3cm
481
The most sensitive indicator of initial onset of sensory block
Alcohol swab to assess for loss of temperature
482
The most accurate assessment of overall sensory block with epidural
Pinprick
483
Why are caudal blocks not used in adults?
after age 12 sacral anatomy changes and makes it more difficult
484
Site of needle insertion for caudal epidural block
Sacrococcygeal Membrane
485
Dosage for caudal epidural in children
0.5-1.0 mL/kg (0.125%-0.5% Bupivacaine)
486
Dosage for caudal epidural in adults
S5-L2: 15-25 mL | S5-T10: 35 mL
487
Nerve roots of the cervical plexus
C1-C5
488
Nerve roots of the phrenic nerve
C3-C5 (70% for C4)
489
Nerve roots for the brachial plexus
C5-C8,T1
490
Extension of the elbow test what nerve
Radial Nerve
491
Flexion of the elbow test what nerve
Musculocutaneous Nerve
492
Flexion of the wrist test what nerve
Ulnar nerve
493
Opposition of the middle, forefinger, and thumb test what nerve
Median Nerve
494
Volume for cervical plexus block
4mL per level
495
What are the approaches to the brachial plexus block?
Interscalene Supraclavicular Infraclavicular Axillary
496
What volume of LA is used for an inter scalene block?
40mL
497
Where does the musculocutaneous nerve lie
Within the coracobrachialis
498
What are the landmarks for an Ulnar nerve block at the elbow?
The medial condyle of the humerus | Olecranon process of the Ulna
499
The femoral nerve block (aka 3 in 1 block) is used to provide anesthesia to what areas?
Anterior thigh, knee, and a small part of the medial foot
500
What nerves are blocked in the 3-in-1 approach?
Femoral, Genitofemoral, & lateral femoral cutaneous nerve
501
What nerve roots contribute to the Sciatic Nerve?
L4-L5 & S1-S3 (lumbosacral trunk)
502
Sensory innervation of the sciatic nerve
Posterior Hip Capsule and the Knee, Sensory to everything distal to the knee except the anteromedial aspect (Motor to hamstring and all muscles distal to the knee)
503
List the 5 nerves that are blocked in the ankle block
``` Posterior Tibial: L4-L5/S1-S3 Sural: branch of Tibial Saphenous: Branch of femoral (L3-L4) Deep Peroneal: L4-L5/S1-S2 Superficial Peroneal: L4-L5/S1-S2 ```
504
What is the largest division of the sciatic trunk?
Posterior Tibial Nerve
505
What nerves provide Sensory innervation to the foot?
- Post. Tibial: Skin of the heel and medial aspect of the sole of the foot - Sup. Peroneal: Dorsum of the foot & 1st-5th toes - Saphenous: medial side of the leg, ankle, and foot - Sural (is Lateral): post lateral aspect of lower calf and lateral side of the foot and fifth toe - Deep Peroneal: Medial half of the dorsal foot between the 1st and 2nd digits
506
What is the most common postoperative peripheral neuropathy?
Ulnar nerve damage
507
How does ulnar nerve damage present?
Claw Hand: decreased sensation the ring and pinky
508
What is the second most common postoperative neurologic injury?
Brachial Plexus
509
How is the brachial plexus injured intraoperatively?
Stretch injury: Head extended and turned away and arm is abducted > 90 degrees Compression injury: B/w clavicle and 1st Rib with improper placement of shoulder braces or spreading of the sternum
510
Presentation of radial nerve injury
Wrist drop
511
presentation of Median nerve injury
APE Hand (unable to oppose thumb)
512
Inability to abduct the arm indicates injury to which nerves?
Axillary n.
513
Inability to flex the forearm indicates injury to which nerves?
Musculocutaneous n.
514
What is the most common mechanism by which the sciatic nerve is injured?
Improperly placed in lithotomy
515
What is the most commonly damaged nerve of the lower extremity?
Common Peroneal Nerve
516
What is one of the common ways in which damage to the common peroneal nerve occurs?
Compression of nerve between fibula (lateral aspect of knee) and metal brace while in lithotomy
517
Damage to this nerve causes foot drop
Anterior Tibial Nerve Sciatic nerve Common peroneal
518
How does damage to the femoral nerve occur?
Compression agains pelvic brim by self retaining retractors and by excessive angulation of the thigh when placed in lithotomy
519
How is the Obturator nerve damaged?
Excessive flexion of thigh to the groin | Difficult forceps delivery
520
How is MAC affected by pregnancy?
It is decreased (Also faster induction d/t higher alveolar ventilation)
521
What are the Cardiac Output changes during the phases of labor?
``` Increases Latent Phase 15% Active phase 30% Second Stage 45% Postpartum 80% ```
522
What is the normal uterine blood flow during pregnancy?
10% of CO =700-800mL/min
523
What is the uterine blood flow in a non pregnant state?
50mL/min
524
List the stages of labor and when they begin and end
1st stage: From Onset of contractions to complete dilation 2nd stage: Dull cervical dilation (10cm) to delivery of the infant 3rd stage: Ends with delivery of the placenta
525
Pain from the stages of labor originates in which nerve roots?
1st stage: T10-T12 progression to L1 | 2nd stage: T10-S4
526
Innervation to the perineum is via what nerve?
The pudendal Nerve (S2-S4)
527
What are some signs of fetal distress?
Nonreassuring FHT Fetal Scalp pH < 7.20 Meconium Stained Amniotic Fluid Oligohydraminos
528
Symptoms of placenta previa
PAINLESS vaginal bleeding
529
Symptoms of Placental abruption
PAINfull vaginal bleeding | Uterine tenderness
530
Lab values for DIC
``` Fibrinogen <150mg/dL PLT count <50,000 Thrombin time > 100 sec PT > 100 sec PTT >100 sec ```
531
normal fibrinogen levels
200-350 mg/dL
532
Normal thrombin time (TT)
8-12 seconds
533
What is HELLP
Hemolysis Elevated Liver enzymes Low Platelets
534
Dosing of magnesium for preeclampsia
Bolus 4-6mg over 30 min | Infusion 1-2 g/hr
535
Normal magnesium level
1.8-2.5 mg/dL
536
Pediatric airway characteristics
Laryngeal location at C2-C4 (vs C3-C6 in adults) Narrowest (fixed) portion Cricoid Omega shaped epiglottis (U shaped) Less vertical takeoff of RT mainstem bronchus Funnel shaped larynx
537
How to determine pediatric tube size?
(age/4)+4 (-0.5 for cuffed tubes)
538
How to determine pediatric tube depth at mouth?
ETT size x 3 | [ or (age/2)+12 or (kg/5)+12]
539
How to calculate EBV for pediatrics?
80mL/kg
540
How to calculate Max allowable blood loss?
EBVx(Hct - Min Hct)/ actual Hct
541
How to calculate fluid maintenance?
For infants < 6months 4mL/kg (1st 10kg) 2mL/kg (2nd 10kg) 1ml/kg (over 20kg) For infants > 6months 10-40mL/kg over 1-4 hours
542
What is the % TBW in Preterm, Term and 6-12 month old?
Preterm= 80-90% Term= 75% 6-12 Months= 60%
543
Where is the most common site of congenital diaphragmatic hernia?
70-90% of defects are on the left side (Left foramen of bochdalek)
544
Hallmark signs of congenital diaphragmatic hernia?
``` Arterial hypoxia (d/t Lt to Rt shunt) Barrel shaped chest SCAPHOID abdomen, ```
545
What is the goal of anesthetic management of the patient with a congenital diaphragmatic hernia?
- Maintain Preductal saturation > 85% with PIP < 25cmH2O (allow PCO2 to rise to 45-55mmHg) - Decompress the stomach - Avoid hypothermia, hypoxia, acidosis
546
What is VACTERL syndrome?
``` Vertebral Defect Anal Atresia Cardiac anomalies Tracheoesophageal fistula Esophageal atresia Renal dysplasia Limb anomalies ```
547
What is the most common type of TEF?
Ends in a blind pouch and a lower esophagus that connects to the trachea (Type C)
548
How do we ventilate patients with TEF?
Small TV faster rate (avoid PPV)
549
What is the most common metabolic presentation of Pyloric stenosis?
Hypokalemic, hypochloremic primary metabolic alkalosis, with secondary respiratory acidosis
550
What are some signs and symptoms of pyloric stenosis?
non-bilious projectile vomiting at 2-5 weeks of age Jaundice (d/t starvation) OLIVE-LIKE MASS palpated in the epigastrium
551
Common postoperative complication for patients who undergo surgery for pyloric stenosis?
PostOp ventilatory depression
552
What are the S/S of Acute Epiglottitis?
- Age 3-6years - High Fever - Rapidly progresses from sore throat to dysphagia - Sitting forward & upright; Chin up, mouth open, drooling
553
What is the etiology of acute epiglottis?
Bacterial (Hemophilus influenza Type B, Staph aureus)
554
What are the S/S of laryngotracheal bronchitis?
AKA CROUP - Age 6 months - 3 years - Low grade fever - Croupy "barking" Cough - Slow Onset - Hoarsness - Steeple sign
555
What is the treatment for Croup?
Cool humidified O2 & racemic Epi
556
What is the etiology of Croup?
Viral
557
Consideration for gastroschisis
Prevent hypothermia, infection, and dehydration
558
Which pediatric congenital abdominal herniation abnormality is associated with other anomalies?
Omphalocele (has a SAC or Amnion covering)
559
Shivering increases O2 consumption by how much?
400%
560
Time of onset of post operative cognitive dysfunction
delayed onset , may present weeks or months AFTER surgery
561
What is the most sensitive indicator of renal function in the elderly?
Creatinine Clearance
562
How is MAC affected by age?
Reduced by 4-6% per decade over the age of 40
563
How to calculate IBW?
``` Female = Ht(cm) - 105 Male = Ht(cm) - 100 ```
564
Type of obesity that is associated with increased risk of CV events?
Android (Cushingoid, Centra, Truncal, Apple)
565
A major predictor of problematic intubation in the Obese patient?
Neck Circumference (large)
566
The only ventilatory parameter that has been shown to improve respiratory function in the obese patient
PEEP
567
What are the most sensitive indicators of anastomotic leak after bariatric surgery?
Tachycardia (MOST SENSITIVE) Fever (also ABD pain)

NCE Review Material (8 decks)

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