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Anesthesia Practice > AP 2 Test 4 > Flashcards

AP 2 Test 4 Flashcards

1
Q

What vessel supplies the anterior 2/3rds of the spinal cord with blood

A

Anterior spinal artery

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2
Q

From what vertebral levels does the Artery of Adamkiewicz stem from in the majority of patients (60%)?

A

T9-T12

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3
Q

What is a collective term for disorders of the spinal cord?

A

Myelopathy

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4
Q

What is a collective term for disorders of the spinal nerve roots?

A

Radiculopathy

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5
Q

Between which layers of the spinal cord are the vessels supplying the cord with blood located?

A

Between the arachnoid and pia mater

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6
Q

What is spina bifida

A

Failure of fusion of one or more vertebral arches

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7
Q

What is special about the anatomy of the vessels in the vertebral plexus?

A

They are valveless

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8
Q

Which vertebrae do the vertebral arteries travel through?

A

C1-C6

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9
Q

Which directions do most herniations of the spinal cord occur in?

A

Posteriorly and laterally b/c the posterior ligament is not very wide

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10
Q

What is important to ask pre-op when assessing pain of a patient presenting for a spinal surgery?

A

Where their pain is and what medication they are taking for it

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11
Q

Which table used in spinal surgeries helps decompress the epidural veins and prevent bleeding?

A

Jackson table

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12
Q

What is the most common intubation technique for a C1-C2 fusion surgery?

A

Fiberoptic intubation

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13
Q

What are the extubation considerations for a C1-C2 fusion surgery?

A

Delayed extubation so swelling can go down

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14
Q

What is an important structure that the surgeon must be careful of during an ACDF that could injure the patient’s airway if damaged?

A

Recurrent laryngeal nerve

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15
Q

What is a cervical laminoplasty?

A

A small section of the lamina is moved to expand the spinal canal to relieve pressure on the spinal cord or nerves

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16
Q

What test is done after a posterior cervical fusion to test dural closure?

A

Valsalva

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17
Q

What airway device may be needed during thoracic spine reconstruction and fusions of the T1-T8 spine?

A

Double lumen tube

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18
Q

What is scoliosis?

A

Lateral curvature and rotation of vertebrae

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19
Q

What measurement indicates the severity of respiratory impairment due to scoliosis?

A

Cobb angle

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20
Q

The lungs develop until what age?

A

8

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21
Q

How is FEV1/FVC affected in a patient with scoliosis?

A

Not affected - normal ratio

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22
Q

What pulmonary pattern presents on a flow-volume loop of a patient with scoliosis?

A

Restrictive

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23
Q

A patient with scoliosis has a vital capacity that is __-__% the normal value

A

60-80%

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24
Q

How does scoliosis affect lung volumes?

A

Decreased TLC, FRC, inspiratory capacity, expiratory reserve

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25
Q

Worsening pulmonary function due to scoliosis has to do with what aspects of the disease?

A
  • How many vertebrae are involved

- How cephalad the discurvature lies

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26
Q

What cardiovascular issues occur in patients with scoliosis?

A
  • Pulmonary HTN
  • Right ventricular hypertrophy
  • Mitral valve prolapse
  • Cardiomyopathy
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27
Q

What pre-op workups are standard for almost every scoliosis surgery?

A
  • CBC
  • Type and screen
  • Chest X ray
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28
Q

What pre-op test is needed if a patient with scoliosis has a history of pulmonary HTN?

A

ABG

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29
Q

What is a common anesthetic plan for patients with osteoporosis coming for a kypho- or vertebro- plasty?

A

Prone MAC

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30
Q

What huge nerve creates pain in the lower back and hip and down the back of the thigh when it is impinged?

A

Sciatic nerve

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31
Q

Vertebral roots of the sciatic nerve

A

L4-S3

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32
Q

If there is a spinal cord herniation between L4 and L5, which nerve root is being compressed?

A

L5

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33
Q

Most surgeons want a MAP above __ during lumbar fusion/laminectomies to maintain spinal cord perfusion

A

80

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34
Q

What regions of the spinal cord are the largest?

A

Cervical and lumbosacral b/c they’re innervating the limbs

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35
Q

Somatosensory evoked potentials monitor what part of the spinal cord?

A

Posterior cord

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36
Q

Motor evoked potentials monitor what part of the spinal cord?

A

Anterior cord

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37
Q

What nerves are stimulated during SSEP?

A
  • Median
  • Ulnar
  • Posterior tibial
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38
Q

What spine surgeries use evoked potentials?

A
  • Scoliosis
  • Laminectomy w fusion
  • Fractures
  • Cord tumor
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39
Q

What MAC level can be run when monitoring SSEPs?

A

0.5-1 MAC

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40
Q

How does propofol affect SSEPs?

A
  • Decreases amplitude

- Increases latency

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41
Q

How does etomidate affect SSEPs?

A
  • Increases amplitude

- Increases latency

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42
Q

How does ketamine affect SSEPs?

A

Increases amplitude

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43
Q

How does nitrous affect SSEPs?

A

Decreases amplitude

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44
Q

Where is stimulation occuring during MEP?

A

Transcranial stimulation

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45
Q

What airway adjunct must you use during MEPs to avoid a swollen tongue?

A

Bilateral bite blocks

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46
Q

Where is the response to SSEPs monitored?

A

In the brain

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47
Q

Where is the response to MEPs monitored?

A

Hands, feet, teeth

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48
Q

During which evoked potential monitoring can you not use NMB?

A

Motor

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49
Q

What is the max MAC level you can use during MEP monitoring?

A

0.5 MAC

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50
Q

What anesthetic technique is commonly used when monitoring MEPs?

A

TIVA

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51
Q

What does spontaneous EMG monitor?

A

Muscle activity in a specific peripheral nerve when stimulated

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52
Q

What nerve is stimulated with a NIMs tube?

A

Recurrent laryngeal nerve

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53
Q

What is the purpose of triggered EMG?

A

To determine whether a pedicle screw is properly located

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54
Q

When should you considering setting up blood for spinal surgeries?

A
  • When the patient has a tumor b/c usually you cannot use cell saver
  • Multiple redo
  • Multilevel surgery
  • If surgeons are working near great vessels
  • If the patient is anemic
  • ESRD
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55
Q

What is spinal shock?

A

Flaccid paralysis below a spinal cord injury that causes loss of sensation and vascular reflexes

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56
Q

How are vitals affected when a patient has spinal shock?

A

Hypotension and bradycardia due to increased vagal tone

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57
Q

If a patient with spinal shock does not have tachycardia in response to hypovolemia, you know the injury occurred at what levels

A

T1-T4 - cardiac accelerators

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58
Q

Patients with spinal shock can only have succinylcholine in the first __ hours of the injury

A

48

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59
Q

When does hyperkalemia due to spinal shock peak?

A

2 weeks

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60
Q

How should CO2 levels be maintained in a patient with spinal shock?

A

Avoid hypocarbia because that will decrease spinal blood flow

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61
Q

Autonomic hyperreflexia can occur with a complete transection above what spinal level?

A

T6

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62
Q

What is autonomic hyperreflexia?

A

Vasoconstriction below the level of a spinal transection but vasodilation above the transection - occurs after spinal shock has worn off and is set off by a stimulation below the level of the injury

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63
Q

What are the cardiovascular signs of autonomic hyperreflexia?

A

Hypertension with bradycardia

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64
Q

Treatment for autonomic hyperreflexia

A
  • Stop surgery
  • Deepen anesthetic
  • Nitroglycerin
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65
Q

Which spine surgeries have the highest incidence of post-op blindness

A
  • Scoliosis

- Posterior lumbar fusion

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66
Q

How does ischemic optic neuropathy occur (ION)?

A

Decreased blood supply and O2 delivery to the optic nerve

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67
Q

What type of ION is more common after spine surgeries?

A

Posterior

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68
Q

Patients in the prone position are at risk of what eye injury?

A

Central retinal artery occlusion

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69
Q

What treatments are available for central retinal artery occlusion?

A
  • Stellate ganglion block
  • Ocular massage
  • Acetazolaminde
  • 5% CO2 in oxygen inhaled
  • Local hypothermia
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70
Q

What are the surgical risk factors for post-op vision loss?

A
  • Prone positioning
  • Wilson frame
  • Prolonged robotic surgery with head down
  • Surgery greater than 6 hours
  • EBL greater than 1 liter
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71
Q

What is the anesthetic risk factor for post-op vision loss?

A

Decreased percent colloid

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72
Q

What are the patient risk factors for post-op vision loss?

A
  • Male

- Obese

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73
Q

What are the ASA’s recommendation for avoiding post-op vision loss?

A
  • Decrease venous congestion and edema in the head
  • Keep head at or above level of the heart
  • Include colloid in fluid replacements
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74
Q

Venous air embolism is most common in what position?

A

Sitting

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75
Q

What methods can we use to detect venous air emboli?

A
  • TEE
  • Precordial doppler
  • Mill wheel murmur
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76
Q

Cardiovascular signs of a VAE

A
  • Hypotension
  • Tachycardia
  • Increased PA pressure
  • Decreased cardiac output
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77
Q

Effect of VAE on saturation

A

Decreases saturation

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78
Q

Effect of VAE on end tidal gases

A
  • Decreased ETCO2

- Exhaled nitrogen

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79
Q

Treatment of VAE

A
  • Flood field with fluid
  • 100% O2
  • Aspirate if you have CVP
  • Fluid bolus
  • Pressors
  • Jugular compression to prevent further entrainment
  • CPR
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80
Q

What position is used to treat VAE

A

Left side down

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81
Q

What should be included in your post-op assessment of a patient who’s undergone spinal surgery?

A
  • Edema of face/eyes
  • Vision
  • Position
  • Neuro exam
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82
Q

What are the risks involved in laser surgery for ENT cases?

A
  • Airway fires

- Eye injury

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83
Q

What are the risks associated with jet ventilation techniques used in ENT surgery?

A
  • Hypercapnia

- Barotrauma

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84
Q

What risks are associated with fiberoptic intubations used for ENT surgery?

A

A failed intubation means an emergency surgical airway is the backup

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85
Q

What risks are associated with nasal intubations?

A

Epistaxis

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86
Q

What risk is associated with TIVAs used for ENT surgery?

A

Awareness

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87
Q

What risk is associated with controlled hypotension in ENT surgeries?

A

Ischemia

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88
Q

What abnormal patient characteristics are commonly found in ENT?

A
  • Head/neck cancers
  • Limited c-spine ROM
  • Decreased mouth opening
  • Decreased tissue compliance
  • Receding jaw
  • Distorted airway anatomy
  • Vocal cord dysfunction
  • Large tongue
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89
Q

How should analgesia be managed for most ENT surgeries?

A

Good intraop and postop analgesia is necessary because most procedures are performed on highly reflexogenic areas

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90
Q

It’s common to keep the patient’s systolic pressure under ___ mmHg to maintain a bloodless field for ENT surgeries

A

100

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91
Q

What is the goal MAP for patient’s undergoing ENT surgery in order to maintain a bloodless field?

A

60-70

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92
Q

What are the various types of endoscopies used in ENT surgeries?

A
  • Laryngoscopy
  • Microlaryngoscopy
  • Esophagoscopy
  • Bronchoscopy
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93
Q

What are common indications for endoscopies?

A
  • Voice disorders
  • Stridor
  • Hemoptysis
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94
Q

What are pre-op considerations for endoscopies?

A
  • Focus on H&P to look for any potential airway problems

- Review prior notes and imaging from ENT clinic

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95
Q

If you aren’t expecting to be able to easily mask ventilate or DL your patient in an ENT surgery, what should be done?

A

Secure the airway before induction with a fiberoptic bronchoscope or awake tracheostomy

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96
Q

What are the critical steps when preparing for a fiberoptic intubation?

A
  • Have patient mentally and pharmacologically prepared
  • Have ALL equipment prepared
  • Make sure the ENT surgeon is in the room so they can assist
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97
Q

What is the dose of atropine when used as an antisialagogue for fiberoptic intubation?

A

0.5-1mg IV or IM

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98
Q

What is the dose of glycopyrrolate when used as an antisialagogue for fiberoptic intubation?

A

0.2-0.4mg IV or IM

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99
Q

What is the loading dose of dexmedetomidine when used as a sedative?

A

1mcg/kg over 10 min

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100
Q

What is the infusion dose of dexmedetomidine when used for sedation?

A

0.2-0.7mcg/kg/hr

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101
Q

Dose of Alfentanil

A

100-1000mcg IV

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102
Q

When should antisialogogues be given for a fiberoptic intubation?

A

20-30min prior to airway manipulation

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103
Q

1 side effect of dexmedetomidine

A

Bradycardia

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104
Q

Which commonly used antisialogouge crosses the blood brain barrier and can cause psychosis, confusion, and dizziness?

A

Atropine

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105
Q

What are the advantages to using Afrin nasally before local topicalization for nasal intubation?

A

It provides vasoconstriction and keeps the lidocaine from getting absorbed systemically

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106
Q

How should lidocaine swabs be used before a fiberoptic intubation?

A

Swab the patient’s nose with 2-4% lidocaine and leave for 5-15 minutes before intubation

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107
Q

What cranial nerve innervates the nasal cavity and turbinates?

A

Trigeminal

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108
Q

What are the topicalization options available for the oropharynx and larynx?

A
  • Gargle with lidocaine
  • Benzocaine spray (hurricaine)
  • Facemask or oral nebulizer with 2-4% lidocaine
  • Lidocaine ointment to posterior pharynx with tongue depressor
  • Trans-tracheal block
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109
Q

What issue can occur when too much hurricane (benzocaine) spray is applied?

A

Methemoglobinemia

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110
Q

What membrane is pierced during a trans-tracheal block?

A

Cricothyroid membrane

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111
Q

What cranial nerve innervates the oropharynx and posterior third of the tongue?

A

Glossopharyngeal

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112
Q

What cranial nerve innervates the epiglottis and more distal airway structures?

A

Vagus

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113
Q

How must muscle relaxation be managed for a laryngeal endoscopy?

A

There must be masseter muscle relaxation until the end of the case, can be achieved with intermittent non-depolarizing blockade boluses or a SUX infusion

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114
Q

What can occur if you run a sux infusion too long?

A

You can get a Phase II blockade and the sux will act like a non-depolarizing blockade

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115
Q

What tube is often used for a laryngeal endoscopy?

A

Specialized microlaryngoscopy tube

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116
Q

What is special about a specialized microlaryngoscopy tube?

A
  • Longer than standard ETT tube
  • High volume/low pressure cuff
  • Stiffer so it is less prone to compression
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117
Q

What is the issue with jet ventilation that you must be very careful with?

A

It does not ensure ventilation so you must be very careful to allow a full exhalation by watching the chest rise and fall completely

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118
Q

How long and at what pressure should inspiration with a jet ventilator be administered?

A

1-2 seconds at 30-50psi

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119
Q

How long should you allow for expiration after a breath with a jet ventilator?

A

4-6 seconds

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120
Q

What anesthetic method is required when using jet ventilation?

A

TIVA

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121
Q

What monitor is not available when using jet ventilation?

A

ETCO2

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122
Q

What cardiovascular considerations should be accounted for during a laryngeal endoscopy?

A

There are alternating times of extreme stimulation and no stimulation so there is frequent alternations between hypo- and hyper- tension

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123
Q

What are the advantages of a metal ETT tube used for laser surgery?

A
  • Combustion resistant
  • Kink resistant
  • Double cuff
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124
Q

What are the disadvantages of a metal ETT tube used for laser surgery?

A
  • Thick walled
  • Transfers heat
  • Reflects laser beams
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125
Q

What are the advantages of a silicone ETT tube used for laser surgery?

A
  • Small
  • Non-reflective
  • Atraumatic
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126
Q

What are the disadvantages of a silicone ETT tube used for laser surgery?

A
  • Silicone is combustible
  • Teflon ignition=toxic ash
  • Metal foil can unwrap and cause occlusion of airway
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127
Q

What is the ideal FiO2 for laser surgery?

A

21%

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128
Q

What should be placed in the airway during laser surgery to limit risk of ETT ignition?

A

Saline-soaked pledgets

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129
Q

What is the fire triad?

A

1) Oxidizer (O2, N2O)
2) Ignition source (laser, scopes, surgical devices)
3) Fuel (ETT, gauze, alcohol solutions)

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130
Q

What should be done when an airway fire occurs?

A

1) Stop the procedure
2) Stop ventilation and flow of all airway gases
3) Remove the tube and flammable materials
4) Pour saline in patients airway
5) Ventilation with facemask on room air
6) Reintubate as soon as you can

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131
Q

What are special pre-op considerations for nasal and sinus surgeries

A
  • Could be a difficult mask ventilation
  • Asthma/allergic disorders
  • Recent use of ASA/Plavix
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132
Q

What airway equipment is often needed for nasal and sinus surgeries?

A
  • Oral airway during mask ventilation

- Oral RAE

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133
Q

What are positioning considerations for nasal and sinus surgeries?

A
  • Arms often tucked

- Slight head up positioning (make sure patient doesn’t have risk factors for CVA)

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134
Q

Extubation technique for nasal and sinus surgeries

A

Usually deep extubation

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135
Q

Why is the NIMs tube often used for anterior neck surgeries?

A

To preserve superior laryngeal, recurrent laryngeal, and vagus nerve branches

136
Q

How does the NIMs tube work?

A

Stimulates motor nerves and records EMG response

137
Q

How should NIMs ETT be secured?

A

Midline

138
Q

What muscle relaxants can be used with a NIMs tube?

A

Sux - NO non-depolarizers!!

139
Q

Pre-op considerations for head/neck cancer surgeries

A
  • Abnormal airway
  • Obstruction lesions
  • History of radiation
  • May need awake fiberoptic/tracheostomy
140
Q

Flap protocol at EUHM states to keep crystalloid fluids under __ liters

A

5

141
Q

Flap protocol at EUHM states to keep PRBC administration under __ units

A

3

142
Q

Flap protocol at EUHM states to keep albumin administration under __ liters

A

2

143
Q

Flap protocol at EUHM states to keep operative time under __ hours

A

10

144
Q

What are the potential contraindications for immediate post-op extubation according to flap protocol at EUHM?

A
  • Over 75 years old
  • Asa 4+
  • CV unstable
  • Current alcohol abuse
  • Greater than 7L fluids intraop
  • Major pharyngeal reconstrution
145
Q

Lines/access necessary according to flap protocol at EUHM

A
  • 2 peripheral IVs 18G or larger

- A line

146
Q

Where should the a-line transducer be zeroed for a flap procedure?

A

At the level of the brain

147
Q

What nerves need to be preserved during a flap procedure?

A

Facial and spinal accessory

148
Q

When is it okay to remove anesthesia’s ETT during a tracheostomy?

A

After correct positioning is confirmed by ETCO2 and chest movement and/or auscultation by the surgeon

149
Q

What could be causing increased PIPs after a tracheostomy?

A
  • Malpositioned tube
  • Bronchospasm
  • Debris/secretions in trachea
  • Pneumothorax
150
Q

Intraop considerations for maxillofacial reconstruction and orthognathic surgery

A
  • Long procedure with high EBL
  • Throat pack in place
  • Head up positioning
  • Controlled hypotension
  • Local infiltration with epi solutions
  • Laser precautions
151
Q

What gas is rarely used for ear surgeries?

A

N2O

152
Q

What is a post-op risk of ear surgeries?

A

Increased PONV and vertigo, fall risk

153
Q

How can we decrease risk of PONV from ear surgeries?

A
  • Propofol drip
  • Decadron
  • Zofran
154
Q

What nerve comes out from under the earlobe and innervates the orbicularis oculi?

A

Facial

155
Q

What causes a “brain stem anesthetic” that can occur during a retrobulbar block?

A

There is a subarachnoid space in the orbit, so there can be inadvertent local injection into this space in the eye that will travel to the brain stem

156
Q

How soon after injection do signs of a brain stem anesthetic show up?

A

4-7 minutes after injection

157
Q

What are the most common symptoms of a brain stem anesthetic?

A

Patient becomes apneic and unresponsive

158
Q

At the least, what monitor should be used when placing a retrobulbar block?

A

Pulse ox

159
Q

Functions of the ciliary body

A
  • Secrete aqueous humor

- Fatten/thin lens to accommodate and focus light

160
Q

What are the long term effects of undiagnosed/treated glaucoma?

A

It can lead to optic nerve atrophy and causes a shrinking of the visual field until full blindness occurs

161
Q

What supplies the back of the eye with blood?

A

Choroid plexus

162
Q

What is normal intraocular pressure

A

Less than 22mmHg

163
Q

How much phenylephrine is contained in 1 drop of 10% phenylephrine?

A

7mg

164
Q

3 determinants of intraocular pressure

A

1) Extrinsic pressure
2) Scleral rigidity
3) Alteration of intraocular contents

165
Q

What structure divides the eye into anterior and posterior chambers?

A

Iris

166
Q

What are the 2 most important determinants of intraocular pressure?

A
  • Rate of formation

- Drainage

167
Q

4 contributors to increased intraocular pressure

A
  • Acute HTN
  • Hypoxia
  • Hypercarbia
  • Succinylcholine
168
Q

Contributors to decreased intraocular pressure

A
  • Inhaled anesthetics
  • CNS depressants
  • ND-NMBs
  • Hyperventilation
  • Hypothermia
  • Ganglionic blockers
  • Diuretics
169
Q

Afferent nerve in the oculocardiac reflex

A

Trigeminal (opthalamic branch)

170
Q

Efferent nerve in the oculocardiac reflex

A

Vagus

171
Q

What events can set off the oculocardiac reflex?

A
  • Pressure on the globe
  • Retrobulbar block
  • Pressure on orbital contents after enucleation
  • Traction on EOM
  • Ocular trauma
172
Q

Most common side effect of oculocardiac reflex

A

Bradycardia

173
Q

Effects from oculocardiac reflex

A
  • Bradycardia
  • V tach
  • V fib
  • Sinus arrest
  • Asystole
174
Q

Treatment of oculocardiac reflex

A

Ask the surgeon to stop - symptoms will quickly end

175
Q

Anesthetic method for cataract surgery

A

Very minimal sedation

176
Q

What is the issue with using succinylcholine for strabismus procedures?

A

It causes contractions of the muscle that prevent forced duction testing

177
Q

What is forced duction testing?

A

Tests to see how well the eye moves and if there is tension in the extraocular muscles

178
Q

Patients with strabismus are susceptible to what intra-op crisis?

A

MH

179
Q

Strabismus surgery is one of the major risk factors for ____ due to oculo-gastric reflex

A

PONV

180
Q

What glaucoma medications should we be aware of when managing a patient for glaucoma surgery?

A
  • Timolol - a nonspecific beta blocker that decreases production of aqueous humor, but can get systemic absorption and get bronchospasm and bradycardia
  • Pilocarpine
  • Meds with epi
181
Q

What block is used for glaucoma and retinal detachment surgeries?

A

Opthalamic block

182
Q

Intraocular gas used for retinal detachment surgery

A

Sodium hexaflouride

183
Q

Most common eye injury in ophthalmic surgery

A

Corneal abrasion

184
Q

What is the result of patient movement during eye surgery?

A

Blindness

185
Q

What is expulsive subchoroidal hemorrhage?

A

Sneezing or coughing with the eye open forces the retina outward and squeezes eye contents through the anterior eye wall

186
Q

Additive in local anesthetic for retrobulbar block to penetrate fat surrounding the eyeball

A

Hyaluronidase

187
Q

Needle used for retrobulbar and peribulbar blockers

A

Single bevel flat-ground needle

188
Q

Why is a retrobulbar block like a spinal?

A

Low volume and rapid onset

189
Q

Which facial nerve block only supplies the orbicularis oculi?

A

Van Lint

190
Q

What block for eye surgery avoids injection into the muscle cone and lowers the risk of globe perforation?

A

Peribulbar block

191
Q

Advantages of peribulbar block

A
  • Avoids need for facial nerve block
  • Avoids muscle cone injection
  • Lowers risk of globe perforation
  • Direct effect on orbicularis oculi
192
Q

Disadvantages of peribulbar block

A
  • Requires large volume

- Frequently requires supplementation

193
Q

Indications for peribulbar block

A
  • Long axial length (near-sighted)

- Previous extra-ocular surgery

194
Q

Patients with spherical correction less than ____ need a peribulbar block

A

-5.00D

195
Q

Normal axial length

A

20-22mm

196
Q

Appropriate sedation level for a patient getting an eye block

A
  • Arousable
  • Responds to verbal commands
  • Not moving
197
Q

Sedation techniques for eye blocks

A

1) Give small amounts of versed and fentanyl then titrate in propofol until patient is breathing but doesn’t respond
2) Give small amounts of fentanyl and versed and give incremental doses of alfentanil (~3-5cc at 1000mcg/cc), monitoring patients respiratory rate and level of consciousness

198
Q

Which type of pain, chronic or acute, is associated with neuroendocrine stress?

A

Acute pain

199
Q

How long can pain persist and still be labeled “acute pain”

A

3-6 months

200
Q

What term is defined as “a state of adaption in which exposure to an opioid drug induces changes that result in a decrease of the drug’s effect over time”?

A

Opioid tolerance

201
Q

What is opioid induced hyperalgesia (OIH)?

A

Prolonged administration of opioids results in a paradoxic increase in atypical pain that appears to be unrelated to the original nociceptive stimulus

202
Q

What is the treatment for OIH?

A

Decrease opioid administration and work in something that is not working strictly at Mu receptors, such as ketamine

203
Q

What is the most prescribed opioid?

A

Tramadol

204
Q

What schedule is Tramadol?

A

Schedule IV

205
Q

What is Actiq?

A

A fentanyl lollipop that is very short acting

206
Q

What are the receptor actions of Methadone (Dolaphine)

A

Mu agonist, NMDA antagonist

207
Q

How long does it take for Methadone to reach a steady state for its analgesic action?

A

5-7 days

208
Q

Why is there a black box warning for Methadone?

A

Respiratory depression when combined with short acting narcotics

209
Q

How does Methadone affect cardiac conduction/EKG in doses over 60mg?

A
  • Prolongs QT interval

- Torsades de Pointes

210
Q

What opioid is contained in a Duragesic patch?

A

Fentanyl

211
Q

What is the black box warning for Duragesic patch?

A

Don’t give unless the patient has been taking…

  • 60mg Morphine
  • 30mg Oxycodone
  • 8mg Hydromorphone for a WEEK or longer
212
Q

When is the Duragesic patch contraindicated?

A
  • Acute pain

- Post-op pain

213
Q

Opioid side effects

A
  • Resp. depression
  • Sedation
  • Confusion
  • Pruritus
  • N/V
  • Constipation
  • Urinary retention
  • Myosis
  • Muscle twitching
214
Q

What are the receptor actions of ketamine?

A
  • Mu agonist

- Non competitive antagonist at the NMDA receptor

215
Q

What metabolite of ketamine can cause prolonged analgesic action?

A

Norketamine

216
Q

“GINTL” (gin and tonic with lime) encompasses which non-opioid methods of pain management?

A 
G - gapapentin/neuronitin
I - ice
N - NSAIDs (ketorolac, celebrex, ibuprofen)
T - tylenol/acetaminophen
L - lidocaine patches
217
Q

How do the pupils look when a patient has taken narcotic analgesics such as heroin and various pain pills?

A

Pinpoint

218
Q

How do the pupils look when a patient has taken meth, cocaine, ritalin, diet pills, or hallucinogens?

A

Very dilated

219
Q

High doses of methamphetamine may induce what physiologic crisis

A

Malignant hyperthermia

220
Q

How much does an epidural allow the dosing of narcotics to decrease?

A

1/10th the dose

221
Q

Benefits of an epidural

A

Decreases….

  • Post-op resp. complications
  • Incidence of post-op MI
  • Stress response to surgery
  • Blood transfusion requirements
222
Q

Surgical regions that indicate epidural placement

A
  • Thoracic
  • Abdominal
  • Pelvic
  • Lower extremity
223
Q

Epidurals are contraindicated when the platelets are below…

A

100,000

224
Q

Epidurals are contraindicated when what lab value is elevated and indicating infection?

A

WBC

225
Q

What central nervous system diseases contraindicate epidural placement?

A
  • Multiple sclerosis

- Syringomyelia

226
Q

In what common surgeries is toradol a contraindication?

A
  • Spinal surgeries

- Tonsillectomies due to the increase in bleeding

227
Q

Appropriate dose of toradol for most patients older than 60 years old

A

15mg

228
Q

An epidural can stay into place for up to…

A

2 weeks

229
Q

Can a patient with a spinal nerve stimulator receive an epidural?

A

No

230
Q

Can a patient with an intrathecal pump receive an epidural?

A

Yes

231
Q

A dose of heparin cannot be given within __ hours of an epidural placement

A

6

232
Q

Low molecular weigh heparins such as Enoxaprin, Dalteparin, Tinazaprin cannot be given within ___ hours of an epidural placement

A

24

233
Q

How long before an epidural placement must Coumadin be discontinued

A

3-4 days

234
Q

What lab must be checked before an epidural if the patient has been taking Coumadin

A

PT

235
Q

How long before an epidural placement must the anti-platelet Ticlopidine be discontinued

A

14 days

236
Q

How long before an epidural placement must the anti-platelet Plavix be discontinued

A

7 days

237
Q

How long before an epidural placement must the direct thrombin inhibitor Dibigatran (Pradaxa) be discontinued?

A

5 days

238
Q

How long before an epidural placement must the Factor Xa inhibitor Xarelto be discontinued?

A

9 hours

239
Q

How long before an epidural placement must the Factor Xa inhibitor Arixtra be discontinued?

A

21 hours

240
Q

Complications of epidural placement

A
  • Infection
  • Bleeding
  • PDPH
  • Nerve damage
  • Hematoma
  • Abcess
  • Seizures
  • Cardiac arrest
241
Q

Side effects of opioids in epidurals

A
  • Hypotension
  • Sedation
  • Pruritus
242
Q

If a patient has opioids in their epidural, can you still give them opioids IV or PO?

A

No

243
Q

Treatment of hypotension from an epidural in the recovery room

A
  • Fluid bolus
  • Hold or decrease epidural infusion
  • Consider opioid only
244
Q

What are some examples of surgeries that should have opioid only in their epidurals?

A
  • AAA
  • HIPECCS
  • Lobectomy
245
Q

Primary narcotics given in a spinal

A

Morphine, hydromorphone

246
Q

Should a patient who comes into preop with a fentanyl patch take it off before they go back for surgery?

A

No

247
Q

If a patient has intrathecal narcotics, they shouldn’t get more than ___ mcg of fentanyl during the case

A

250

248
Q

Geriatric patients are defined as being __ years or older

A

65

249
Q

Pharmacokinetic considerations in geriatric patients

A
  • Decreased protein binding so higher unbound drug levels in the plasma
  • Slower redistribution
  • Increased elimination half life

*ALL LEAD TO INCREASED DRUG LEVELS AT TARGET ORGANS

250
Q

Changes in body compartments in geriatric patients

A
  • Loss of skeletal muscle/lean body mass
  • Increased percentage of fat
  • 20-30% reduction in blood volume
251
Q

Changes in drug metabolism in geriatric patients

A

Drug metabolism slows because…

  • Clearance decreases b/c liver blood flow, liver mass, and kidney function decreases
  • Volume of distribution increases because of increased body fat and decreased albumin levels
252
Q

In general, by what percentage should you reduce the dose of propofol for geriatric patients

A

20-50%

253
Q

In general, by what percentage should you reduce opioid doses in geriatric patients

A

50%

254
Q

How does the action of muscle relaxants change in geriatric patients?

A

The dose needed doesn’t change but it may take longer to see effects

255
Q

How does the MAC values of volatile agents change per decade after 40?

A

MAC decreases by 6%

256
Q

Considerations for benzodiazepine use in geriatric patients

A

They are more sensitive to CNS effects of drugs so if you are using them reduce the dose

257
Q

Considerations for using anticholinergics and antihistamines in geriatric patients

A

Can lead to confusion and increased risk of post up delirium

258
Q

What specific drugs should you consider avoiding in elderly patients

A
  • Scopolamine
  • Diphenhydramine
  • Meperidine
259
Q

How does aging affect arterial function?

A
  • Loss of elasticity causes arterial stiffening
  • Increased pressure in aortic root leading to increased SVR
  • Can lead to ventricular hypertrophy and impaired diastolic filling
260
Q

How does aging affect venous function?

A
  • Veins stiffen
  • Veins are less able to adapt to changes in blood volume
  • Volume shifts can cause exaggerated changes in cardiac filling
261
Q

Ventricular changes in geriatric patients

A

The ventricle stiffens and causes impaired lusitropy (rate of myocardial relaxation) which can lead to dependence on higher filling pressures

262
Q

What is the most common cause of heart failure in patients over 75?

A

Diastolic dysfunction

263
Q

Elderly patients have less responsiveness to which receptor?

A

Beta receptors - which decreases their increase in heart rate with stress

264
Q

What cardiovascular qualities do NOT diminish with age?

A
  • Intrinsic quality of the muscle (heart does not weaken due to age alone)
  • Peripheral vasoconstriction (patients have enhanced sympathetic tone at rest)
265
Q

How do elderly patient’s blood pressures tend to trend in response to anesthetics?

A

You are likely to see labile blood pressures - very high one minute and very low the next

266
Q

How is vital capacity changed in elderly patients

A

Decreased vital capacity

267
Q

How is residual volume changed in elderly patients

A

Increased residual volume

268
Q

How is gas exchange in the airways changed in elderly patients?

A
  • There is a breakdown of elastin connections in the lower airways, making them prone to collapse
  • Decreased surface area for gas exchange
  • Increased shunting
  • Increased dead space
269
Q

How does the time needed for adequate preoxygenation change in elderly patients?

A

Preoxygenation takes longer in elderly due to the increasing V/Q mismatch

270
Q

Mean PaO2 in patients over 60

A

81 mmHg (71-91 range)

271
Q

How is the ventilatory response to hypercapnia and hypoxia changed in elderly patients?

A

They have a blunted response, the change in minute ventilation in response to hypoxia/hypercapnia is about half of what it is in a healthy 25 year old

272
Q

Airway changes in elderly patients

A
  • Decreased C spine mobility
  • Smaller mouth opening
  • Smaller glottic opening (consider smaller tube)
  • Fragile/missing teeth
  • Decreased sensitivity of protective airway reflexes (increased risk of aspiration)
273
Q

What factors make elderly patients more prone to hypoxia in the PACU?

A
  • Longer time for preO2
  • More difficult airway
  • Lower PaO2
  • Prone to airway collapse
  • Increased work of breathing
  • Slower drug clearance
274
Q

Why are elderly patients more prone to hypo- and hyperthermia?

A
  • Don’t vasoconstrict or shiver until temps are very low
  • Lower resting metabolic rate
  • Decreased ability to adjust peripheral and cutaneous blood flow
275
Q

GI changes in elderly

A
  • Decreased HCl
  • Decreased saliva
  • Decreased taste buds
276
Q

Endocrine hormones that are decreased in elderly

A
  • T3

- Testosterone

277
Q

Endocrine hormones that are increased in elderly

A
  • Insulin
  • Norepinephrine
  • Parathyroid hormone
  • Vasopressin
278
Q

Lab values that are changed in elderly patients

A
  • Sed rate
  • Creatinine
  • Alkaline phosphatase
  • PSA
  • Serum iron
  • Total iron binding capacity
279
Q

What is a common finding in elderly patient’s urinalysis? Abnormal finding?

A
  • Pyuria common

- Hematuria not normal

280
Q

CNS structural changes in elderly

A
  • Brain mass decreases
  • Decreased cerebral blood flow
  • Decreased CMRO2
  • Decreased Ach, dopamine, NE
281
Q

What is the most common manifestation of perioperative CNS dysfunction?

A

Post op delirium

282
Q

What are the signs of post op delirium?

A
  • Acute confusion
  • Decreased alertness
  • Misperception
  • Agitation
283
Q

Post op delirium is __ times as common in elderly patients when compared to younger populations

A

2

284
Q

What factors pre-dispose geriatric patients to post-op delirium?

A
  • Drug withdrawal
  • Benzos
  • Tricyclic antidepressants
  • Anticholinergics
  • Pre-existing depression/dementia
  • Metabolic disturbances
285
Q

What metabolic disturbances might cause post op delirium?

A

Abnormal levels of…

  • Na+
  • K+
  • Glucose
  • Albumin
  • BUN/Cr
286
Q

Strategies to reduce post op delirium

A
  • Minimize benzos/anticholinergics/antihistamines
  • Maintain BP greater than 2/3rds of baseline
  • O2 sat greater than 90%
  • Gct greater than 30%
287
Q

Common treatable causes of post op delirium

A
  • Hypoxemia
  • Hypercarbia
  • Hypotension
  • Pain
  • Sepsis
  • Metabolic disturbances
288
Q

Using Haloperidol to treat post op delirium is contraindicated in patients with what disease?

A

Parkinson’s

289
Q

Post op cognitive dysfunction is more common in which types of patients?

A

1) Elderly
2) Less well educated
3) Previous history of CVA

290
Q

Risk factors for POCD (post-op cognitive dysfunction)

A
  • Advanced age
  • Long operation
  • Limited education
  • Second operation
  • Infection
  • Respiratory complications
  • Cardiopulmonary bypass
  • Orthopedic surgery
291
Q

Which pre-existing conditions make elderly patients at a significantly increased risk for POCD?

A
  • MI within 6 months
  • Pulmonary edema
  • Unstable angina
  • Aortic stenosis
292
Q

What is the most important part of a medical history of elderly patients?

A

Assessing functional status

293
Q

Which type of hypersensitivity reactions are cytotoxic

A

Type II

294
Q

Which type of hypersensitivity reactions are delayed

A

Type IV

295
Q

Which type of hypersensitivity reactions are immune complex reactions

A

Type III

296
Q

Which type of hypersensitivity reactions are immediate

A

Type I

297
Q

Examples of Type I hypersensitivity reactions

A
  • Atopy
  • Urticaria
  • Angioedema
  • Anaphylaxis
298
Q

Examples of Type II hypersensitivity reactions

A
  • Hemolytic transfusion rx

- HIT

299
Q

Example of Type III hypersensitivity reaction

A

Serum sickness

300
Q

Example of Type IV hypersensitivity reaction

A

Contact dermatitis

301
Q

Signs of contact dermatitis (type IV rxn)

A
  • Pruritus

- Red weepy skin

302
Q

What is required in order for a type I anaphylactic reaction to occur

A

Prior exposure to antigen

303
Q

Systems affected by type I anaphylactic reaction

A
  • Cardiovascular
  • Pulmonary
  • Cutaneous
304
Q

What mediates type I anaphylactic reactions

A

Antigen:antibody reaction of the immune system

305
Q

Grade IV anaphylactic reaction

A

Cardiac arrest

306
Q

What exposure causes the fastest and most severe anaphylactic reactions?

A

IV and mucous membrane

307
Q

Risk factors for anaphylactic reactions

A
  • Mastocytosis (large concentration of mast cells)
  • Allergic to drug used
  • Risk factors for latex allergy
  • Atopy
  • History of uninvestigated life threatening event
308
Q

Mechanism of anaphylactic reaction

A

A susceptible person is exposed to an antigen and their body produces antigen-specific IgE antibodies against it. Re-exposure to this antigen results in mass release of chemical mediators from mast cells and basophils

309
Q

What effect of anaphylaxis do histamine, leukotrienes, and prostaglandins all cause?

A

Bronchoconstriction

310
Q

What is an anaphylactoid reaction

A

A reaction that is NOT dependent on IgE antibodies. Mast cells and basophils cause a massive release of histamine

311
Q

Does a patient have to be previously exposed to an antigen in order to have an anaphylactoid reaction to it?

A

No

312
Q

Patients who are predisposed to anaphylactoid reactions

A
  • Pregnant
  • Young
  • Patients with atopy
313
Q

What is often the first sign of an anaphylactic reaction under anesthesia?

A

Hypotension

314
Q

Signs of anaphylaxis under anesthesia

A
  • Hypotension w/ tachycardia
  • Circulatory collapse
  • Bronchospasm
  • Flush
  • Edema
  • Cardiac arrest
315
Q

Pulmonary signs of anaphylaxis

A
  • Wheezing
  • Bronchospasm
  • Increased PIP
  • Laryngeal edema/stridor
  • Acute pulmonary edema
  • Acute respiratory failure
  • Hypoxia
316
Q

Cutaneous signs of anaphylaxis

A
  • Urticaria
  • Flushing
  • Periorbital and perioral edema
317
Q

Treatment of anaphylactic reaction

A
  • Stop administration
  • 100% O2
  • Positive pressure ventilation
  • Discontinue volatile anesthetics
  • Volume expanders (1-4L)
  • Epinephrine
  • Put patient’s head down
  • Cardiac massage
  • TEE
318
Q

How does epinephrine treat an anaphylactic reaction?

A
  • Increases cAMP which inhibits mediator release and increases Ca2+
  • It’s a B2 agonist so it relaxes bronchial smooth muscle
  • It’s an alpha agonist so it vasoconstricts vessels and increases SVR
319
Q

Why might a patient not respond to catecholamines if they are in anaphylactic shock?

A
  • On beta blockers

- Increased synthesis of nitric oxide

320
Q

What drugs are helpful if your patient is resistant to epinephrine during an anaphylactic rxn?

A
  • Norepi
  • Glucagon
  • Phenylephrine
321
Q

Why does vasopressin treat anaphylactic rxns if epinephrine isn’t working?

A
  • Causes a non-adrenergic vasoconstriction via V1 receptors

- Decreases nitric oxide

322
Q

How long after the onset of anaphylactic shock should you wait to give vasopressin?

A

10-20min

323
Q

What has been shown to treat anaphylaxis when epi and vasopressin aren’t working? Why?

A

Methylene blue because it interferes with nitric oxide

324
Q

Dosage of diphenhydramine to treat anaphylaxis

A

1-2mg/kg

325
Q

Dosage of hydrocortisone to treat anaphylaxis

A

2mg/kg

326
Q

Why would Aminophylline be used to treat symptoms of anaphylaxis?

A

To treat resistant bronchospasm

327
Q

What is indicated by an increase in plasma histamine after a suspected anaphylactic reaction

A

It indicates mast cell/basophil activation

328
Q

What test can be used to determine immune vs. nonimmunologic anaphylactic reaction?

A

Tryptase

329
Q

If a patient has both increased tryptase and histamine, what type of reaction did they have?

A

Immunologic anaphylaxis

330
Q

If a patient has increased histamine but NO increase in tryptase, what type of reaction did they have?

A

Nonimmunologic anaphylaxis

331
Q

What is the gold standard for detection of IgE-mediated reactions that identifies the culprit agent?

A

Intradermal skin testing

332
Q

Common offenders of anaphylactic reactions

A

1) Sux/vec/atracurium
2) Latex
3) Antibiotics
4) Opioids
5) PABA ester local anesthetics
6) Hypnotics (propofol)

333
Q

Is there cross-reactivity between non-depolarizing and depolarizing relaxants?

A

Yes

334
Q

Is there cross-reactivity between cephalosporins and PCNs?

A

Yes

335
Q

Is there cross-reactivity between ester and amide local anesthetics?

A

No

336
Q

Populations at high risk for latex allergy

A

1) Spina bifida
2) Spinal cord injury
3) Healthcare workers
4) Allergies to bananas, avocados, kiwis

337
Q

Risk factors for protamine allergy

A
  • Seafood allergy
  • Diabetics on NPH insulin
  • Prior vasectomy

Anesthesia Practice (9 decks)

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