Adult

Question 1

Hydroxyurea

Answer 1

• hydroxyurea is used for sickle cell PT to decrease risk of stroke
• hydroxyurea stimulates the production of fetal hemoglobins and prevent vaso-occlusion crisis

Question 2

Tapentadol

Answer 2

• tapentadol is synthetic miu agonist with strong norepinephrine reuptake inhibition and weak serotonin reuptake inhibition.
• 10 mg morphine = 25 mg tapentadol
• do not use tapentadol with MAOI

Question 3

Ideal tidal volume for one lung ventilation?

Answer 3

• tidal volume of 4-6 mL/kg of ideal body weight for one lung ventilation

Question 4

Which opioid less likely depending on CYP2D6 metabolism?

Answer 4

• morphine and hydromorphone doesn’t depend on CYP2D6

Question 5

Laser and it’s goggles

Answer 5

• CO2 laser - clear goggle
• KTP laser - red
• ARGON laser - Orange
• Nd:YAG laser - green

CO2 clear - CC

KTPR

ARGOrange

YAGreen

Question 6

What drugs needs CYP 2D6 for metabolism?

Answer 6

• 2D6: oxycodone, hydrocodone, codeine, meperidine, methadone
• pts w 2D6 deficiency ie poor metabolizeers will have build up of these opioids

Question 7

Emergency reverse coumadin?

Answer 7

• emergency reversal of coumadin is PCC prothrombin complex concentrate
• urgently reversal of coumadin - FFP

Question 8

Antidote for xarelto (rivaroxaban) and eliquis (Apixaban)

Answer 8

Andexanet

Question 9

Electroconvulsion therapy - COVID era

Answer 9

At baseline we did these procedures in PACU with Jackson rees circuits. Currently, as additional precautions, we use full PPE N95 and an anesthesia machine (has scavenger system) with viral filter right above mask.

Give glyco and preoxygenate to et O2 80% using rubber mask straps to create good seal, induce. Once paralyzed turn off gas flows and remove mask, psychiatrist places rubber bite block- administers shock-removes bite block. After seizure, replace mask with mask straps on patient and turn on gas flow, wait for patient to begin spontaneous ventilation, chin lift prn. When patient is spontaneously breathing and not requiring supplemental O2, turn off gas flows, disconnect at viral filter, and transfer to recovery with mask and viral filter remaining secured by mask strap until fully awake.

This method has alleviated need to mask ventilate or suction any patient with exception of 1 with OSA who had required nasal trumpet for procedure pre- covid era. He required 2 breaths post shock which mask straps made easier and provided superior seal. Patients have also tolerated this well.

Question 10

OB anesthesia- neurofibromas and epidural? If no MRI, will you say no to epidural?

Answer 10

• Yes. The neurofibromas can grow in the spine and with pregnancy hormones are also more likely to grow. Not only do you want an mri but you’d like it in the third trimester if possible because the closer it is to actual delivery the more accurate you will know what is going on in her spine. Ob anesthesiologist.

Question 11

Cyanide toxicity tx

Answer 11

• cyanide toxicity suspected when PT on nitroprusside gtt > 10 mcg/kg/min > 24 hrs
• presents as tachyphylaxis to hypotensive effect of nitroprusside
• cyanide attacks cytochrome oxidase in mitochondrion-> inability of tissue to use oxygen -> metabolic acidosis -> lactic acidosis, increased mixed venous PO2 and cerebral venous PO2, change in mental status and seizures
• TX: stop nitroprusside gtt, give O2, bicarbonate to correct metabolic acidosis
  + sodium thiosulfade 150 mg/kg over 15 mins
  + if severe cyanide toxicity (hemodynamics instability, metabolic acidosis) sodium nitrate 5mg/kg slow IV -> convert cyanide to methemoglobin ie cyanide to cyanomethemoglobin

Question 12

chemicals in cannabis and its affects

Answer 12

chemicals in cannabis = THC + CBD

• THC tetrahydrocannabinolic acid is bad-
  increased risk of heart attacks, atrial fibrillation and heart failure
• CBD cannabidiol, may lower blood pressure and reduced inflammation

Question 13

PT with morphine allergy undergoing C/S

Answer 13

1. Pt with morphine allergy undergoes C/S spinal anesthesia –> dilaudid 75mcg + fent 15-20 mcg + 0.75% bupi hyperbaric 1.4-1.8 ml

Question 14

Following delivery of fetus, uterus is found boggy, what to do next?

Answer 14

1. Following delivery of fetus, uterus is boggy –> check if pitocin was given as it causes peripheral vaso dilation, hypotension and tachycardia–> treat w phenylephrine

Question 15

Alfentanil

Answer 15

Alfentanil is “4” fentanyl
Alfentanil has 4x faster onset than fentanyl
Alfentanil is 1/4 potent of fentanyl
Alfentanyl lasts about 1/4 of fentanyl

Question 16

Breast cancer sx with TIvA and PONV prevention

Answer 16

My PONV cocktail is:

1. Zofran 4mg
2. IV decadron 4mg
3. Diphenhydramine 6.25mg IV after going to sleep
4. Scope patch ATLEAST 1 hr before induction. If unable to do this, atropine 0.2mg after induction. No scopolamine patch for over 65 yo or glaucoma pts

Squirt the rest of my propofol from induction into my bag of IVF. At end of case, waste the rest of IV bag and go to pacu with fresh IVF.

TIVAs
Paravertebral or PEC 1&2 blocks

Question 17

Anyone experience anything like this? Obstetrics.

G1, induction, epidural requested very early. Given without issue.

Five hours later patient rolls over,0 complains of sharp back pain, then of sensation returning (ie, epidural no longer working). Nurse gives nursing bolus, which patient reports intensifies the back pain. Pain in back spreading up spine, both sharp and dull. RN stops pump.

By the time I get there, patient says pain in back has eased off. I tested with 2ml 2% lidocaine. No reaction. She’s able to lay back. Tried 2ml 0.2% ropi. Still no reaction. Gave the 4ml nursing bolus and 1mL in she starts complaining of the pain again. Strong reaction. This is the same bag that has been running the entire time though, so although it seems like something is amiss with the medicine, she was fine with it for 5 hours prior to this.

Pulled epidural, tip intact, went down one space, easy placement. As saline went in she seemed jumpy. As soon as I started the test dose she had the same reaction. Said it was shooting pain in her back. I stopped, allowed it to subside somewhat, and would give some without telling just to see how she would react, same reaction. Tried bolusing saline, same reaction. Pulled the catheter, again, tip intact.

Went up two spaces above first placement. Easy placement again. Same reaction. Patient still in early latent labor, decision was made to rely on just IV meds right now.

Has anyone ever seen anything like this before?

Update: my colleague Meagan Horst replaced the epidural as she posted below. Again, after 5 hours, patient started complaining that her epidural was wearing off and she was having back pain right at the insertion site. Seems like our options are now very limited.

Answer 17

• it may be related to spinal ischemia secondary to the pressure. Replacing the catheter has never changed outcome. The best thing would be to limit how much she is getting in her bolus or take away bolus function
• This is related to the epidural catheter going into a space that it isn’t intended to. Read work by Clive Collier - he has identified an “intradural” space that epidural catheters can enter and I think this is what is happening. The epidural injectate then stretches those layers apart more and the pain is excruciating. They mostly complain in between shoulder blades. If the space gets really stretched you are more likely to enter it when you replace. My approach is to replace catheter as soon as I suspect this (at a different interspace), do a CSE with a heavier dose of local than normal (that would be 2.5 mg of 0.25% bupi for me as I usually use 1.25 mg) and that buys them time to let the fluid and pressure dissipate. Post-pone programmed bolus for 1 hour after (ours usually starts at 30 minutes) and tell patient to not push button in the interim. Long ago we thought it only happened to short heavy girls who were crazy button pushers but then we’ve had patients experience this who are tall and lean and haven’t had the epidural for too long. In my experience these patients do not get spinal headaches and recover just fine.

Question 18

Codeine metabolites?
Oxycodone?
Heroin?

Answer 18

Codeine-> morphine + hydrocodone

Oxycodone -> oxymorphone

Heroin -> morphine + 6-monoacetylmorphine

6-monoacetylmorphine is not found in any commercial opioid so it’s used as marker to check for illicit opioid use

Question 19

Cerebral T waves

Answer 19

• ECG Abnormalities with increased Intracranial Pressure
• Increased ICP is associated with certain characteristic ECG changes:

+ Widespread T-wave inversions (“cerebral T waves”).
+ QT prolongation.
+ bradycardia (the Cushing reflex – indicates imminent brainstem herniation).

• Other possible ECG changes that may be seen:

+ ST segment elevation / depression — this may mimic myocardial ischaemia or pericarditis.
+ Increased U wave amplitude.

• Other rhythm disturbances: sinus tachycardia, junctional rhythms, premature ventricular contractions, atrial fibrillation.
• In some cases, these ECG abnormalities may be associated with echocardiographic evidence of regional ventricular wall motion abnormality (so-called “neurogenic stunned myocardium”)

Causes

ECG changes due to raised ICP are most commonly seen with massive intracranial haemorrhage:

Subarachnoid haemorrhage
Intraparenchymal haemorrhage (haemorrhagic stroke)
They may also be seen with:

Massive ischaemic stroke causing cerebral oedema (e.g. MCA occlusion)
Traumatic brain injury
Cerebral metastases (rarely)

** the incidence of EKG changes correlates with amount of intracranial blood - these EKG abnormalities are not indicative of cardiac dz, these are more likely manifestation of sympathetic hyperactivity due to increased norepinephrine level

Question 20

Precedex causes diuretic effect?

Answer 20

• precedex alpha 2 agonist produces diuretic response by decreasing ADH release and decreased ADH sensitivity peripherally.

Question 21

Your patient is undergoing a general anesthetic using an endotracheal tube (ETT) through a mature tracheostomy. What is the OPTIMAL depth of the ETT (read from the skin surface of the tracheostomy) to ensure the tip of the ETT is safely positioned?

Answer 21

For patients with mature tracheostomies who are having further head and neck procedures, it is advantageous to remove the existing tracheostomy tube and insert a wire-reinforced endotracheal tube (ETT) through the stoma, pulling it back after placement until the top of the ETT cuff can be visualized. Placement of an ETT through a mature tracheostomy should not extend past 5 to 6 cm to avoid risking carinal irritation or endobronchial intubation

As opposed to mature tracheostomies, recently created tracheostomies may be safely managed using an exchange technique or a fiberoptic bronchoscope, and position may be assessed using direct visualization.