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Anesthesiology > ACE 2012 9B > Flashcards

ACE 2012 9B Flashcards

1
Q

What is naltrexone used for and what is its mechanism of action?

A

Alcohol or opioid dependency and is a mu, kappa, and delta receptor competitive antagonist

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2
Q

What do you do preoperatively for a patient taking naltrexone for alcohol dependency?

A

Stop it because it will hinder with pain control when you give opioids intraop (do not need to taper)

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3
Q

How would your opioid management change in a patient who is taking ER morphine/naltrexone pill?

A

No change, the naltrexone is actually behind a physical barrier in the pill (center) so that it only gets released if the patient tries to abuse it by crushing/chewing it

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4
Q

What does the t-test determine?

A

Parametric test to determine if there is a significant difference between the means of 2 groups

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5
Q

What does the Kaplan-Meier plot tell us?

A

Distinguish between the duration of survival observed among those who died and the duration of survival among those alive at the end point of the observation period (y-axis: fraction alive, x-axis: time)

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6
Q

What is a parametric test?

A

Relies on the assumption that the underlying data being tested falls in a normal distribution

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7
Q

What are some common side effects to gabapentin?

A

Sedation, peripheral edema, and weight gain (relatively safe)

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8
Q

What side effect do you see with bisphosphonate medications like alendronate?

A

Jaw necrosis

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9
Q

How does hyperthyroidism affect SVR, lusitropy, contractility, cardiac output?

A

Decreased SVR, increased lusitropy, increased contractility, increased CO

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10
Q

What cardiac finding do you see in almost 30% of patients with hyperthyroidism?

A

Atrial fibrillation (risk increases with age)

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11
Q

Would you see pericardial effusions with hyper- or hypothyroidism?

A

Hypothyroidism

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12
Q

What would PFTs show in idiopathic pulmonary fibrosis?

A

Restrictive pattern (decreased FVC and FEV1, normal to increased ratio)

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13
Q

What do almost 85% of patients with idiopathic pulmonary fibrosis have?

A

Pulmonary HTN (from chronic hypoxia or hypertrophy of small pulmonary vessels)

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14
Q

What are the common anterior mediastinal masses?

A

5 T’s: Thymoma, Thyroid tumor, Teratoma, Terrible lymphoma, and Thoracic aorta dilation

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15
Q

What is crucial with induction of GA with patients with compressive anterior mediastinal masses?

A

Maintenance of spontaneous ventilation (paralysis can cause collapse of airways)

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16
Q

What is the definition of acute kidney injury?

A

One of the following over less than 48 hours:

  1. absolute increase in serum creatinine of 0.3 mg/dL or more
  2. 50% increase in serum creatinine
  3. Reduction of UOP to less than 0.5cc/kg/hr for more than 6hours
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17
Q

What is the traditional stimulus and response for SSEP? MEP?

A

SSEP: stimulus - median nerve, response - L/R scalp electrode over sensory cortex
MEP: stimulus - L/R scalp electrode over motor cortex, response - EMG in abductor pollicus brevis (APB)

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18
Q

Is the primary motor cortex anterior or posterior to the central sulcus? Primary sensory cortex?

A

Motor cortex: anterior

Sensory cortex: posterior

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19
Q

Do older patients require more or less hypnotic medication (i.e. propofol) and why?

A

Less because they have a reduced drug distribution, slower drug elimination from central compartment, and increased sensitivity to CNS depression

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20
Q

What is the difference between lean body weight and ideal body weight?

A

LBW: total body weight - weight of the fat
IBW: calculation based on sex, age and height

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21
Q

How should you dose propofol, fentanyl, remifentanil, succinylcholine, vecuronium, and rocuronium? Ideal body weight, total body weight, or lean body weight?

A 
Propofol: TBW
Fentanyl: LBW
Remifentanil: LBW
Succinylcholine: TBW
Vecuronium: IBW
Rocuronium: IBW
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22
Q

What are the fundamental differences between a pediatric and adult airway?

A
  1. Relatively larger tongue
  2. Larynx is more cephalad (C3-C4) vs adults (C4-C5)
  3. Narrow, omega-shaped epiglottis
  4. Anterior angulation of vocal cords
  5. Narrowest portion is at cricoid ring vs adults (glottic opening) - may or may not be true now
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23
Q

What is the mechanism of action for the following: clopidogrel, dabigatran, ticlopidine, tirofiban

A

Clopidogrel/Ticlopidine: ADP receptor antagonist
Dabigatran: direct thrombin inhibitor
Tirofiban: IIb/IIIa receptor inhibitor

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24
Q

What coagulation factors are involved in the intrinsic vs extrinsic pathway?

A

Intrinsic: XII, XI, IX, VIII
Extrinsic: VII, III (tissue factor)

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25
Q

What nerve is injured if you have sensory loss of the 5th finger? Wrist drop? Loss of thumb Abduction?

A

Ulnar nerve
Radial nerve
Median nerve

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26
Q

What TEE view is the best for evaluating the coronary sinus?

A

Midesophageal (ME) 4 chamber view and the ME 2 chamber view

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27
Q

What TEE view is best for evaluating wall motion abnormalities of the LV?

A

Transgastric (TG) mid-papillary short axis view

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28
Q

Does the carotid body or carotid sinus act as a baroreceptor? Which acts as a chemoreceptor?

A

Baroreceptor: Carotid sinus
Chemoreceptor: Carotid body

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29
Q

What are common nerves affected by a carotid endarterectomy?

A

Recurrent laryngeal, superior laryngeal, and hypoglossal nerves

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30
Q

If you suspect pulmonary artery rupture from PA catheter placement when coming off CPB, what is the next step?

A

Resume CPB
If minor hemorrhage: double-lumen tube and PEEP while weaning off CPB
If major hemorrhage: brochial blocker vs. double-lumen tube, possible lobectomy, temporary PA occlusion

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31
Q

What of the following agents would you avoid in patients with congenital QT prolongation: ondansetron, succinylcholine, propofol, glycopyrrolate, neostigmine

A

Avoid ondansetron (5-HT antagonist), glycopyrrolate & neostigmine, succinylcholine (K+ shifts and autonomic effects)

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32
Q

What is a normal carboxyhemoglobin level in cigarette smokers?

A

10%

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33
Q

What is the treatment for acute carbon monoxide poisoning?

A

Supplemental O2, hyperbaric O2 if you have neurologic complications, myocardial ischemia, fetal distress in pregnant women, COHb >25%, any pediatric patient

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34
Q

Which medication would be best for a pediatric patient with a space-occupying brain lesion undergoing MRI who you want to be spontaneously ventilating: propofol infusion, IV midazolam/fentanyl, dexmedetomidine infusion, oral chloral hydrate

A

Dexmedetomidine infusion; the others cause decreased ventilatory drive causing increased PaCO2 leading to increased ICP; chloral hydrate is sedative that is usually ineffective in children >3 yo

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35
Q

What is a common side effect of dexmedetomidine?

A

Bradycardia (alpha-2 agonist effect)

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36
Q

What is the rate of atlantoaxial instability in Down Syndrome patients?

A

7% to 36%

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37
Q

Should children with Down Syndrome get cervical spine studies for atlantoaxial instability?

A

The American Academy of Pediatrics recommends getting studies for all patients between 3-5 years of age

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38
Q

How long can an ET tube be out of its packaging before it is not considered clean for tracheal intubation?

A

Up to 48 hours

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39
Q

Does airway equipment need to be sterile before intubation?

A

No, just need standard decontamination and disinfection

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40
Q

What are the 4 absolute indications for lung separation/one-lung ventilation?

A
  1. Avoiding contamination from one lung to the other (i.e. pus)
  2. Bronchopleural fistula or cyst rupture
  3. Unilateral bronchopulmonary lavage (i.e in CF)
  4. VATs
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41
Q

What is Osler-Weber Rendu Syndrome and what anesthetic complications do you have to worry about?

A

Hereditary hemorrhagic telangiectasia; autosomal dominant disease resulting in the absence of small capillaries -> multiple AVMs; can be in cerebral, pulmonary, or hepatic vasculature

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42
Q

How does pregnancy complicate Osler-Weber-Rendu Syndrome?

A

Enlarges the AVMs with weakened walls (increased CO and hormonal changes)

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43
Q

Which of the following is most likely to be present after a postdural puncture headache: tinnitus, photophobia, neck stiffness, hyperacusis?

A

Neck stiffness

44
Q

What medications should be avoided in patients taking lithium?

A

ACE-I, NSAIDs, loop diuretics, and metronidazole

45
Q

What is most likely to be the first manifestation of oxygen toxicity?

A

Retrosternal tightness -> cough -> decreased vital capacity + decreased DLCO (~24hrs)

46
Q

What determines the onset of action of local anesthetics?

A

pKa and concentration (lower pKa and higher concentration has faster onset of action)

47
Q

What determines the potency of local anesthetics?

A

Lipid solubility (increased = more potent)

48
Q

What determines the duration of action of local anesthetics?

A

Protein binding (higher protein binding = longer duration of action) and addition of epi

49
Q

What does adding sodium bicarbonate to local anesthetics do to the pharmacokinetics?

A

Increases pH which increases the amount of LA in the non-ionized form -> faster onset of action

50
Q

Why has hydroxyethyl starch gone out of favor?

A

Increased risk of renal insufficiency/failure and increased mortality in critically ill patients

51
Q

How long in advance must you quit smoking before you confer pulmonary benefits?

A

At least 4-8 weeks in advance

52
Q

What effects do you see in smokers who quit 2-3 days before surgery?

A

Increased secretions and more reactive airways; decreased carboxyhemoglobin

53
Q

What physiologic changes do you see in patients with autonomic hyperreflexia after stimulus?

A

Hypertensive and bradycardic with vasodilation

54
Q

What patients are at risk of autonomic hyperreflexia?

A

Spinal cord injury at T7 or above

55
Q

What is the advantage of a retrobulbar vs. peribulbar block?

A

Faster onset of action (retrobulbar > peribulbar)

56
Q

How does paraplegia affect non-depolarizing neuromuscular blockade?

A

Increased resistance to non-depolarizing NMB

57
Q

What does a full tank of N2O read and what volume does that correlate to?

A

750 psi, 1600L

58
Q

When would you notice the psi to decrease in a tank of N2O?

A

When all the liquid form of N2O has been vaporized (~25% remaining = 400L)

59
Q

At what voltage do you shock a pediatric patient during a code according to PALS?

A

First time: 2 J/kg, the resume CPR

Second time: 4 J/kg and resume CPR

60
Q

What is the gold standard to rule out malignant hyperthermia?

A

Caffeine halothane contracture test

61
Q

What anesthetic plan should you have with a patient who tested negative for malignant hyperthermia according to genetic test?

A

A negative test does not exclude susceptibility for MH and you should avoid all triggering agents

62
Q

In a patient with elevated carboxyhemoglobin levels, how would the readings of a conventional pulse oximetry and a co-oximetry differ?

A

The conventional value would be higher than the co-oximetry value

63
Q

Which NMB does not produce metabolites?

A

Rocuronium

64
Q

How is rocuronium excreted?

A

Unchanged in the bile

65
Q

What is the mechanism of action for tapentadol?

A

Binds mu-opioid receptors, prevents reuptake of NE and 5-HT

66
Q

What are the primary CV side effects seen with hypercalcemia?

A

Prolonged PR, shortened QT, HTN

67
Q

What is the treatment for hypercalcemia?

A
  1. IV fluids
  2. Loop diuretic (avoid thiazide diuretics since they increased reabsorption of Ca)
  3. Bisphosphonates
68
Q

According to the Revised Cardiac Risk Index, which of the following is associated with an increased risk of major cardiac event in the perioperative period: >70yo, hip fracture surgery, Hgb

A

Preoperative use of insulin; the 6 factors are:

  1. Major surgery (intrathoracic, intraperitoneal, or aortic)
  2. Hx of stroke/TIA
  3. Ischemic heart disease
  4. CHF
  5. Preoperative use of insulin
  6. Creatinine >2.0 mg/dL
69
Q

What is the normal residual volume for a 70kg adult?

A

Approximately 1.5L

70
Q

What is the normal FRC for a 70kg adult?

A

Approximately 2.5L

71
Q

When is the cardiac output during pregnancy/labor is highest and why?

A

Immediately post-partum because of relief of caval compression and loss of maternal vascular resistance (placenta)

72
Q

Which narcotic has the fastest onset of peak analgesia: sufentanil, alfentanil, fentanyl, or meperidine?

A

Alfentanil (highest fraction of nonionized drug at physiologic pH)

73
Q

How does hypothermia affect plasma propofol concentrations? Fentanyl? MAC value?

A

Propofol: increases by 10% per 1C decrease
Fentanyl: increases by 5% per 1C decrease
MAC: decreased by 5% per 1C decrease

74
Q

How does hypothermia affect coagulation?

A

Thrombin activity decreases and increased coagulopathy

75
Q

What local anesthetic has the greatest risk of transient neurologic symptoms? Timing? Treatment?

A

Lidocaine
Pain begins within 24 hours and resolves within 72 hours
Tx: NSAIDs

76
Q

Which surgical position has the greatest risk of transient neurologic symptoms?

A

Lithotomy (30-35% chance) compared to supine (4-8% chance)

77
Q

Does lidocaine concentration affect the chances of transient neurologic symptoms? What about dose or baricity?

A

These are all independent of the risk of TNS

78
Q

At what age do you normally see problems with patients with a bicuspid aortic valve? What is the most common complication?

A

Around 50 years old

Increased risk of developing an aortic dissection (single gene defect)

79
Q

What cardiac findings do you see with Turner’s syndrome?

A

Bicuspid aortic valves + Coarctation of the aorta

80
Q

Do patients with a bicuspid aortic valve need endocarditis ppx?

A

No

81
Q

Why would a patient be completely asymptomatic but have no pulse and no NIBP reading?

A

The patient has a nonpulsatile, continuous flow LVAD

82
Q

Do patients undergoing a CEA have strokes?

A

Many will have embolic events but with no neurologic sequelae

83
Q

What is a normal SaO2 for a healthy neonate within 5 minutes of delivery?

A

<90%

84
Q

How does the cerebral autoregulation curve differ between a neonate and an adult?

A

The neonates curve is shifted left and down (lower CBF)

85
Q

What are the steps for treatment of DKA?

A

Intubation of AMS
IV insulin + continuous insulin
IV fluids (can have a fluid deficit up to 10L)
Potassium repletion (even though K+ is high, it is from intracellular shifts)

86
Q

How do you calculate serum osmolarity?

A

(2 * Na+) + (BUN/2.8) + (glucose/18)

87
Q

What stage of labor is increased by use of an epidural? Do epidurals increase the risk of C-section?

A

Stage 2 (full dilation to delivery of fetus) is increased
No increased risk of C-sections
All other stages of labor are NOT affected

88
Q

What happens to the acetylcholine receptors when you have third degree burns? Are they more or less resistant to non-depolarizing NMB?

A

Increased fetal and adult nicotinic Ach receptors; fetal Ach receptors are easier to stimulate and stays open longer allowing for more potassium to leave the cell (higher risk of hyperkalemia)
More resistant to non-depolarizing NMBs (more receptors to hit + fetal Ach receptors are more resistant)

89
Q

When do you worry about succinylcholine-induced hyperkalemia after a burn? When is it thought to be safe to use succ after a burn?

A

After 24 hours

Waiting period is 1-2 years

90
Q

What makes up the lumbar plexus?

A

Ventral rami of L1-L4 with variable contributions from T12 and L5

91
Q

How are pacemakers described?

A
  1. Paced chamber (A, V, D, O)
  2. Sensed chamber (A, V, D, O)
  3. Response to sensed chamber (I, T, D, O)
  4. Rate modulation
  5. Multisite pacing
92
Q

Explain how a neuron maintains its resting potential and how local anesthetics play a role in stopping an action potential

A

Resting potential: -70 to -60 mV maintained by the Na/K pump and selective permeability of K+ to leave the cell
LA: block voltage-gated Na channels, not allowing for the influx of Na

93
Q

What PFT parameter is normal in a patient with ascites?

A

FEV1/FVC ratio (since both FEV1 and FVC are decreased as seen in restrictive lung diseases)

94
Q

What does the C5 nerve root innervate? What happens if you injure the C5 nerve root?

A

Deltoid (axillary nerve), supraspinatus and infraspinatus (suprascapular nerve), rhomboid (dorsal scapular nerve), biceps (musculocutaneous nerve)
Shoulder weakness

95
Q

What does the C6 nerve root innervate? What happens if you injure the C6 nerve root?

A

Biceps (musculocutaneous)

Innervation to thumb side of the hand, motor deficits in elbow flexion and wrist extension

96
Q

What does the C7 nerve root innervate? What happens if you injury the C7 nerve root?

A

Motor to triceps and back of hand

Weakness of elbow extension, midscapular pain

97
Q

What does the C8 nerve root innervate? What happens if you injure the C8 nerve root?

A

Ulnar nerve muscles

Handgrip weakness, loss of sensation to the 5th finger

98
Q

How are ICDs described?

A
  1. Chambers shocked
  2. Chambers stimulated for antitachycardia pacing
  3. Tachycardia sensing (either ECG or hemodynamic based)
  4. Chambers stimulated for antibradycardia pacing
99
Q

How does ingestion of garlic affect our anesthetic plan? When should it be stopped? What other herbs can do this?

A

Inhibits platelet aggregation (increased risk of bleeding)
Stopped 1 week before surgery
The G’s (garlic, ginseng, gingko, ginger) + saw palmetto

100
Q

Which anti-cholinesterase is used to reverse the effects of scopolamine?

A

Physostigmine (crosses the blood brain barrier)

101
Q

What condition causes an ascending paralysis and how is it treated?

A

Guillian Barre Syndrome

Tx: IVIG, plasmapheresis, mechanical ventilation if respiratory status is of concern

102
Q

What medication should be avoided in patients with Guillian Barre Syndrome?

A

Succinylcholine (risk of hyperkalemia)

103
Q

What hemodynamic worries do you have with Guillian Barre Syndrome patients?

A

Autonomic dysfunction (hyper/hypotension, brady/tachycardia)

104
Q

What condition causes skeletal muscle weakness with repetitive use and what is the pathophysiology? Treatment?

A

Myasthenia gravis; auto-antibodies against Ach receptors

Tx: anticholinesterase drugs (i.e. pyridostigmine) -> corticosteroids -> plasmapheresis -> thymectomy

105
Q

How does a patient with myasthenia gravis respond to depolarizing NMB? Non-depolarizing NMB?

A

Depolarizing: Resistance (decreased # of functional receptors)
Non-depolarizing: Sensitive (same reason)

106
Q

What factors have been shown to increase the risk of post-operative mechanical ventilation in patients with myasthenia gravis?

A
  1. MG for >6 years
  2. Daily pyridostigmine dose >750mg
  3. Preoperative vital capacity <2.9L
  4. Presence of pulmonary disease unrelated to MG

Anesthesiology (21 decks)

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