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Step 2 > Anesthesia > Flashcards

Anesthesia Flashcards

1
Q

Important to give to pregnant mom before epidural is placed?

A

Antacid (reduce risk of aspiration pneumonitis)

During pregnancy, there is decreased gastric emptying (increased progesterone) and displacement of the pylorus from the distended uterus

A risk of epidural is total spinal anesthesia –> may need to be intubated and always a risk of aspiration pneumonitis w/ intubation.

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2
Q

Inhaled halogenated gas effect on uterus?

A

Relaxes uterus

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3
Q

During carotid endarterectomy, dissection of the carotid body results in stimulation of carotid body and reflex bradycardia. What 2 options can help treat this reflex?

A 
Injecting 1% Lidocaine into carotid body
OR
IV Atropine (reverse the bradycardia)
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4
Q

What is malignant hyperthermia?

How long until it presents?

What is treatment?

A

Hyper metabolic response to inhaled halogenated anesthetics (e.g halothane) or depolarizing agents (succinylcholine) –> massive uncontrolled intracellular Ca release from sarcoplasmic reticulum

Presents w/in 30 minutes of starting anesthesia

Tx:

1) D/C offending agent
2) DANTROLENE

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5
Q

What gene is red flag for possible malignant hyperthermia?

A

RVR1 gene (ryanodine receptor gene)

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6
Q

Signs of malignant hyperthermia?

A

1) Hyperthermia (climbs 1-2 degrees every 5 minutes)
2) Muscle Rigidity (sustained muscle contractions, especially masseter)
3) Tachycardia
4) Cyanosis & skin mottling

Presents w/in 30 minutes of starting anesthesia

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7
Q

Why are crystalloids NOT an adequate source to improve BP over long term?

A

Only 1/3 of volume infused remains in intravascular space –> if you need to raise BP after persistent hypotension (shock), then use PRBC

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8
Q

During operation, a man’s HR is 145 while his pressure and urine output are stable. Post-op, he is profoundly hypotensive (

A

Likely cardiac event (intra-op) causing increased myocardial demand but low cardiac output = ischemic event –> now has cardiogenic shock (low cardiac output & vasoconstriction from increased peripheral resistance)

Mgmt: inotropic agent (dobutamine)

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9
Q

Maximum dose of lidocaine for numbing agent?

A

300mg ; 500mg if used w/ epinephrine

For 1% solution –> 1g/100mL (10mg/mL)
300mg/(10mg/mL) = 30mL max

For 2% solution –> 2g/100mL (20mg/mL)
300mg/(20mg/mL) = 15mL max

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10
Q

What 2 drugs are in Vicodin? What are their concentrations and dosages?

A

hydrocodone & acetaminophen –> 5mg/300-325mg

1-2 tab PO q 4-6 hrs PRN

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11
Q

Patient has jugular distention w/ B/L rales over both lung bases. What should most likely be done prior to elective surgery?

A

Treat patient for CHF (ACEi, B-blocker, diuretics, dig)

CHF (JVD, rales B/L @ bases) very risky for elective surgery

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12
Q

What local anesthetic, if it gains systemic access, can cause cardiac arrest? What is antidote?

A

Liposomal bupivicaine

Tx: Intra-lipid rescue

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13
Q

Shortly after spinal anesthesia is placed, patient’s blood pressure drops to 75/20. He looks warm and flushed but central venous pressure is near 0. What are you thinking? What should be included in his therapy?

A

Neurogenic shock –> high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation caused by sympathetic blockage

Tx: a-adrenergic peripheral vasoconstrictor

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14
Q

Why are hypotonic solutions not often administered?

A

Cause cellular swelling

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15
Q

Why can’t LR be given with PRBC’s?

A

Potential for initiating clotting cascade due to presence of Ca in LR

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16
Q

What are the 4 components for fluid requirements?

A

1) Maintenance (4-2-1 or wt + 40) for hourly isotonic fluids
2) Insensible losses: sweat, airway, etc
3) Urine output, NG tube
4) “3rd space” losses: due to surgical trauma - replaced w/ b/w 4-10mL/kg/hr

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17
Q

Of the new fluid replacement strategy, what are 2 changes to the protocol?

A

1) Ignore pre-op NPO deficits when calculating replacement
2) fluid admin begins w/ colloid (6% Hespan) to replace blood loss at 1:1 ratio. If blood loss exceeds 1.5L, then crystalloid is added

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18
Q

How much volume of water comprises 1 kg of body weight?

A

1 liter water in 1 kg body wt

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19
Q

Muscle relaxant w/ increased risk/incidence of pulmonary complications?

A

Pancuronium (long half-life & risk of residual muscle weakness including diaphragm)

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20
Q

Most important predictor for risk of pulmonary complications during surgery?

A

Location of surgical excision to diaphragm (thoracic & upper abdominal have highest risk)

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21
Q

In a patient w/ chronic kidney failure, what opioid must NOT be used?

A

Meperidine (renal clearance)

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22
Q

Important drugs for consideration before surgery?

A

1) B-blockers (decrease peri-op morbidity) –> use this to get HR 70 & Systemic BP 110
2) Anti-HTN’s: D/C ACEi/ARBS!! but continue other anti-HTN meds
3) D/C MAOIs
4) D/C herbals

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23
Q

What anti-HTN must be continued during surgery or risk refractory HTN crisis during operation?

A

Clonidine & B-blockers –> their receptors are unregulated and d/c-ing them results in hypersensitivity of the receptors

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24
Q

Most common drugs used during anesthesia to cause anaphylaxis?

A

Paralytic muscle relaxants, NOT Abx

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25
Q

What 2 conditions cause laxity in transverse ligament that secures the dens of C2 and are contraindications for direct laryngoscopy?

A

Rheumatoid arthritis

Down syndrome

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26
Q

In emergency situations, what blood type is generally used, except in childbearing-age women and why?

A

O+ most commonly given

NOT given in childbearing-age women b/c the (+) Rhesus factor can cause Ab formation in mom and cause future erythroblastosis fetalis in subsequent pregnancies!!

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27
Q

What is “Type and Screen” mean?

A

Type: the ABO and Rhesus factors are identified in patient’s blood

Screen: patient’s blood screened for presence of various Ab’s via indirect Coombs test

This take only minutes

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28
Q

What is “Type and Crossmatch”?

A

Type: patient’s blood tested for ABOU & Rhesus factor identification

Crossmatch: donor’s RBCs exposed to patient’s serum - looking for any reactions

More time consuming and expensive

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29
Q

What physical sign can tell you if a person is in Stage 2 of anesthesia (moderate sedation)?

What common mistake is made during this stage?

A

Divergent eye gaze: not looking at me when I open their eyelids

Patient starts to cough and gag against ET tube, especially if they are a smoker. Tendency is to want to pull out the ET tube –> DO NOT PULL IT OUT! They could laryngospams and lose the airway!

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30
Q

Where is the epidural space located?

A

It’s a potential space located b/w the ligamentum flavum and dura

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31
Q

Where is the intrathecal/subarachnoid space located?

A

Beneath the arachnoid mater

32
Q

Layers of the back?

A

Skin, sub-Q, muscle, supraspinous ligament, interspinous ligament, ligamentum flavum, dura/arachnoid mater

33
Q

What neural structures does an epidural act on? Intrathecal?

A

Epidural –> BOTH spinal cord & spinal roots

Intrathecal –> ONLY spinal cord

34
Q

What drug tends to inhibit sensory neurons before motor neurons?

A

Bupivicaine (& derivatives)

35
Q

DOC for labor anesthesia? Why?

A

Bupivicaine –> only eliminates sensory perception but still allows mom to have motor control (pushing the baby out!)

36
Q

What is “baricity?”

A

Density of drug relative to CSF

Hyperbaric = "sinks" once administered into CSF
Hypobaric = "floats" once administered into CSF

*Patient positioning very important for drug distribution

37
Q

During regional anesthesia, what nerves are easiest to inhibit first? What effect does this have?

A

Sympathetic nerves!

Basal sympathetic tone = vasoconstriction
*If sympathetic tone (-) by regional block –> you often get vasodilation –> hypotension from decreased preload –> proportionate to spinal level of injection (higher in spine = more vascular affected)

38
Q

Feared complication of neuraxial blockade?

A

Epidural hematoma

39
Q

Why are finger/toe blocks done W/O epinephrine?

A

Vasoconstriction from Epinephrine causes distal necrosis of digits

40
Q

In small children, when peripheral access is not accessible via IV, what is the preferred route of access?

A

Intraosseous (IO) cannulation

41
Q

3 important potential side effects of Protamine Sulfate infusion during surgery?

A

1) Induce histamine release causing vasodilation –> hypotension
2) Anaphylactoid-like reaction (hypotension, bronchospasm, urticaria) –> tx w/ epinephrine + fluids
3) Increases pulmonary artery pressures

42
Q

What is correlation b/w vasectomies & protamine sulfate?

A

Increased chance of allergic-like reaction to protamine

43
Q

What can be given before propofol infusion to reduce burning sensation?

A

Lidocaine

44
Q

Name 2 important effects of lidocaine prior to induction?

A

1) Mild sedating effect

2) Blunts response from stimulation of laryngoscopy

45
Q

If child becomes bradycardic during laryngospasm, what is drug to use?

A

Succinylcholine –> give you several minutes to secure airway b/w laryngospasms

Initially during laryngospasm, the child will be tachycardic –> over time, if the laryngospasm doesn’t break, they will become bradycardic

46
Q

What is another option to try prior to succ that breaks laryngospasm 50% of the time?

A

PPV

47
Q

What is important to do prior to extubation to help prevent laryngospasm?

A

Suction secretions from throat/oropharynx

Stay midline, especially w/ throat surgery, to prevent bleeding

48
Q

For acute pain control, how long until IV opioids take effect?

A

Less than 8 minutes –> if no response, increase dose by 50% (for morphine)

49
Q

Which opioid has the highest amount of histamine release?

A

Morphine

50
Q

Very short acting opioid w/ NO histamine release?

A

Fentanyl (vs. morphine w/ high histamine release)

51
Q

What is treatment for N/V secondary to opioids?

A

Anti-cholinergics –> they block muscarinic receptors & inhibit cholinergic transmission from vestibular nuclei to vomiting center

52
Q

If 1 dose of Zofran doesn’t work for nausea?

A

MOVE ON to another drug –> no effect on nausea; only vomiting!

53
Q

Anti-dopaminergic antiemetics?

A

Phenergan & compazine

54
Q

Pro-kinetic agent used for reducing N/V?

Used a lot in what anesthetic situation?

A

Metoclopramide

OBGYN (deliveries)

55
Q

Situations to NOT give succinylcholine?

A

Burns, muscular dystrophies, children under certain ages (undiagnosed muscular dystrophies), hyperkalemia

56
Q

If you give succinylcholine and person suddenly becomes asystolic/dysrrhythmia , what is going on?

A

Hyperkalmia

57
Q

If person is acidotic or alkalotic (etCO2), what are 2 ways you can handle this problem?

A

Change:

1) RATE of ventilations
2) VOLUME of ventilations

58
Q

Which drug used for reflux disease can inhibit volatile anesthetic metabolism, leading to high drug concentrations?

A

Cimetidine

59
Q

Which drug used for reflux disease can inhibit volatile anesthetic metabolism, leading to high drug concentrations?

A

Cimetidine (H2 blocker)

60
Q

What duration and dosage of steroids must you consider giving a higher stress dose of short-acting glucocorticoids prior to surgery?

A

Higher stress dose w/ >3wk duration of >20mg

Pt’s on

61
Q

What IV anesthetic INHIBITS steroid synthesis & can cause acute adrenal crisis?

A

Etomidate

Avoid during surgery in patients w/ suspected HPA suppression

62
Q

What is most potent regulator of cerebral blood flow (CBF)?

How does this work?

A

PaCO2

As cerebral PaCO2 levels rise = blood flow rises (vasodilation)
*Hypoventilation

As cerebral PaCO2 decreases = blood flow decreases (vasoconstriction)
*Hyperventilation

63
Q

What is it bad for person to bite down on ET tube and take big inhalation breath?

What other condition can this occur?

A

Negative pressure pulmonary edema –> closed upper airway results in very large negative intrathoracic pressure (near -100 cmH2O) generated by patient’s increased effort to breath. This causes increase in LV preload & afterload. It also causes a decrease in extramural hydrostatic pressure. The hypoxia changes pulmonary vascular resistance (vasoconstriction) –> RV dilation, intraventricular septum deviates to L & LV diastolic dysfunction occurs. This causes flash pulmonary edema

Laryngospasm another cause!

64
Q

What is a cause for the SpO2 to suddenly drop while HR, BP, etCO2 are all normal?

A

Inflated BP cuff on same arm as pulse ox monitor

65
Q

First step in person with post-op disorientation? Why?

A

Start supplemental O2 –> most lethal cause of post-op disorientation is hypoxia

**Transient hypoxia is not uncommon after surgery –> often breathe shallowly due to incisional pain and narcotic use

66
Q

What are parameters for extubation?

A

Rapid shallow breathing index –> ratio of resp rate to tidal volume

 * Lower the # the better --> low resp rate w/ high tidal volume
 * Cutoff is
67
Q

Ventilator tidal lung volumes used during intubation:
Asthma?
COPD?
ARDS?

A

Asthma =

68
Q

Preferred method to establish an airway in person with cervical spine injury and apneic?

A

Orotracheal intubation with rapid-sequence intubation

69
Q

Man had a MVA and is severely hypotensive. He requires several units of PRBC for transfusion. Once he is stabilized, he complains of paresthesias in his fingers and toes. His blood Ca2+ is low. Why?

A

Citrate is stored with packed/whole RBC to prevent anticoagulation.

The citrate will chelate serum Ca2+ = hypocalcemia

70
Q

What are contraindications for succinylcholine use?

A

Hyperkalemia
- Depolarizing agent causing massive K release from cells

  • Crush/burn injuries >8hrs old
  • Demyelinating syndromes (Guillan-Barre)
  • Tumor lysis syndrome
71
Q

What is MOA of non-de polarizing NM agents?

How to reverse their effects?

A

Competitive blockers of ACh at 1 of 2 alpha subunits on ACh receptor on motor end plate

ACh-esterase blocker –> neostigmine, pyridostigmine, physostigmine, edriphonium

72
Q

What Hb levels should you give PRBCs?

A

Stable patients –> if Hb if Hb

73
Q

What should always be done to confirm placement of CV catheter?

A

CXR –> proximal to cardiac silhouette or angle b/w trachea and R mainstem bronchus

74
Q

What induction agent will people maintain their respiratory drive and not become apneic?

A

Etomidate

75
Q

What effect does methylene blue have with MAOIs?

A

Can cause serotonin syndrome –> inhibits MAOI action

76
Q

What is the Curarie Cleft?

A

On etCO2 waveform, if the patient is trying to initiate spontaneous breaths while the ventilator is rest, there will be a downward deflection of the waveform (slight inspiration effort) during mid-exhalation on the vent

Indicates patient is coming out of anesthesia

77
Q

Common side effect of Zofran?

A

Headache

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