Anesthesia Grabbag

Question 1

Aspiration on induction. WWYD?

Answer 1

Intubate immediately. Trendelenburg
Bronch and suction large particles
Do NOT lavage (can push down aspirate)
Sxn stomach for pH + bacteria analysis (<2.5 = pneumonitis)
No evidence for empiric abx or steroids.

Question 2

4 things to do to investigate desat

Answer 2

Auscultate, EtCO2, PAWP, and tidal volumes

Question 3

Why not extubate a patient that is cold?

Answer 3

1 reason: Thermal discomfort of the patient.

Also possible: altered mental status more likely from lower metabolism of the anesthetics than a direct effect of the temperature.

Question 4

what causes stroke volume variation (SVV)

Answer 4

Increased intrathoracic pressure from ONE positive pressure breath 1st increases LV preload (and CO) while decreasing RH preload so that the 2nd beat of the left heart has less preload (and CO)

Question 5

How do you measure abdomen pressures (for Abd compartment syndrome)?

Answer 5

Bladder pressures while patient is paralyzed. Can also measure direct pressures through belly wall or through fem vein

Question 6

What are the effects of cirrhosis? (canned answer)

Answer 6

By system I’m worried about potential for AMS, high CO, varicesa and anemia, PPHTN, HPS, HRS, bleeding from lack of factors/platelets,

Question 7

What are the systemic effects of abdominal compartment syndrome? (canned answer)

Answer 7

(add answer)

Question 8

Normal intra-abdominal pressure?
Normal IAP in pregnant/obese/cirrhotic pts?

Answer 8

Normal: 0-5 mmHg
Preg/obese/cirr: 10-15 mmHg

Question 9

pressure for Abd HTN? Abd Compartment Synd?

Answer 9

Abd hypertension is >= 12
Abd Compartment Syndrome >20 with signs of organ failure

Question 10

what is hepatopulmonary syndrome? What is portopulmonary HTN

Answer 10

HPS: hypoxia from dilation of pulm vasculature (high CO->sheer stress–> vasodilator release–> misses crap liver–> dilates lungs)

PPHTN: pHTN in liver dz. (unclear cause but vasc smooth muscle hypertrophies and micro thromboses present)

Question 11

How to treat portopulm HTN

Answer 11

Prostaglandins (inhaled like epoprostenol, IV like Veletri. Same as regular pHTN)

Question 12

pharmacotherapy for varices

Answer 12

Betablocker. for acute bleeding give Octreotide

Question 13

Components of MELD score

Answer 13

Bilirubin, INR, Creatinine

Question 14

What are your concerns during the pre-anhepatic stage in liver txplnt

Answer 14

mostly bleeding (no factors, bad Plt, high CO), and hypotension from draining the ascites

Question 15

What are your concerns during the anhepatic stage in liver txplnt

Answer 15

Low preload, hypothermia, hypoCa if you transfuse (because no liver to metabolize citrate)

Can give products and/or TXA to help with bleeding

Question 16

What are your concerns during the neo-hepatic stage in liver txplnt

Answer 16

reperfusion syndrome (when clamp released): hTN, high K, acidosis
If gave TXA during anhepatic, must stop because can make pt hypercoagulable.

Question 17

DDx for delayed emergence:

Answer 17

1) anesthetics
2) neuro (stroke, szr)
3) glucose
4) sodium/e-lytes

Question 18

How do you differentiate between central and nephrogenic DI?

Answer 18

Administer ADH. Central will respond. Nephrogenic will not.

Question 19

Na+ needs to be below __ for elective surgery?

Answer 19

150 mEq/L

Question 20

Choice of anesthetic in a hypernatremic patient

Answer 20

Regional or neuraxial if possible to monitor mental status. Otherwise GA is fine.

Question 21

Pt is hyperNa on presentation. What do you want to know?

Answer 21

Volume status. Mental status.

Question 22

Rate of HypER-Na correction

Answer 22

No faster than 10 mEq/day.
Faster can cause cerebral edema

Question 23

Rate of hypO-Na correction

Answer 23

Can go faster! 10 mEq every 6 hours.
Faster causes central posting myelinolysis

Question 24

What is PRIS?

Answer 24

ACIDOSIS from propofol gtt. Rhabdo (and subsequent kidney failure), and cardiac failure. ICU not OR

Question 25

What does the capnogram look like in bronchospasm

Answer 25

Delayed upslope. It is an obstructive process on exhale.

Question 26

Dantrolene dose (loading and infusion)

Answer 26

Load: 2.5 mg/kg q5min up to 10 mg/kg
Infusion: 0.25 mg/kg/hr
Can continue up to 72 hrs after MH.

Question 27

MH principals. What does it do?

Answer 27

Defect in IM Ca++ release channels
Hypermetabolism.
Acidosis, hyperK, tachy, temp. Hyper myoglobin.

Can happen minutes to hours after (including postop).

Treat numbers & symptoms. No Ca channel blockers.

Question 28

Patient has masseter muscle rigidity after induction. Ddx? Concerns?

Answer 28

MMR 2/2 sux or volatile (correlation with MH volatile>sux)
Opioid rigidity
MH
Underdose of anesthesia/paralytic

Must observe for 12-24 hr for MH symptoms. Can continue case if mild.

Question 29

How do you do a superficial cervical plexus block?

Answer 29

U/s transverse posterior to the SCM and halfway between the mastoid process and the C6 transverse process (Chassaignac tubercle). Needle in plane posterior to anterior. nerves are right behind the SCM

Question 30

Oxyhemoglobin dissoc curve. What shifts left? Right? What does this mean?

Answer 30

pO2 is X, Hgb saturation is Y. So R means more O2 needed to saturate (favors tissues) left means less (favors Hgb).
Left shifts: lower CO2, H+, temp; also met-Hb, CO-hb, fetal-Hb
Right Shifts: HIGHER CO2, H+, Temp, DPG

Question 31

What tests are ordered to confirm the likely presence of PHEOCHROMOCYTOMA

Answer 31

Urine VMA and total metanephrines (metabolites of NE and Epi respectively)

Question 32

Patient presents with for pheo removal. What other conditions are you worried about?

Answer 32

1: Cardiomyopathy (from catecholamines). Also LVH,

#2: syndromes: MEN II (look at thyroids, parathyroids) and vonHL (eyes brain)
Also: hyperglycemia (no tmt needed), hypoMag

Question 33

Are there any drugs you would avoid in this patient with renal failure

Answer 33

Drugs dependent on renal elimination or have active metabolites that can accumulate (atropine, glycopyrrolate, ketamine, morphine, Demerol). Also, reduce doses of drugs that are highly protein bound (BZDs)

Question 34

Canned answer: what can cause hypoxia right after intubation:

Answer 34

1) Intubation of the esophagus
2)main stem intubation
3) inadequate ventilation
3) atelectasis
4) bstruction of the ET tube
5) delivery of a hypoxic gas mixture

Question 35

You shouldn’t start BBs on DOS. For those @ high risk for aFib, what should you give?

Answer 35

Diltiazem (CCBs).
Those at risk are: old males with COPD and CAD.

Question 36

Ddx for post incision hypotension. Always consider:

Answer 36

1) surgical bleeding/hypovolemia
2) tension ptx
3) hypoxia
4) arrhythmia
5) anesthesia overdose

Question 37

PPeak elevated, PPlateau nml

Answer 37

Airway problem (bronchospasm, obstruction, etc.)

Question 38

PPeak and PPlateau both elevated

Answer 38

Resistance! From lung, chest wall, or abd compartment.

Question 39

Model for Improvement and PDSA

Answer 39

1) what are we trying to accomplish?
2) How do we measure change?
3) What changes can we make that will result in Improvement?
Plan, Do, Study, Act

Question 40

Lean-Six Sigma (DefMAIC)

Answer 40

Define (goals)
Measure (Baseline, metrics)
Analyze (study current system)
Improve (implement new measures in small area and test them, educate)
Control (make new system permanent)

Question 41

Standard extubation criteria

Answer 41

Awake, following cmds, paralytics reversed, gag reflex intact, vital capacity >10mL/kg, Vt >6mL/kg, inspiration force > 20cmH2O, SpO2 >90% on room air, RSBI <100

Question 42

Steps for every vital sign crisis:

Answer 42

1) Verify
2) temporize
3) physical exam/machine or tube check/check surgery
4) treat