ACE 2013 10B Flashcards
How do NSAIDs affect the kidneys?
They inhibit production of prostaglandins which cause afferent arterial vasodilation which can cause acute renal failure
Which is a side effect seen with NSAIDs: obstructive uropathy, elevated BP, renal vasodilation, hypokalemia
Elevated BP - thought to be secondary to Na retention and volume expansion
What is the treatment for neurogenic diabetes insipidus?
Infusion of isotonic fluids (use hypotonic fluids if plasma osmolarity reaches 290 mOsm/L or higher) + desmopressin (DDAVP)
What is the treatment for nephrogenic diabetes insipidus?
Infusion of isotonic or hypotonic solutions + chlorpropamide or clofibrate (potentiate effects of arginine vasopressin on renal tubules)
What is the treatment for nephrogenic diabetes insipidus?
Infusion of isotonic or hypotonic solutions + chlorpropamide or clofibrate (potentiate effects of arginine vasopressin on renal tubules)
Which of the following increases risk of postop apnea in a ex-32 weeker: post-conceptual age 60 weeks, intraop caffeine, anemia, hx of necrotizing enterocolitis
Anemia
What is the Modified Aldrete Scoring System and what does it consist of?
PACU discharge criteria
Consists of Respiration, oximetry, BP, level of consciousness, and activity
What is the Post-Anesthetic Discharge Scoring System and what does it consist of?
PACU discharge criteria
Consists of pain, bleeding, nausea, CV changes, activity
What is the Post-Anesthetic Discharge Scoring System and what does it consist of?
PACU discharge criteria
Consists of pain, bleeding, nausea, CV changes, activity
Which of the following is an absolute contraindication for ECT: pregnancy, AICD, pheochromocytoma, neuroleptic malignant syndrome
Pheochromocytoma
Which of the following is an absolute contraindication for ECT: pregnancy, AICD, pheochromocytoma, neuroleptic malignant syndrome
Pheochromocytoma
What level are the cardiac accelerator fibers located?
Sympathetic fibers from T1-T4
Why might you see bradycardia following spinal anesthesia to T10?
Reverse Bainbridge reflex: normally, increased venous return causes increased HR (via SNS and inhibition of vagal outflow); this is the opposite where decreased venous return (from spinal) causes bradycardia
Why might you see bradycardia following spinal anesthesia to T10?
Reverse Bainbridge reflex: normally, increased venous return causes increased HR (via SNS and inhibition of vagal outflow); this is the opposite where decreased venous return (from spinal) causes bradycardia
Name some medications that are given intraoperatively that should be avoided in patients with Parkinson Disease
Promezathine, droperidol, metoclopramide (any medication that decreases the effects of dopamine)
How long after cosmetic liposuction via the tumescent technique do you expect peak serum levels of lidocaine?
12-14 hours after injection
How long after cosmetic liposuction via the tumescent technique do you expect peak serum levels of lidocaine?
12-14 hours after injection
What do you worry about in a neonate with generalized cyanosis and a concave abdomen?
Congenital diaphragmatic hernia
What congenital abnormalities are most commonly associated with congenital diaphragmatic hernias?
CVS (50%): ASD/VSD, ToF, Coarctation
GI (40%): malrotation
CNS (20%): spina bifida, hydrocephalus, microcephaly
What side effects do you worry about in patients taking cyclosporine?
Acute kidney injury
What side effects do you worry about in patients taking bleomycin?
Pulmonary fibrosis
What side effects do you worry about in patients taking bleomycin?
Pulmonary fibrosis
What are the classic characteristics of obesity hypoventilation syndrome?
- Obesity (BMI >30)
- Daytime awake hypercapnia and hypoxia
- Sleep-disordered breathing without another known cause
What are the classic characteristics of obesity hypoventilation syndrome?
- Obesity (BMI >30)
- Daytime awake hypercapnia and hypoxia
- Sleep-disordered breathing without another known cause
What medications are capable of producing burst suppression?
Volatile anesthetic gases (~2 MAC), etomidate, propofol, and barbiturates
Which is least likely to cause airway obstruction 1 hour after total thyroidectomy: neck hematoma, recurrent laryngeal nerve injury, tracheomalacia, hypercalcemia
Hypercalcemia (total thyroidectomies lead to hypocalcemia from parathyroid removal)
Which is least likely to cause airway obstruction 1 hour after total thyroidectomy: neck hematoma, recurrent laryngeal nerve injury, tracheomalacia, hypercalcemia
Hypercalcemia (total thyroidectomies lead to hypocalcemia from parathyroid removal)
What do you worry about in chronic methamphetamine users?
- Depletion of neurotransmitters (NE and epi) - hypotension
2. Cardiomyopathy (40% of patients)
PEEP of 10 cm H2O will decrease which of the following: FRC, airway resistance, dead space, arterial oxygen sat
Airway resistance (from increase in lung volume)
What does the addition of sodium bicarbonate to lidocaine do?
Decreases pain on subcutaneous infiltration; although there are more non-ionized forms from the decreased pH, studies have not shown decreases in onset time or block intensity
Which is most associated with increased risk of worsening neurologic function in MS: epidural, peripheral nerve block, GA, hyperthermia
Hyperthermia - Uhthoff phenomenon (body temp elevation of 0.5C or more will exacerbate MS symptoms)
Which is most associated with increased risk of worsening neurologic function in MS: epidural, peripheral nerve block, GA, hyperthermia
Hyperthermia - Uhthoff phenomenon (body temp elevation of 0.5C or more will exacerbate MS symptoms)
What are some ECG findings for hypercalcemia? Hypocalcemia?
Hyper: shortened PR and QTc intervals
Hypo: prolonged QTc interval
What medication should you try to avoid in hypercalcemia?
Thiazide diurectics - they will induce hypercalcemia
What are common findings for critical illness polyneuropathy?
Respiratory muscle weakness (slow to wean off vent) and distal weaknesses (mostly lower extremity); you do NOT see cranial nerve or facial abnormalities
Which is least likely to occur after femoral nerve block: loss of skin sensation over anterior thigh, loss of sartorius muscle function, loss of sensation over medial leg and foot, loss of adductor longus function
Loss of adductor longus function (innervated by the obturator nerve)
What nerves make up the femoral nerve? Obturator nerve?
Femoral: Posterior division of L2-L4
Obturator: Anterior division of L2-L4
What pain medication can worsen opioid-induced constipation?
TCAs
Vacuum-assisted devices in OB increase the risk of what to the infant?
Cephalohematomas and subgaleal hemorrhages
Forceps-assisted deliveries in OB increase the risk of what to the infant?
Cephalohematomas and intracranial hemorrhages
Forceps-assisted deliveries in OB increase the risk of what to the infant?
Cephalohematomas and intracranial hemorrhages
Why doesn’t succinylcholine readily cross the placenta?
It is highly ionized and has a low lipid solubility
What is the mechanism of action of dexmedetomidine and what hemodynamic effects do you see from it?
Alpha-2 agonist
Bradycardia and hypotension
How is dexmedetomidine metabolized?
Liver (conjugation and methylation)
How is dexmedetomidine metabolized?
Liver (conjugation and methylation)
What are the conditions listed in the Revised Cardiac Risk Index?
- Hx of ischemic heart disease
- Hx of CHF
- Hx of CVA
- Renal insufficiency
- DM
What are the major cardiac risk factors that should be treated prior to elective surgery?
- Unstable coronary disease (angina, recent MI)
- Decompensated heart failure
- Severe valvular disease
- Significant dysrhythmias
What are the major cardiac risk factors that should be treated prior to elective surgery?
- Unstable coronary disease (angina, recent MI)
- Decompensated heart failure
- Severe valvular disease
- Significant dysrhythmias
How is remifentanil metabolized?
Nonspecific blood and tissue esterases (NOT plasma cholinesterase)
How is remifentanil metabolized?
Nonspecific blood and tissue esterases (NOT plasma cholinesterase)
What is the first-line therapy for bony metastatic pain?
NSAIDs, then opioids
What is the first-line therapy for bony metastatic pain?
NSAIDs, then opioids
During a laparoscopic procedure, what do you suspect if you see hypercapnia increase by 25% after 30 minutes of pneumoperitoneum? What if you see hypoxemia after 15 min?
- Subcutaneous emphysema
2. Bronchial intubation (diaphragm pushed up)
During a laparoscopic procedure, what do you suspect if you see hypercapnia increase by 25% after 30 minutes of pneumoperitoneum? What if you see hypoxemia after 15 min?
- Subcutaneous emphysema
2. Bronchial intubation (diaphragm pushed up)
What changes in the respiratory function of a patient who has a spinal to a level of T3?
Abdominal and intercostal muscles involved in active exhalation are affected, causing decreased ERV and thus vital capacity
What changes in the respiratory function of a patient who has a spinal to a level of T3?
Abdominal and intercostal muscles involved in active exhalation are affected, causing decreased ERV and thus vital capacity
What are some risk factors for developing post-operative ulnar neuropathy?
- Male (thicker flexor retinaculum and bony protuberance is more prominent with less adipose protection)
- Obesity or very thin body habitus
- Prolonged immobilization
- Older age
What are some risk factors for developing post-operative ulnar neuropathy?
- Male (thicker flexor retinaculum and bony protuberance is more prominent with less adipose protection)
- Obesity or very thin body habitus
- Prolonged immobilization
- Older age
How does progesterone affect respiration in pregnancy?
Shifts the CO2 response curve to the left (direct respiratory stimulant) so you have a higher tidal volume
Also is a bronchodilator (increased dead space)
How does progesterone affect respiration in pregnancy?
Shifts the CO2 response curve to the left (direct respiratory stimulant) so you have a higher tidal volume
Also is a bronchodilator (increased dead space)
What nerve is injured if you have a foot drop with decrease sensation of the lateral calf and foot?
Lumbosacral trunk
What nerve is injured if you have weak quadriceps, decrease sensation of the medial calf, and loss of the patellar reflex?
Femoral nerve
What nerve is injured if you have decreased sensation of the medial aspect of the thigh and inability to adduct the thighs?
Obturator nerve
What is the mechanism of action of gabapentin: agonism of GABA-A receptors, agonism of GABA-B receptors, NMDA antagonist, or calcium channel modulation
Calcium channel modulation (gabapentin increases release of GABA but is not an agonist)
What is the mechanism of action of gabapentin: agonism of GABA-A receptors, agonism of GABA-B receptors, NMDA antagonist, or calcium channel modulation
Calcium channel modulation (gabapentin increases release of GABA but is not an agonist)
What does the posterior tibial nerve provide sensation to in the foot? Saphenous? Sural? Superficial peroneal? Deep peroneal?
PT: plantar surface of foot
Saphenous: medial ankle and foot
Sural: lateral foot
Superficial peroneal: dorsal surface of foot
Deep peroneal: web space between first and second toes
What does the posterior tibial nerve provide sensation to in the foot? Saphenous? Sural? Superficial peroneal? Deep peroneal?
PT: plantar surface of foot
Saphenous: medial ankle and foot
Sural: lateral foot
Superficial peroneal: dorsal surface of foot
Deep peroneal: web space between first and second toes
What is first indicator of hypovolemia in a 3 year old patient with trauma?
Tachycardia (given the underlying SNS tone of children)
What TEE view gives you simultaneous information about all 3 major coronary arteries?
Transgastric mid-papillary short axis view
What is the landmark used when performing a stellate ganglion block?
Chassaignac tubercle (transverse process of C6)
Why do we use leukocyte reduced pRBCs?
Decrease in febrile non-hemolytic transfusion reactions, decreased transmission of CMV, decreased alloimmunization
What is more noxious: surgical skin incision or laryngoscopy with intubation? Without intubation?
Laryngoscopy without intubation is less noxious but with intubation is more noxious
What are the symptoms of serotonin syndrome?
- AMS (agitation/delirium/confusion)
- Autonomic nervous system hyperactivity (hyperthermia, sweating, tachycardia, flushing)
- Neuromuscular abnormalities (rigidity, tremor, shivering)
What is the mechanism of action for tramadol?
Weak mu opioid receptor agonist and wean SNRI
What should you worry about if you have immediate bilateral lower extremity numbness and weakness progressing to paraplegia in a patient who had a left-sided TFESI with methylprednisolone?
Spinal cord infarct secondary to arterial injury or intraarterial injection of particular steroid (not likely nerve trauma since it is bilateral)
What is the first-line treatment for trigeminal neuralgia?
Carbamazepine
What are some more serious side effects of carbamazepine?
SJS, toxic epidermal necrolysis, hyponatremia due to SIADH, aplastic anemia, agranulocytosis, abnormal LFTs, and pancytopenia
Which chemotherapeutic agents are associated with cardiomyopathies?
Doxorubicin and danorubicin
What chemotherapeutic agent is associated with pulmonary fibrosis?
Bleomycin
What is the first thing you do when there is an airway fire?
Call for help and remove the ETT
Patient has allergies to fish, soy beans, shellfish, and avocados; which drug(s) might cause an allergic reaction: protamine, propofol, povidone iodine, latex
Latex; the others are associated with but have not been shown to cause an allergic reaction
What is supine hypotensive syndrome in the mother and what hemodynamic signs does it present with?
During late pregnancy, nausea/dyspnea, cyanosis and LOC after assuming the supine position (compression of IVC)
Hypotension + bradycardia
What is the main advantage of using liposome-encapsulated morphine rather than standard morphine?
Increased duration of action
Which medication increases the risk of pediatric emergence agitation: isoflurane, sevoflurane, propofol, dexmedetomidine
Isoflurane (more so than sevoflurane because it is less soluble), the other two are used to treat emergence agitation
What is the oculocardiac reflex and what can increase the likelihood of provoking the reflex?
OCR: pressure on the globe, traction on EOM, or manipulation of the conjunctiva which causes bradycardia
Hypoxia and hypercapnia increases likelihood
Can the oculocardiac reflex occur with enucleated orbits? In the presence of a retrobulbar block?
Yes for both
What is the purpose of the dispersive pad (bovie pad)?
Reduce current density
With a double lumen tube, what do you suspect if you have a sudden increase in peak airway pressures and decreased expiratory tidal volumes with elevated HR and BP?
Malpositioning of the DLT; deflate the bronchial cuff and evaluate with a fiberoptic
