ACE Exam 2022 Flashcards
When doing TOF on foot, what n are you assessing?
posterior tibial
***ONLY motor n in foot, the remainder are sensory
TOF at foot v hand
foot takes longer to onset and recovers faster
STOP BANG, BMI to inc risk of OSA
> 35
STOP BANG, neck circumfrence to inc risk of OSA?
40 cm (16 incchs)
STOP BANG, age to inc risk of OSA?
> 50
abrupt dec in SpO2, what dye given?
Methylene Blue -> absorbs at the same wavelength as deoxy Hg
Indigo carmine SpO2
little/no change
Indocynanine Green SpO2
slight dec 5-8%
Drugs that cross placenta easily
-lipophilic
-not protein bound
-nonionized
-small
-higher proportin of unionized drug in maternal plasma
RF for post herpetic neuralgia
-limited physical activity due to severe prodromal symptoms
-inc pain severity during infxn
-comorbid dx states incl resp dx and DM
What meds take the longest to infuse in?
Vancomycin
Fluoroquinolones: Ciprofloxacin
b/l blockages of superior laryngeal nerves cause
numbness above VC
what Local anesthetic causese the most pain on injection?
Etidocaine
-most lipid soluble
-Bupivacaine is also highly lipid soluble so 2nd most painful
Least painful local anesthetic on injxn?
Chloroprocaine least lipid soluble
-lidocaine 2nd least
What vasopressor may cause serotonin syndrome?
Methylene Blue
-MAO inh
SE of hydroxocobalamin used as vasopressor
chromaturia
-red colored urine
What herbal meds theoretically impact coagulation?
Garlic
Ginkgo
Ginseng
How long before surgery does garlic need to be d/c for neuraxial?
As long as no other anticoagulant drugs are being taken, does not need to be d/c
MC reason for pediatric liver transplant
biliary atresia
MC genetic cause of childhood liver dx
alpha 1 antitrypsin def
In noncardiac surgery, most common reason for periop stroke?
HypoTN (def as > 30% dec in baseline blood pressure)
Colloid osmotic pressure in preeclampsia
DECREASED
-plasma albumin is reduced due to loss of albumin in the protein and leaking of plasma protein through capillaries
CI to intraaortic balloon pump
-AR
-aortic dissection
-severe PVD
-pts w/ mulitple organ failure w/ no hope of reovery
-aortic stent or grafts
-septic shock
-pt refusal
How to know if pt is adequately alpha blocked for pheo surgery?
After 7-14 days of alpha blockade
-BP < 160/90
-some degree of postural hypoTN
-no ventricular arrythmias or ST or T changes for 2 weeks prior to surgery
What intraop infusions would be beneficial during a pheo removal?
-remifentanil
-esmolol
-Mg sulfate
-precedex
**Mg especially b/c dec catechlamine release, dec sensativity of alpha rec to catecholamines, antiarrythmic, direct vasodilation
What is important before ligation of adrenal vein in pheo removal?
volume explansion!! pt is going to get hypoTN after removal b/c of loss of catecholamines and already alpha blockedinsulin and pheo
What is important before ligation of adrenal vein in pheo removal?
volume explansion!! pt is going to get hypoTN after removal b/c of loss of catecholamines and already alpha blocked
insulin and pheo
-dec in catecholamines after pheo removal -> dec gluconeogenesis and inc in insulin release -> pts end up hypoglycemic
In trauma what causes the least movement of cervical spine?
intubation
-jaw thrust, head tilt and oral airway insertion inc cervical movement
Normal FHR
110-160
FHR for uterine rupture
likely late decelerations or persistent fetal bradycardia
Postop visual loss due to direct pressures
central retianl artery occlusion
postop vision loss not related to direct pressure
ischemic optic neuropathy
RF for ischemic optic neuropathy
-male sex, older, obesity
-intraop: hypoTN, large volume replacement w/ crystalloid, long duration of operation, Wilson frame, excessive blood loss
How long after catheter removal can heparin be restarted? ppx dose
1 hour
how long after heparin stopped can catehter be put in? ppx dose
4-6 hours
Why hypoTN after aoritc clamp off?
Mediator induced vasodilation
-fluid shifts from central to peirpheral compartments
What other congenital defect is found in peds w/ aortic coarctation?
bicuspid aortic valve (MC 80%))
PDA (50%)
What n block to use in circumcision w/ tethered spinanl cord?
pudendal
PPV in dec mycoardial contractility, effect on LV afterload?
decreased
At what MAC are pts going to get amnesia?
0.5-0.7 age adjusted MAC
MCC of death in hospitalized pts w/ SAH?
rebleeding
Which opioid metabolism does renal failure most affect?
Morphine -> M6G has resp depression
Meperidine -> CNS excitation sz
Sub-Tenon optho block
essentially peribulbar block w/ catheter at end of syringe instead of needle
What causes gastroschisis?
occlusion of omphalomesenteric artery
Goal Hg for ESRD pts on EPO?
10
ACLS pregnant woman
-manul L uterine displacement, don’t tilt the table
-if no ROSC in 5 minutes, hysterotomy
-no change to J for shocking
-compressions at normal lower sternum site
What muscle relaxant is most likely to cause inc in catecholamine release?
succinylcholine
If in OR and airway fire, what type of event?
sentinel event
-means that there is a catastrophic pt safety issue that requires evaulation ASAP
Six Sigma
set of QI tools and techniques
What n likely to be paralyzed w/ deep cervical plexus block?
phrenic
why does epi hel pw/ pain control when intrathecal?
alpha 2 agonist
What level of CO2 promotes upper airway dilating muscle activity?
hypercarbia ~45
What def makes people more susceptible to LAST?
Carnitine
Iodinated contrast v gadolinium contrast, which has higher radiopacity?
iodinated
RF for postop urinary retention
male
age
BPH
anesethesia lol (spinal, epidural, and GA)
-anticholinergics
-excessive IVF
-anorectal surgery
-lower limb arthroplasty
-long duration of surgery
Which genetic defect gets harder to intubate w/ age?
Pierre RObin
Hurler Syndrome, what is it? symp?
lysosomal storage d/o
-airway obstruction, cervical spine instability, cardiac dysnfxn, restrictive lung dx, cognitive dyzfxn, dec vision and hearing
f**atlanto axial instabolity
ESRD autonomic dysregulation
inc sympathetic, dec paraympathetic NS
-delayed gastric emptying
-inc resting HR
-dec HR variability
-dec exercise tolerance
-orthostatic hypoTN
What n to block for cleft lip?
Infraorbital
target for lumbar sympathetic block
L3 anterolateral aspect of vertebral body
where is the celiac plexus located?
T12/L1
MC complications in donors for livingn liver transplant
infxn
bile leak
pleural effusion
What test is most useful for assessing pts post thoracotomy outcome?
maximal O2 consumption
-risk of M&M is low if VO@ > 20
Assessment of M&M in lung resection surgery
***maximum O2 consumption is most useful!
-VO2 < 15-20 higher risk, or 6 minute walk test < 400 m
-FEV1 < 40% higher risk
-DLCO < 40% higher risk
Best way to assess max O2 consumption
6 minute walk test -> how far can a pt walk in that time?-normal 400-600
-> if less than 400 time to do formal testing
-if COPD divide 6MWT by 30 to get VO2
In ambulatory surgery center w/ no volatile anesthetics, which must they have? succ? dantrolene or both?
just succ
In ambulatory surgery center w/ volatile anesthetics, which must they have? succ? dantrolene or both?
both
What herbal medical can cause serotonin syndrome w/ MAOi?
Ephedra
-sounds like esmerelda -> she dances and inc serotonin in herself and those around her
why cancel elective cases w/ positive COVID 19?
inc risk in pt periop complications
Dose of methadone for 35 hr coverage?
20 mg
Dose of methadone for 3-4 hr coverage?
10 mg
When should chemoppx for DVT start postop after brain surgery?
Ideal within 72 hours!
-24 hours better than 96
Paraneoplastic syndrome w/ squamous cell carcinoma
hyperCa (PTHrP)
Paraneoplastic syndrome w/ adenocarcinoma
Cushings
growth hormone
caffeine and ECT
inc sz duration
What factor def can cause abnormal bleeding despite normal PT, PTT, and functional thrombin and fibrinogen time?
factor XIII
blood supply?
R coronary artery
how to tell a tension HA from a migraine?
tension: b/l, mild to moderate
migraine: photophobia, phonophobia, rhinorrhea, lacrimation, conjunctival injxn, miosis, ptosis
why clevidipine so short acting?
metabolized by blood and tissue esterases
clveidipine arterial or v vasodilator?
selective arterial vasodilator
-already has a v so just arterial vasodilating
After how many weeks can intraop FHR monitoring be done?
22 weeks
Porphyrias cause?
congenital errors in the synthetic chain that leads to production of Hg -> def in this cause accumulations of intermediates
Why do pts w/ acute porphyrias get attacks intraop?
because they lose blood -> body wants to make more -> triggers inc in enzymes to make more Hg, but they have issues w/ that
-stressors that trigger: dehydration, infxn, fasting
where in brachial plexus is interscalene block done?
roots C5-C7
Where is supraclav done in brachial plexus?
Trunks
Infraclav, where done in brachial plexus?
Cords
Unsafe avoid in porphyria
All barbiturates
CCB
Amiodarone
Phenytoin
Spironolactone
Valproic Acid
Ketamine
Safe in porphyria
all volatiles
atropine
fentanyl
midaz
meperidine
neostigmine
nitrous oxide
propfol
succ
vecuronium
pt w/ low SVR and high PVR, what pressor to use?
Vasopressin
cardiac concerns w/ scleroderma
pulm HTN
-sclerosis of coronary arteries
-issues w/ electrical conduction
TEF repair, and sudden desat and dec in EtCO2 next step?
advance ETT
RF PONV peds
-age > 3
-strabismus surgery
-family hx PONV
-surgery > 30 minutes
pts allergic to hemostatic agents, more likely to be allergic to?
red meat
-Mg
-heparin
-gabapentin
-tylenol
faster onset: rectal midaz, intranasal clonidine, PO precedez?
rectal midaz
best regional block for coverage for a median sternotomy?
erector spinae
What is multisystem inflammatory syndrome in peds?
kids 0-19 fever > 3 days
-rash, hypoTN, myocardial dysfxn, coagulopathy, acute GI problems
-inc ESR, CRP
-no other microbial cause
what opioid is assoc w/ serotonin syndrome?
Fentanyl!
SVR and pneumoperitoneum
increased!
Sickle cell dx and moyamoya and stroke, best steps?
-so no hyperventilation b/c moyamoya has profoundly small vessels distally -> vasoconstrictiona nd ischemic stroke
-mannitol CI
-dec HbS through transfusion!
blood product most assoc w/ infxn?
plts room temp storage
Where does greater occipital n originate?
C2 medial branch of dorsal ramus
-on back of head, like dorsal more posterior
severe hyperK next steps?
EKG to confirm actually severe -> Ca
PPV of what is considered fluid responsive?
13%
WHen is PPV to assess fluid responsiveness unrelieable?
-arrythmias (must be NSR)
-RV failure
-low lung compliance
-low TV
-sponatenous respirations
-inc intraabd pressure
-open chest
Naloxegol MOA
selective mu opioid antagonist
inc in inspiratory flow rate on I:E ratio?
decrease
-less time in inh b/c flowing faster to get to the TV
