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Anesthesiology > ACE 2017 > Flashcards

ACE 2017 Flashcards

1
Q

What is the blood-gas partition coefficient of nitrous oxide?

A

0.47

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2
Q

What is the blood-gas partition coefficient of nitrogen?

A

0.015

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3
Q

Which is more soluble in blood: nitrous oxide or nitrogen?

A

Nitrous oxide is about 30 times more soluble than nitrogen.

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4
Q

What concentration of nitrous oxide will theoretically result in a doubling in size of an air-filled cavity?

A

50% inspired nitrous oxide

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5
Q

What concentration of nitrous oxide will theoretically result in a quadrupling in size of an air-filled cavity?

A

75%

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6
Q

How long does it take for doubling in size of an intrapleural gas cavity versus the lumen of abdominal organs?

A

Intrapleural 10 minutes; abdominal organ lumens nearly 2 hours

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7
Q

Is use of nitrous oxide an absolute or relative contraindication in the setting of pneumothorax?

A

Absolute contraindication

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8
Q

Is use of nitrous oxide an absolute or relative contraindication in the setting of bowel obstruction?

A

Relative contraindication, particularly if prolonged surgical procedure is anticipated.

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9
Q

What neurological injury leaves patients at risk for delayed cerebral ischemia?

A

Aneurysmal subarachnoid hemorrhage

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10
Q

What percentage of patients who initially survive an aneurysmal subarachnoid hemorrhage suffer delayed cerebral ischemia?

A

Up to 40%

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11
Q

What is the primary cause of mortality in a subarachnoid hemorrhage if the hemorrhage progresses to infarction?

A

Delayed cerebral ischemia

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12
Q

What medication as of 2017 is the only class 1, level A intervention that improves outcomes after aneursymal subarachnoid hemorrhage?

A

Nimodipine

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13
Q

How should intravascular volume/fluid balance be approached in patients with subarachnoid hemorrhage?

A

Patients should be euvolemic and normal circulating volumes should be the target.

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14
Q

What is the role of prophylactic hypervolemia in patient with subarachnoid hemorrhages?

A

Associated with increased cardiopulmonary complications and not commonly recommended.

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15
Q

What is the role of prophylactic hyperventilation in patients with subarachnoid hemorrhage?

A

Prophylactic hyperventilation - once thought useful - may cause a deleterious decrease in cerebral blood flow and is NOT employed in the management of subarachnoid hemorrhage.

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16
Q

When is delayed cerebral ischemia after subarachnoid hemorrhage thought to occur?

A

4 - 9 days after the subarachnoid hemorrhage

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17
Q

What are the two major complications anticipated after subarachnoid hemorrhage and when do they occur?

A

Rebleeding: 1 - 30 days after the SAH. Vasospasm: 4 - 9 days after the subarachnoid hemorrhage

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18
Q

What conditions justify “medical necessity” for appropriate MAC billing for GI endoscopic procedures?

A
  • Prolonged or therapeutic procedure requiring deep sedation (eg ERCP, tortuous colon) - poor response to moderate/conscious sedation -pregnancy -h/o drug or alcohol abuse -uncooperative or agitated patient -increased risk for airway obstruction
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19
Q

Define ventilatory “dead space”

A

The volume of gas that is in the airway system but not exchanged within the alveoli.

20
Q

Where is ventilatory “dead space” in circle systems of modern anesthesia machines?

A

Y- piece to the conducting airways.

21
Q

How can one decrease the ventilatory deadspace in a circle system?

A
  • use lower volume Y-piece or smaller ETT -place ETT as close to carina as possible - trim ETT and secure it as closely as possible to patient’s face.
22
Q

What is cardiac tamponade?

A

When fluid accumulates in the pericardial space and there are clinical signs that intrapericardial pressure limits filling of the heart.

23
Q

What are ten signs and symptoms of cardiac tamponade?

A
  1. Dyspnea (earliest and most sensitive sign) 2. chest discomfort 3. hemodynamic collapse 4. low-volt QRS on ECG 5. electrical alternans (oscillating QRS amplitude between beats) 6. t- wave abnormalities 7. Beck’s triad 8. absence of y-descent on CVP 9. equalization of diastolic pressures 10. pulsus paradoxus
24
Q

What is Beck’s triad?

A

The classical diagnostic signs for tamponade: 1. decreased arterial pressure 2. increased CVP 3. muffled heart sounds

25
Q

What changes are expected on CVP waveform in cardiac tamponade?

A

Absence of y-descent (absence of passive ventricular filling)

26
Q

Name the components of the CVP waveform and corresponding physiological event.

A

a-wave: atrial contraction c- wave: isovolumetric ventricular contraction x-descent: atrial relaxation v-wave: atrial filling y-descent: passive/early ventricular filling

27
Q

What are the three pressure peaks of the CVP waveform?

A

a, c, and v

28
Q

What are the two pressure descents of the CVP wave form?

A

x and y

29
Q

What are the systolic components of the CVP waveform?

A

c, x and v

30
Q

What are the diastolic components of the CVP wave form?

A

y and a

31
Q

What is pulsus paradoxus and what causes it?

A

A decline in SYSTOLIC blood pressure of greater than 12mmHg during spontaneous inspiration. Due to increased filling of the right side of the heart with a consequent reduction in stroke volume of the left ventricle.

32
Q

When is pulsus paradoxus seen?

A

Classically in cardiac tamponade but is not specific for it. Can also be seen in obstructive lung disease or RV ischemia.

33
Q

What does this arterial blood pressure tracing demonstrate? (Arrows mark respiratory inspiration)

A

Pulsus paradoxus.

The image shows a decrease in systolic blood pressure greater than 12 mm Hg. Note the concomittant decrease in pulse pressure during inspiration as well.

34
Q

What does the CVP wave marked ‘B’ show and what pathological condition is it consistent with?

A

Absence of y-descent and prominent x-descent during ventricular systole. These are consistent with cardiac tamponade.

35
Q

Draw a normal ECG and a corresponding normal CVP waveform. Label the components of each.

A
36
Q

What does this ECG show and with what condition is it associated?

A

Electical alternans (oscillating QRS amplitudes between beats)

Low-voltage QRS complexes

Both associated with cardiac tamponade.

37
Q

What is electrical alternans?

A

Electrical alternans is oscillation of the QRS amplitude from beat to beat. It is sometimes seen in cardiac tamponade.

38
Q

How does coagulopathy develop in massive hemorrhage?

A

Begins with dilution and consumption of clatting factors and platelets

Tissue ischemia leads to active release of antifibrinolytic compounds and failure of the endothelial side of in vivo coagulation.

39
Q

What are 4 key characteristics of massive transfusion protocols?

A
  1. Enables rapid communication between OR and blood bank with availability of all products necessary at bedside
  2. a. Attention to adequate IV access
    b. Rapid anatomic control of bleeding
    c. Maintenance of temperature
  3. early admin of plasma and platelets in an empiric ratio
  4. adjuvant admin of antifibrinolytic medication early in resuscitation
40
Q

How long after spinal cord injury does proliferation of extrajunctional acetylcholine receptors occur?

A

24 hours, at minimum

41
Q

When do extrajunctional acetylcholine receptors occur in patients with severe burns?

A

Days to weeks after injury but succinylcholine is contraindicated after first 24 hours after injury.

42
Q

How has the use of succinylcholine in severe traumatic brain injury or open globe injuries contributed to adverse outcomes?

A

Succinylcholine has not been associated with an increase in adverse outcomes in TBI or open globe injuries despite the theoretical concern that it can cause transient increases in pressure in the brain and eye.

43
Q

What are absolute contraindications to the use of succinylcholine?

A

MHS

old spinal cord injury

demyelinating disease

44
Q

What are seven risk factors for PONV?

A
  1. Previous history of PONV
  2. Use of GA (and not regional/sedation)
  3. Female sex
  4. Younger age
  5. Nonsmoking status
  6. Surgery in abdomen
  7. Planned use of opioids post-op
45
Q

What is the relationship between duration of anesthesia and risk for PONV?

A

There is no association between duration of GA and risk for PONV.

46
Q

Name eight classes of medications that have documented antiemetic effects.

A
  1. Neurokinin 1 (NK1) receptor antagonists
  2. 5-Hydroxytryptamine 3 (5-HT3) receptor antagonists
  3. Glucocorticoids
  4. Phenothiazines
  5. Phenylethylamines (e.g. ephedrine)
  6. Butyrophenones
  7. Antihistamines
  8. Anticholinergics
47
Q

What are current (as of 2018) adult recommendations for PONV prophylaxis?

A

Patients with 3 or more risk factors should receive prophylactic medications from at least 2 different classes prior to emergence from anesthesia.

Anesthesiology (11 decks)

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