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Anesthesia Practice > AP 3 Test 2 > Flashcards

AP 3 Test 2 Flashcards

1
Q

Do regurgitant valves cause a pressure overload or a volume overload?

A

Volume overload

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2
Q

Do stenotic valves cause a pressure overload or a volume overload?

A

Pressure overload

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3
Q

What is the ventricles response to a pressure overload lesion?

A

Hypertrophy

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4
Q

Do hypertrophied ventricles normally have systolic dysfunction or diastolic dysfunction?

A

Diastolic dysfunction because it is so stiff that it cannot relax fully and fill adequately

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5
Q

Hypertrophied ventricles are very dependent on what component of blood flow through the heart?

A

Preload, it needs a high atrial kick to maintain cardiac output

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6
Q

What is the final response to a chronically hypertrophied ventricle

A

Ventricular dilation and failure

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7
Q

What is the ventricles response to a volume overload lesion?

A

Dilation to accommodate for the increased volume (regurgitant volume)

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8
Q

What is eccentric hypertrophy?

A

An increase in chamber size relative to the overall heart size

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9
Q

What is concentric hypertrophy?

A

An increase in wall thickness of the chamber, but the size inside the chamber stays the same

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10
Q

Which type of hypertrophy is seen in mitral regurgitation?

A

Eccentric

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11
Q

Which type of hypertrophy is seen in aortic stenosis?

A

Concentric

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12
Q

How does aortic stenosis affect afterload?

A

Increases afterload

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13
Q

How does preload affect afterload?

A

With increases in preload, you get increases in afterload

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14
Q

How are systolic and diastolic pressures affected by aortic stenosis?

A

Systolic pressure decreases, diastolic pressure increases

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15
Q

Common clinical presentation of aortic stenosis

A
  • Angina: due to impaired coronary blood flow
  • Dyspnea: due to increased LVEDP
  • Syncope: due to orthostatic hypotension
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16
Q

Common clinical presentation of mitral regurgitation

A
  • Pulmonary edema and congestion

- Dysrhythmias: due to long standing atrial enlargement

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17
Q

What factors affect CaO2?

A
  • Hemoglobin concentration

- SpO2

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18
Q

What factors affect cardiac output?

A
  • HR

- Stroke volume

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19
Q

How do we commonly measure oxygen delivery to the tissues?

A
  • Lactate

- SvO2

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20
Q

SvO2 can be an inaccurate indication of oxygen delivery under what circumstance?

A

With transfusion - old blood decreases offloading of oxygen and can give us a falsely high SvO2

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21
Q

How should we manage preload in a patient with aortic stenosis?

A

Keep it increased, they are very preload dependent so we need to give them fluids to maintain stroke volume

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22
Q

How should we manage contractility in a patient with aortic stenosis?

A

Maintain it

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23
Q

How should we manage afterload in a patient with AS?

A

Increase it to drive coronary perfusion pressure

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24
Q

How should we manage heart rate in a patient with AS?

A

Keep it low and maintain sinus rhythm to give adequate diastolic filling time

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25
Q

How should we manage preload in a patient with mitral regurgitation?

A

Maintain it - avoid overload because these patients are already volume overloaded. These patients usually come in pretty dry because they are almost always on Lasix.

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26
Q

How should we manage contractility in a patient with MR?

A

Increase it with epi, dobutamine, etc. since systolic function is impaired

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27
Q

How should we manage afterload in a patient with MR?

A

Decrease it to promote forward flow and decrease regurgitant volume

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28
Q

How should we manage heart rate in a patient with MR?

A

Have them at a “high normal”

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29
Q

Which patient can tolerate a-fib better - a patient with MR or AS?

A

MR because the atria are full and have high pressures

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30
Q

Most common anesthetic technique for a patient with AS

A

General

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31
Q

Why is a spinal anesthetic relatively contraindicated in a patient with AS?

A

Because it decreases afterload and preload and reflexively increases heart rate

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32
Q

Why is a general anesthetic great for a patient with MR?

A

It drops preload and afterload

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33
Q

Patients with which valvular lesion are the least tolerant of general anesthesia?

A

Severe mitral stenosis

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34
Q

Hemodynamic goals for managing a patient with mitral stenosis

A
  • Slow HR to have as much filling time as possible
  • Good afterload to maintain perfusion
  • Maintain preload but don’t overload
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35
Q

Can patients with MS tolerate a-fib?

A

No - it is very detrimental to them

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36
Q

Is tricuspid regurgitation a volume overload or pressure overload lesion?

A

Volume overload

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37
Q

What usually causes tricuspid regurgitation?

A

Right ventricular dilation due to pulmonary hypertension

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38
Q

Effect of tricuspid regurgitation on other body systems

A
  • JVD
  • Liver congestion
  • Coagulopathies
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39
Q

Can you use a CVP wave to determine degree of regurgitation?

A

No because we are trying to determine regurgitant volume but the CVP waveform gives us pressure

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40
Q

What tube sizes should be set out for a cardiac case

A

Big tubes - 8.5 for men and 8.0 for women

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41
Q

What is the order that the drips should be placed on the pole while setting up for cardiac cases?

A

1) Insulin on top
2) Phenylephrine
3) Norepinephrine on bottom

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42
Q

What drug is commonly given through a buretrol in cardiac cases?

A

Protamine

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43
Q

Induction drugs to have set up for a cardiac case

A
  • Propofol in 20cc
  • Fentanyl in 20cc
  • Roc in 10cc
  • Lidocaine in 5-10cc
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44
Q

Pressors to have set up for a cardiac case

A
  • Norepi (16mcg/ml)
  • Epi (16mcg/ml)
  • Phenylephrine
  • Vasopressin (1-2units/ml)
  • Ephedrine
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45
Q

Concentration of esmolol

A

10mg/ml

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46
Q

Concentration of nicardipine

A

100mcg/ml

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47
Q

Concentration of nitroglycerin

A

50mcg/ml

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48
Q

Concentration of calcium

A

100mg/ml

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49
Q

Which drug should you have available but NOT draw up while setting up for cardiac cases?

A

Protamine

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50
Q

A-line and CVPs should be placed using what technique?

A

Sterile

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51
Q

What surgeries can you expect to have to place your a-line in the right arm?

A
  • CABG with radial harvest
  • Descending aorta
  • VA ECMO
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52
Q

What surgeries can you expect to have to place your a-line in the left arm?

A
  • Ascending aorta with circulatory arrest
  • Aortic arch
  • Redo case with axillary cannulation
  • Minimally invasive valves
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53
Q

How should the patient be prepared before placing morning lines for a cardiac case?

A
  • Light sedation
  • Nasal cannula
  • Monitors
  • Don’t turn off pre-existing heparin/nitro drips unless instructed
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54
Q

Order of events for a cardiac case

A
  1. Set up
  2. Start IV/a-line
  3. Induction/intubation
  4. TEE
  5. Central line
  6. Echo (during or after central line)
  7. Draw baseline labs/ACT while surgery team is prepping
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55
Q

Heparin dosing for off pump cardiac procedures

A

200units/kg

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56
Q

Goal ACT for off pump cardiac procedures

A

Over 300

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57
Q

What is a LIMA?

A

Left internal mammary artery

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58
Q

Airway management for a robotic CABG

A

Double lumen tube or bronchial blocker and one lung ventilation

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59
Q

Heparin dosing for robotic CABG

A

200units/kg

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60
Q

Extra setup considerations for redo sternotomies

A
  • R2 pads
  • 4 units of blood checked and in the room
  • Large bore access
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61
Q

6 different approaches to transcatheter aortic valve replacements

A
  1. Femoral
  2. Transapical
  3. Transaortic
  4. Transcaval
  5. Transcarotid
  6. Valve in valve
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62
Q

What drug class should be limited or avoided while managing cardiac patients?

A

Benzodiazepines

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63
Q

The brain uses __% of total oxygen body consumption

A

20

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64
Q

Standard CMRO2 value

A

3.5ml/100g/min

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65
Q

Which part of the brain has the highest CMRO2?

A

Gray matter in cerebral cortex

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66
Q

Average value for cerebral blood flow

A

50ml/100g/min (750ml/min)

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67
Q

What extrinsic mechanisms modulate cerebral blood flow

A
  • Respiratory gas tension
  • Temperature
  • Viscosity
  • Autonomic influences
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68
Q

Normal range for cerebral perfusion pressure

A

80-100

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69
Q

CPP at which the EEG is flatlined

A

25-40mmHg

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70
Q

There is irreversible brain damage at CPPs below

A

25mmHg

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71
Q

CBF is directly proportional to PaCO2 between what ranges of PaCO2

A

20-80mmHg

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72
Q

How much does CBF increase per mmHg change in PaCO2?

A

1-2ml/100g/min

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73
Q

How much does CBV increase per 1 mmHg increase in PaCO2?

A

0.05ml/100g

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74
Q

PaO2 increases CBF when it falls below what value

A

50mmHg (severe hypoxemia)

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75
Q

How much does CBF change per 1 degree celsius change in temperature?

A

5-7%

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76
Q

How does hypothermia affect CBF

A

Decrease

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77
Q

How does hyperthermia affect CBF

A

Increase

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78
Q

How does sympathetic stimulation affect CBF

A

Decreases via vasoconstriction

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79
Q

What substances can pass the BBB?

A

Lipid soluble substances

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80
Q

What substances are restricted from crossing the BBB?

A

Ionized molecules or those with large molecular weights

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81
Q

Passage into the BBB is dependent on what 4 factors?

A
  1. Size
  2. Charge
  3. Lipid solubility
  4. Degree of protein binding in the blood
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82
Q

Normal rate of production of CSF

A

0.3-0.4ml/min (500ml/day)

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83
Q

Average total volume of CSF in circulation

A

150ml

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84
Q

What drug classes decrease CSF production?

A
  • Corticosteroids
  • Diuretics
  • Vasoconstrictors
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85
Q

Definition of intracranial pressure

A

Supratentorial CSF pressure measured in the lateral ventricles or over cerebral cortex

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86
Q

Components contributing to ICP

A
  • Brain 80%
  • Blood 12%
  • CSF 8%
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87
Q

Normal values for ICP

A

5-10mmHg

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88
Q

Different techniques for measuring ICP

A
  • Ventriculostomy catheter
  • Intraparenchemal fiberoptic device
  • Subarachnoid screw
  • Epidural transducer
  • Subarachnoid catheter
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89
Q

Definition of intracranial hypertension

A

Sustained ICP over 15mmHg

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90
Q

Possible causes for intracranial HTN

A
  • Expanding tissue/fluid mass (tumor)
  • Depressed skull fracture
  • Abnormalities with CSF absorption
  • Excessive CBF
  • Brain edema resulting from systemic disturbances (i.e. kidney failure)
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91
Q

Signs and symptoms of intracranial HTN

A
  • Headache
  • N/V
  • Papilledema (swelling of optic disk, eyes divert)
  • Mental status changes
  • Blurred vision
  • Cushing reflex
  • Fixed, dilated pupils
  • Decerebrate posture
  • Seizures
  • Altered breathing patterns
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92
Q

How does intracranial HTN affect cushing reflex?

A

When ICP goes up, blood pressure goes up to maintain cerebral perfusion pressure which causes HTN and reflex bradycardia

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93
Q

Treatment for intracranial HTN

A
  • Resolve cause
  • Fluid restrict
  • Decrease CSF volume
  • Decrease CBF
  • Decrease brain volume
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94
Q

Methods to decrease CSF volume

A
  • CSF drainage

- Loop diuretics

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95
Q

Methods to decrease CBF

A
  • Hyperventilation to a PaCO2 of 30-33

- PaO2 over 100mmHg

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96
Q

Methods to decrease brain volume

A
  • Steroids (Decadron 20-100mg)

- Osmotic agents (Mannitol 1g/kg)

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97
Q

What is intracranial compliance

A

Change in ICP in response to change in intracranial volume

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98
Q

What are the compensatory mechanisms the brain uses to maintain intracranial compliance

A
  • CSF movement from cranial to spinal compartment
  • Increase CSF absorption
  • Decrease CSF production
  • Decrease cerebral blood volume
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99
Q

Abnormal posture associated with herniation of cerebral structures

A

Decerebrate

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100
Q

Abnormal posture associated with herniation of corticospinal structures

A

Decorticate

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101
Q

What is the preferred inhaled anesthetic for neuro procedures and why?

A

Isoflurane because of the decrease in CMRO2 and improved CSF absorption

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102
Q

What is the only IV anesthetic agent that will increase cerebral blood flow?

A

Ketamine

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103
Q

Which inhaled anesthetic increases CSF production?

A

Desflurane

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104
Q

How does LIGHT anesthesia (small doses) and surgical stimulation affect the EEG?

A

Increase frequency, decrease voltage

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105
Q

How does deep anesthesia and cerebral compromise affect the EEG?

A

Decrease frequency, increase voltage

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106
Q

Which evoked potential monitor tests the integrity of the dorsal spinal column and sensory cortex?

A

Somatosensory

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107
Q

Which evoked potential monitor tests the adequacy of spinal cord perfusion?

A

Motor

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108
Q

Which evoked potential monitor tests the integrity of CN8 and the auditory pathways above the pons?

A

Brainstem-auditory

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109
Q

Which evoked potential monitor monitors the optic nerve and upper brainstem during resections of large pituitary tumors?

A

Visual

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110
Q

How long can the brain tolerate cerebral ischemia before there is irreversible neuronal injury?

A

3-8 minutes

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111
Q

What is focal ischemia

A

Cerebral ischemia characterized by presence of surrounding non-ischemic brain, possible collateral blood flow to ischemic region

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112
Q

What is global ischemia

A

Insufficient blood supply or O2 delivery to entire brain

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113
Q

What is “global complete” ischemia?

A

Absence of CSF

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114
Q

What is ischemic penumbra?

A

Brain tissue that surrounds a damaged area that has functional impairment but is still viable

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115
Q

What type of ischemia is ischemic penumbra?

A

Focal ischemia

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116
Q

Ischemic penumbras do not receive blood flow higher than what value

A

15ml/100g/min

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117
Q

How does hypothermia serve as a brain protection strategy

A

Decreases brain metabolic requirements

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118
Q

What is the most effective form of brain protection during focal and global ischemia?

A

Hypothermia

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119
Q

What anesthetic agents are used for brain protection?

A
  • Barbs
  • Propofol, etomidate
  • Isoflurane
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120
Q

Anesthetic agents provide protection against which type of ischemia?

A

Focal

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121
Q

Which class of drugs (often used for blood pressure) are used for brain protection? Why?

A

Calcium channel blockers - nimodipine and nicardipine. Treats vasospasm

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122
Q

Strategies to maintain optimal CPP for brain protection

A
  • Normal or high BP
  • Avoid increases in ICP
  • Maintain normocarbia
  • Avoid hyperglycemia above 150mg/dl
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123
Q

Various causes of mass lesions

A
  • Congenital
  • Neoplastic
  • Infectious
  • Vascular
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124
Q

Primary tumor sites for brain tumors

A
  • Glial cells
  • Ependymal cells
  • Supporting tissues
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125
Q

Where are the majority (70%) of mass lesions located

A

Supratentorial

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126
Q

Signs/symptoms of mass lesions

A
  • Headache
  • Seizures
  • Decline in cognition and speech
  • Focal neurological deficits
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127
Q

Types of supratentorial masses (3)

A
  • Meningiomas
  • Gliomas
  • Metastatic lesions
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128
Q

Signs/symptoms of supratentorial masses

A
  • Seizures
  • Hemiplegia
  • Aphasia
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129
Q

Main type of infratentorial mass

A

Posterior fossa

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130
Q

Signs/symptoms of infratentorial masses

A
  • Cerebellar dysfunction (ataxia, nystagmus, dysarthria)

- Brain stem compression (cranial nerve palsies, altered consciousness, abnormal respirations)

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131
Q

What is an astrocytoma

A

Slow growing lesion in cerebral hemisphere derived from astrocyte brain cells

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132
Q

What is the most aggressive type of primary brain tumors

A

Gliomas

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133
Q

There is poor prognosis with morbidity when a glioblastoma has lasted over __ months

A

18

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134
Q

Which tumor type commonly arises in the cerebellum of children

A

Medullablastoma

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135
Q

Characteristics of meningioma

A
  • Slow growing
  • Benign
  • Highly vascular
  • Infiltrates skull
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136
Q

Signs/symptoms of pituitary adenoma

A
  • Headaches
  • Impaired vision
  • Cranial nerve palsies
  • Hypopituitarism
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137
Q

Hypersecreting pituitary adenomas secrete which hormones?

A
  • Prolactin

- Growth hormone

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138
Q

Most common primary sites for metastatic tumors

A
  • Lung

- Breast

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139
Q

At what anatomical point do intracranial aneurysms form?

A

Arterial bifurcations

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140
Q

What gender is more prone to intracranial aneurysms

A

Females

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141
Q

Risk factors for subarachnoid hemorrhage

A
  • Cigarette smoking
  • HTN
  • Alcohol consumption
  • Cocaine/amphetamine abuse
  • Oral contraceptives
  • Hypercholesterolemia
  • Familial
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142
Q

Classic presentation of a subarachnoid hemorrhage

A
  • Acute severe headache
  • Stiff neck
  • Photophobia
  • N/V
  • Transient loss of consciousness
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143
Q

Complications following subarachnoid hemorrhage

A
  • Rerupture
  • Reactive vasospasm
  • Intracranial HTN
  • Hydrocephalus
  • Hyponatremia
  • Seizures
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144
Q

Acute vasospasms occur how soon after a subarachnoid hemorrhage (SAH)

A

5-30min after

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145
Q

Long term vasospasms occur how soon after a SAH

A

3-12 days after

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146
Q

Grade I SAH

A

Asymptomatic

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147
Q

Grade II SAH

A

Moderate headache, nuchal rigidity, no neurological deficit

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148
Q

Grade III SAH

A

Confusion

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149
Q

Grade IV SAH

A

Coma, hemiparesis

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150
Q

Grade V SAH

A

Moribund, decerebrate posture

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151
Q

What are arteriovenous malformations

A

Congenitally malformed capillary beds comprised of high flow, low resistance vessels. Blood flow basically goes from arteries to veins without passing through proper capillaries

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152
Q

AV malformations are associated with what phenomenon?

A

Steal phenomenon which causes cerebral ischemia

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153
Q

Anatomical components of AV malformations

A
  • Arterial feeders
  • Nidus (central point)
  • Arterial collaterals
  • Venous outflow
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154
Q

Definition of a stroke

A

Sudden neurologic insult that results from restriction/cessation of blood flow

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155
Q

85% of strokes are classified as what type of stroke?

A

Ischemic/infarction

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156
Q

15% of strokes are classified as what type of stroke?

A

Hemorrhagic

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157
Q

What is the grave complication associated with strokes?

A

Loss of autoregulation to that portion of the tissue, CPP becomes much more dependent on blood pressure

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158
Q

Most common cause of thrombolytic ischemic strokes

A

Atherosclerosis

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159
Q

Most common cause of embolitic ischemic strokes

A

A-fib

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160
Q

Top 3 causes of ischemic strokes

A
  1. Thrombosis
  2. Embolism
  3. Vasoconstriction
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161
Q

What is a subdural hematoma

A

Blood collection between the dura and cerebral cortex

162
Q

Signs/symptoms of subdural hematomas

A
  • Balance problems
  • Gait changes
  • Mental status changes
  • Seizures
163
Q

What is hydrocephalus

A

Imbalance between CSF production and reabsorption resulting in increased ICP

164
Q

What causes hydrocephalus

A
  • CSF overproduction by choroid plexus
  • Venous drainage obstruction
  • CSF flow obstruction
165
Q

2 types of hydrocephalus

A
  • Noncommunicating

- Communicating

166
Q

What is pseudotumor cerebri

A

Idiopathic intracranial hypertension without a mass lesion caused by a CSF reabsorption anomaly or venous obstruction

167
Q

Treatment for pseudotumor cerebri

168
Q

Pathophysiology of seizures

A

Abnormal synchronized electrical activity in the brain and loss of inhibitory GABA activity. Characterized by enhanced excitatory amino acid release and neuronal firing due to abnormal voltage regulated Ca2+ channels

169
Q

2 classifications of seizure disorders

A
  • Partial (focal)

- Generalized

170
Q

What is a partial (focal) seizure disorder

A

Motor, sensory, or autonomic symptoms - depending on the affected area of the brain

171
Q

3 subclasses of generalized seizure disorders

A

1) Non-convulsive
2) Convulsive
3) Unclassified

172
Q

3 classes of non-convulsive seizures

A

1) Absence
2) Myoclonic
3) Atonic

173
Q

3 classes of convulsive seizures

A

1) Tonic-clonic
2) Tonic
3) Clonic

174
Q

Signs/symptoms of seizure disorders

A
  • Muscle spasms
  • Paresthesias
  • Pallor, sweating, vomiting
  • Memory distortions
175
Q

What should we focus on when doing a preop evaluation of a patient with a seizure disorder?

A

Focus on cause and type of seizure activity and current medication

176
Q

Chronic therapy for seizure disorders can cause resistance to which drug class commonly used under general anesthesia?

A

Nondepolarizing muscle relaxants

177
Q

Which anesthetics should be avoided in a patient with a seizure disorder?

A
  • Ketamine
  • Etomidate
  • N2O
178
Q

What are the steps to take if a seizure occurs under our care

A
  • Maintain open airway and adequate oxygenation

- Administer appropriate drugs for seizure management

179
Q

Dose of propofol for seizure management

180
Q

Dose of thiopental for seizure management

181
Q

Dose of midazolam for seizure management

182
Q

Dose of diazepam for seizure management

183
Q

Dose of phenytoin for seizure management

A

500-1000mg SLOWLY

184
Q

What is epilespy

A

A seizure disorder caused by recurrent paroxysm of cerebral function and characterized by sudden, brief attacks of altered consciousness, motor activity, sensory phenomena, or inappropriate behavior

185
Q

What is status epilepticus?

A

A neurologic emergency caused by continuous or intermittent seizure activity lasting longer than 20 minutes during which the patient does not regain consciousness

186
Q

Types of cerebral palsy

A
  • Spastic (70-80%)
  • Athetoid/dyskinetic (10-20%)
  • Ataxic (5-10%)
  • Mixed
187
Q

Signs/symptoms of cerebral palsy

A
  • Involuntary movements with or without posture instability

- Associated with mental retardation

188
Q

Etiology of cerebral palsy

A
  • Hypoxia/ischemia at birth

- Kernicterus (bilirubin-induced brain dysfunction)

189
Q

Pathophysiology of Parkinson’s disease

A
  • Loss of dopamine producing neurons in substantia nigra
  • Increased GABA activity in basal ganglia which inhibits thalamic and brainstem nuclei
  • Thalamic inhibition suppresses motor system which results in hallmark symptoms
190
Q

Parkinson’s is more common in which gender?

191
Q

Signs/symptoms of Parkinson’s

A
  • Resting tremor
  • Trembling
  • Rigidity
  • Bradykinesia
  • Postural instability/impaired balance
192
Q

Should Parkinson’s medications be continued or discontinued perioperatively?

193
Q

Which 2 medications are contraindicated in Parkinson’s patients?

A
  • Metoclopramide

- Droperidol

194
Q

Which 2 classes of medications are effective against acute symptoms of Parkinson’s?

A
  • Anticholinergics (atropine)

- Antihistamines (benadryl)

195
Q

What drug should be used to treat hypotension in a patient with Parkinson’s?

A

Phenylephrine

196
Q

Pathophysiology of Alzheimer disease

A
  • Marked cortical atrophy with ventricular enlargement

- Severe loss of hippocampal and cortical neurons (short term memory/reasoning)

197
Q

Signs/symptoms of Alzheimer disease

A
  • Slow decline in intellectual function
  • Memory loss
  • Language deterioration
  • Poor judgement
  • Confusion
  • Restlessness
198
Q

Anesthetic management concerns for a patient with Alzheimers

A
  • Disoriented/uncooperative patient
  • Altered responses to drugs
  • DO NOT GIVE PREMED
  • Confusion after extubation
199
Q

If a patient has a right temporal lobe tumor, he may be weak on the left side. How would this affect a NMB monitor reading on the left side?

A

You would get a hyper-response on the left side, so you may think the patients isnt adequately blocked when they actually are

200
Q

What should your IV access be before neuro surgery begins?

A

AT LEAST 2 good running IVs because the table is turned 90 degrees and we only have access to 1 arm

201
Q

How should the ETT tube be secured for neuro cases?

A
  • Secured to the side of the head that will be facing you

- Insert bite blocks so the tube doesn’t kink

202
Q

To what general depth should you insert the ETT tube if the head will be flexed during neuro surgery?

A

Insert the tube shallower than normal because it will go deeper once the head is flexed during positioning

203
Q

To what general depth should the ETT tube be inserted if the head will be extended during neuro surgery?

A

Insert the tube deeper because it will rise up once the head is positioned

204
Q

Why is it hard to estimate EBL in neuro surgeries?

A

There is a very large amount of irrigation fluids used

205
Q

When does a lot of the blood loss occur during neuro surgeries?

A

During closure of the scalp because it is very vascular

206
Q

What drugs are used to decrease the brain’s water content for neuro surgeries?

A

Diuretics - mannitol or lasix

207
Q

Appropriate fluid management for neuro cases

A
  1. Enough fluids for cardiovascular stability
  2. Avoid hyperglycemia
  3. Avoid hyper/hyponatremia
  4. No “free water” (hypoosmolar fluid)
  5. Mannitol (can cause hypotension)
208
Q

What fluid should NOT be used for neuro cases?

A

Hypo osmolar fluids such as D5 0.45% saline

209
Q

You should consider treating any glucose above __ in neuro cases

210
Q

Osmolarity of plasma

211
Q

When does anesthesia need to be “deep” during neuro cases?

A

Only during opening and closing - that is the only time surgical stimulus is high

212
Q

Which neuro surgery has a very quick recovery and wake up time?

A

CHRONIC subdural hematomas in older patients

213
Q

1mmhg increase in CO2 increases CBF by __%

214
Q

What is the critical CBF at which you start losing brain cells

A

18ml/100gm

215
Q

What factors can shift the CBF autoregulation curve to the left?

A
  • Vasodilation
  • Hypercarbia
  • Deep inhalation agents
216
Q

What physical states cause global ischemia?

A
  • Cardiac arrest
  • Severe hypotension
  • Hypoxia
217
Q

How do inhalational anesthetics affect CBF?

A

All increase CBF in a dose dependent fashion

218
Q

Which inhalational agent increases CBF the most?

219
Q

How do inhalational agents affect CMRO2?

220
Q

What is the only anesthetic agent that increases CBF?

221
Q

What are the best agents to treat blood pressure during brain surgery?

A

Alpha agents since they are not physiologically active in the brain

222
Q

What drug can you not use on a patient who had a stroke 2 weeks ago due to high K+?

A

Succinylcholine

223
Q

Normal ICP

224
Q

ICP is considered severely increased if it exceeds…

225
Q

Most common method used to drain CSF

A

Ventriculostomy

226
Q

Risk associated with ventriculostomies

A

Very invasive and can cause infection

227
Q

Subdural bolts are used to drain CSF in which patients

A
  • Acute hepatitis

- Coagulopathy

228
Q

Why is an increase in ICP so detrimental during neuro surgery?

A
  • Decreases CPP
  • Risk of herniation
  • Hard to operate
  • Inadequate brain exposure
  • Retractor’s ischemia
  • Injury to brain
229
Q

What factors increase intracellular fluids in the brain during neuro surgery?

A
  • Acute hyponatremia

- Cellular damage (physical, ischemia, hypoxia)

230
Q

What factors increase extracellular fluids in the brain during neuro surgery?

A
  • Venous engorgement
  • Extreme hypertension
  • Hypervolemia
231
Q

What factors decrease intra/extracellular fluids in the brain during neuro surgery?

A
  • Diuretics
  • Venous drainage
  • Decadron
232
Q

Which diuretic is generally best to use during neuro surgery?

A

Lasix. Mannitol causes a transient increase in ICP which can be damaging and interfere with surgery

233
Q

How does mannitol affect electrolyte values

A
  • Transient hyponatremia because it dilutes sodium in the plasma initially
  • Hyperkalemia
234
Q

Average cerebral blood volume

235
Q

How much cerebral blood volume is in the venous system

236
Q

Acute consequences of venous obstruction

A

Increase in cerebral blood volume thus increase in ICP

237
Q

Long term consequences of venous obstruction

A

Edema formation and decrease in CSF absorption

238
Q

Normal volume of CSF

239
Q

What factors decrease CSF?

A
  • Drainage

- Enhancing absorption by lowering venous pressure in cerebral sinuses

240
Q

Anesthetic drugs to use during neuro surgery to aim for a prompt recovery

A
  1. Barbituates
  2. Propofol
  3. Short acting narcotics
  4. Less than 1 MAC of inhalational agents
241
Q

What are the goals for emergence from a neuro case?

A
  1. No coughing
  2. No hypertension
  3. Prompt
  4. Minimal hypercarbia
242
Q

What neuro patients are not expected to wake up quickly?

A
  1. Acute subdural hematoma
  2. Closed head injury
  3. Patients with a lot of traction on brain
  4. Patients with surgery around brain stem
243
Q

What are the 2 major problems associated with intracranial aneurysms?

A
  • Rebleeding

- Vasospasm

244
Q

When is the highest incidence of rebleeding after an intracranial aneurysm rupture?

A

A few days after the hemorrhage

245
Q

When does the chance of vasospasm after intracranial aneurysm rupture peak?

246
Q

What changes can be seen on an ECG of a patient presenting with an intracranial aneurysm?

A
  • Subendocardial infarcations
  • PVCs
  • ST segment changes
247
Q

Treatment for hyponatremia caused by SIADH

A

Restrict fluids

248
Q

Treatment for hyponatremia caused by cerebral salt wasting syndrome

A

More fluids

249
Q

Sequalae of prolonged bed rest and CNS depression of a patient with intracranial aneurysm

A
  • Aspiration
  • Atelectasis
  • Hypovolemia
250
Q

Standard monitors applied to a patient with intracranial aneurysm

A
  • Standard ASA
  • Aline
  • CVP or Swan Ganz
  • Intra-op angiography
251
Q

What should be avoided by all means during induction of a patient with intracranial aneurysm?

A

Hypertension

252
Q

How long can a clip be applied to an aneurysm intraoperatively and cause no problems to the patient?

A

18 minutes

253
Q

How should blood pressure be managed during temporary clipping of an intracranial aneurysm?

A

Temporary hypertension to increase blood flow to the brain

254
Q

What drugs should be administered during temporary clipping of an intracranial aneurysm to decrease CMRO2?

A
  • Propofol 100mcg/kg/min

- Etomidate

255
Q

How should CO2 levels be maintained during temporary clipping of an intracranial aneurysm?

A

Mild hypocarbia to prevent steal phenomenon

256
Q

What should be done if the aneurysm ruptures during surgery?

A
  • Keep up with blood loss
  • Controlled hypotension
  • Adenosine
  • Propofol
257
Q

Methods for brain protection during neurosurgery

A
  • Relaxed brain
  • Decrease CMRO2 (hypothermia, drugs)
  • Increase focal blood flow (hypocarbia, hypertension)
258
Q

Clinical presentation of vasospasm following intracranial aneurysm rupture

A

Focal deficit, decreased level of consciousness

259
Q

Ultimate method for diagnosis of vasospasm

A

Angiography

260
Q

Treatment options for vasospasm

A
  • Nimodipine
  • Magnesium sulfate
  • HHH therapy AFTER CLIPPING
  • Angioplasty
261
Q

Signs/symptoms of AV malformation

A
  • Headache
  • Seizures
  • Bleeding
  • Focal ischemia
262
Q

Treatment for AV malformation

A
  • Embolization
  • Resection
  • Gamma knife
263
Q

Blood loss for AVM surgery

A

Protracted and massive

264
Q

Blood loss for aneurysm surgery

A

Minimal unless it ruptures

265
Q

Which incidence has a risk of vasospasm - AVM or aneurysm?

266
Q

Which incidence has a risk of hyperperfusion phenomenon - AVM or aneurysm?

267
Q

How should blood pressure be managed following surgery for AVM?

A

Keep BP low

268
Q

How should BP be managed following surgery for aneurysm?

A

Keep BP high

269
Q

How should blood volume be managed following surgery for AVM?

270
Q

How should blood volume be managed following surgery for aneurysm?

271
Q

Mean weight gain during pregnancy

A

12kg (17%)

272
Q

Metabolism increases by approximately __% during pregnancy

273
Q

What causes difficult nasal breathing for the mother during pregnancy?

A

Increased blood flow causes capillary engorgement of the oropharynx, nasal mucosa, and larynx

274
Q

What risk associated with nasal intubation is increased during pregnancy?

A

Epistaxis due to increased blood flow

275
Q

How does airway conductance of the mother change during pregnancy?

A

Increases due to dilation of large airways

276
Q

How does the position of the diaphragm change during pregnancy?

277
Q

During what point of pregnancy is blood volume the highest?

A

3rd trimester

278
Q

What is the average blood volume for a pregnant woman in ml/kg

279
Q

When does the largest increase in cardiac output occur during pregnancy?

A

Immediately post partum

280
Q

How much does cardiac output increase during pregnancy?

281
Q

How much does stroke volume increase during pregnancy?

282
Q

How much does heart rate increase during pregnancy?

A

15-30% (15-20BPM)

283
Q

How much does contractility increase during pregnancy?

284
Q

How much does SVR decrease during pregnancy?

285
Q

How much does PVR decrease during pregnancy?

286
Q

Where does the mom shift on the oxyhemoglobin curve during pregnancy?

A

To the right and releases O2 more readily at tissues

287
Q

Where does the baby shift of the oxyhemoglobin curve during pregnancy?

A

To the left, tries to hold on to oxygen

288
Q

What is the P50 of fetal hemoglobin?

289
Q

P50 of mother’s hemoglobin

290
Q

By how much does uterine blood flow increase during pregnancy?

A

From 50ml/minute to 600-700ml/minute

291
Q

Where does the majority of increased blood flow to the uterus go?

A

To the intervillous space

292
Q

Renal plasma flow is increased by __% at 16 weeks

293
Q

Renal plasma flow is increased by __% at 26 weeks

294
Q

Renal plasma flow is increased by __% at term

295
Q

How much does skin blood flow increase during pregnancy

A

3-4 times normal flow

296
Q

How much does systolic blood pressure decrease throughout pregnancy?

297
Q

How much does diastolic blood pressure decrease throughout pregnancy?

A

20-25% early, returns to normal at term

298
Q

What factors impair uterine blood flow?

A
  • Decreased uterine arterial pressure
  • Increased uterine venous pressure
  • Increased uterine vascular resistance via vasoconstrictors
299
Q

What intra-op factors can impair uterine blood flow via decreasing uterine arterial pressure?

A
  • Supine position
  • Hypovolemia
  • Drug-induced hypotension
300
Q

What intra-op factors contribute to decreased uterine perfusion pressure by increasing uterine venous pressure?

A
  • Vena caval compression
  • Uterine contractions
  • Drug-induced uterine hypertonus (oxytocin, local anesthetics)
  • Skeletal muscle hypertonus (seizures, valsalva)
301
Q

What endogenous vasoconstrictors are often released intra-op and contribute to increased uterine vascular resistance?

A
  • Catecholamines (stress)

- Vasopressin (hypovolemia)

302
Q

What exogenous vasoconstrictors cause increased uterine vascular resistance?

A
  • Epinephrine
  • Pressors (Phenylephrine more so than ephedrine)
  • Local anesthetics
303
Q

Uterine blood flow is ______ dependent, not auto regulated.

304
Q

What patient position causes partial caval obstruction but maintains venous return?

A

Lateral decubitus

305
Q

What patient position completely obstructs inferior vena cava and decreases venous return?

306
Q

How much does the supine position decrease the cardiac output of a pregnant woman?

307
Q

When during pregnancy does caval compression begin?

A

13-16 weeks

308
Q

The supine position significantly compresses the aorta at what spinal levels

309
Q

How much does tidal volume increase during pregnancy?

310
Q

How much does FRC decrease during pregnancy?

311
Q

How does inspiratory capacity change with pregnancy?

A

Increases by 15%

312
Q

How much does residual volume decrease during pregnancy?

313
Q

How is total lung capacity changed during pregnancy?

A

Decreased by ~5%

314
Q

How does respiratory rate of mother change during pregnancy

315
Q

How does minute ventilation and alveolar ventilation change during pregnancy

A

Increase by 40%

316
Q

What is the biggest contributor to the increase in minute ventilation of a pregnant woman?

A

Increase in tidal volume

317
Q

PaCO2 changes in pregnant women

A

Decreases down to 30 (normal is 40)

318
Q

PaO2 changes in pregnant women

A

Increases to 103-107 (normal is 100 on room air)

319
Q

pH changes in pregnant women

A

Increases to 7.44 (normal is 7.4)

320
Q

Bicarbonate changes in pregnant women

A

Decreases to 20-21 (normal is 24)

321
Q

How does MAC change in pregnant women?

A

Decreases by as much as 40%

322
Q

How does the nervous system change during pregnancy?

A

Progesterone mediated CNS depression

323
Q

How does dosing for local anesthetics change during pregnancy?

A

Decreased by 33%

324
Q

What factors contribute to the need for a decrease in local anesthetic dosing?

A
  • Increased epidural blood volume can increase risk of puncturing vein
  • Decreased CSF volume causes enhanced cephalad spread
325
Q

Renal changes of the mother during pregnancy

A
  • Increased renal blood flow
  • Increased GFR
  • Decreased BUN/Cr
326
Q

How do levels of plasma cholinesterase change during pregnancy?

A

Decrease by 30%

327
Q

Colloid osmotic pressure decreases by __mmHg at term

328
Q

How do total protein values change during pregnancy

A

Decrease to ~7.0% (normal is 7.8%)

329
Q

How do albumin values change during pregnancy

A

Decrease from 3.9 to 3.6 to 3.3% throughout pregnancy (normal is 4.5%)

330
Q

What is the only plasma protein to increase during pregnancy?

331
Q

How is coagulation changed during pregnancy

A

Accelerated, compensated coagulation with enhanced platelet turnover, clotting, and fibrinolysis

332
Q

PT is shortened by __% during pregnancy

333
Q

PTT is shortened by __% during pregnancy

334
Q

Bleeding time is shortened by __% during pregnancy

335
Q

What test demonstrates the hypercoagulable state of pregnant women?

A

Thromboelastograph

336
Q

What is the most common part of the endocrine system that is changed during surgery?

337
Q

Thyroid changes during surgery

A

Thyroid gland commonly hypertrophies due to increased estrogen which results in increased iodine uptake and increased T3/T4 levels

338
Q

The metabolic state of the mother during pregnancy mimics what endocrine state

A

Hyperthyroidism

339
Q

Parathyroid function is important to what aspect of pregnancy?

A

Fetal growth

340
Q

How does insulin change during pregnancy?

A

There is insulin resistance by mid 2nd trimester and release of growth producing hormones by the placenta

341
Q

GI changes during pregnancy

A
  • Delayed gastric emptying
  • Decreased GI mobility
  • Silent regurgitation
  • Changes in gastric volume and pH
  • Relaxed lower esophageal sphincter
342
Q

The GI changes during pregnancy lead to an increased risk of…

A

Aspiration

343
Q

The reduced tissue sensitivity to insulin causes what phenomena in pregnant women?

A

Fasting hypoglycemia

344
Q

Pregnancy predisposes the mother to what gallbladder problem

A

Gall stone formation

345
Q

Considerations for ETT size for pregnant women

A

Chose smaller ETT because of increased edema, tissue, and breast size

346
Q

How does maternal oxygenation change under general anesthesia?

A
  • Increase physiologic shunt when supine
  • Increased rate of denitrogenation
  • Increased rate of decline of PaO2 during apnea
347
Q

Protocol for a pregnant surgical patient coming in for elective surgery

A

Delay until postpartum

348
Q

Protocol for a pregnant patient in their 1st trimester coming in for ESSENTIAL surgery

A
  • If no risk, consider delayed until mid-gestation

- If high risk, proceed with surgery

349
Q

Protocol for a pregnant patient in their 2nd/3rd trimester coming in for ESSENTIAL surgery

A

Proceed with surgery

350
Q

Protocol for pregnant patient coming in for an EMERGENCY surgery

A

Proceed with surgery

351
Q

What are the 3 stages of labor

A

Stage 1: Latent phase (onset of labor, minimal dilation) then active phase (increased contractions, dilation up to 10cm)
Stage 2: full dilation, fetal descent and delivery
Stage 3: delivery of placenta

352
Q

Once the water of a pregnant patient breaks, there is an increased risk of…

353
Q

Maternal minute ventilation increases by ___% during intense contractions

354
Q

O2 consumption increases acutely by __% during labor

355
Q

How much blood is displaced from the uterus to central circulation with EACH contraction?

356
Q

Effects of opioids on fetus

A

Can cross the placenta and cause respiratory depression in baby, use with caution

357
Q

Function of Pitocin (oxytocin) during labor

A

Progresses labor by stimulating uterine smooth muscle contractions

358
Q

Function of Methergine and Hemabate during labor

A

Given POST PARTUM intramuscularly to contract uterus and control bleeding

359
Q

Function of Magnesium during contractions

A

Stops contractions, given to eclamptic patients to avoid a seizure

360
Q

What drug class is contraindicated during pregnancy?

A

Benzodiazepines

361
Q

Effect of nitrous oxide on the progression of labor

362
Q

Effect of inhaled anesthetics on the progression of labor

A

Causes uterine relaxation and slows progression of labor

363
Q

Effect of high doses of inhaled anesthetics on labor

A

Causes uterine atony (loss of muscle tone) and increased bleeding at delivery

364
Q

What is pre-eclampsia (PIH)?

A

A triad of

1) Hypertension (Over 140/90 or 20% over baseline)
2) Proteinuria (Over 300mg/day)
3) Edema

365
Q

What is HELLP syndrome?

A

Pregnancy induced hypertension associated with…

1) Hemolysis
2) Elevated Liver Enzymes
3) Low Platelets

366
Q

What is eclampsia?

A

When preeclampsia is accompanied by generalized tonic-clonic seizures

367
Q

Effect of preeclampsia on the baby

A

There is decreased transfer of nutrients to the baby so it is smaller and often delivered early

368
Q

Preeclampsia is exhibited after __ weeks of gestation

369
Q

What is the root of the problem of preeclampsia?

A

Placental ischemia causing cell damage

370
Q

What abnormalities can occur in the endothelium of the placenta and cause preeclampsia to develop?

A
  • Increase in: vascular tone, permeability, fibrin deposition
  • Release of: vasoconstrictors, procoagulants, other humoral factors
371
Q

A decrease in which 3 blood components can cause the development of preeclampsia?

A
  • Platelets
  • Prostacyclin
  • Antithrombin III
372
Q

An increase in which 5 blood components can cause development of preeclampsia?

A
  • Thromboxane A2
  • von Willebran factor
  • Factor VII activity
  • Neutrophil activation
  • Free radicals
373
Q

What abnormal functional states of blood can cause preeclampsia?

A
  • DIC (disseminated intravascular coagulation)

- Hemolysis

374
Q

What is the immediate action that should be taken when an eclamptic patient has a seizure?

A

Airway management

375
Q

What should be ruled out during a differential diagnosis of eclampsia?

A
  • Epilepsy
  • LAST
  • Embolism
376
Q

Patients with eclampsia may have what response to NMB drugs

A

The effect of the drugs may be prolonged because these patients are often on magnesium therapy

377
Q

Renal complications associated with PIH

A
  • Proteinuria
  • Sodium retention
  • Decrease GFR
  • Renal failure
378
Q

Occurrence of an acute fatty liver in pregnant women

A

Rare but high mortality

379
Q

When do symptoms of acute fatty liver present during pregnancy?

A

3rd trimester

380
Q

Symptoms of acute fatty liver

A
  • N/V
  • Epigastric pain
  • Jaundice
  • Decrease serum glucose
  • Increased liver enzymes
381
Q

Treatment of acute fatty liver

A

Treat hypoglycemia with D50, fluids, FFP, platelets

382
Q

What is an amniotic fluid embolism?

A

When amniotic fluid from uterus gets absorbed into mother’s circulation due to vascular tear, delivery, or trauma and there is an anaphylactic response to absorption

383
Q

When does an amniotic fluid embolism most commonly present?

A

During vaginal delivery

384
Q

Symptoms of amniotic fluid embolism

A
  • Sudden unexpected CV collapse
  • Hypotension
  • Resp. depression
  • Cyanosis
  • Seizure
  • DIC
385
Q

Treatment of amniotic fluid embolism

A
  • Supportive care

- Delivery baby via c section

386
Q

What is DIC (disseminated intravascular coagulation)?

A

Widespread systemic activation of coagulation, resulting in intravascular formation of fibrin and ultimately thrombotic formation occlusion of small and mid sized vessels

387
Q

Causes of DIC

A
  • Trauma
  • Sepsis
  • Acute fatty liver
  • Amniotic fluid embolism
388
Q

Treatment for DIC

A
  • Clotting factors

- Platelets

389
Q

What is thromboembolic disease

A

When pregnancy causes an increase in most clotting factors and gravid uterus causes venous stasis

390
Q

What factors increase the risk of thromboembolic disease

A
  • Smoking
  • Obesity
  • Age
  • Genetics
391
Q

Diagnosis of DVT/PE

A

Doppler ultrasound

392
Q

Treatment of DVT/PE

A

Anticoagulation

393
Q

Anesthetics considerations for a pregnant patient with DVT/PE

A
  • Have a clotting screen done before epidural placement
  • Have blood ready
  • Don’t keep patient supine for too long
394
Q

How is pre-existing asthma tolerated during pregnancy

A

It is benign for the pregnancy. Epidurals are still well tolerated and prednisone/B2 agonists are tolerated and can be given

395
Q

What pre-existing respiratory disease is responsible for 10% of maternal death

A

Cystic fibrosis

396
Q

What thyroid disorder is most common in pregnant women

A

Hyperthyroidism

397
Q

Which type of diabetes should be very closely monitored in pregnant women

398
Q

Pregnant patients with a history of a renal transplant tend to do well if the transplant happened how long before pregnancy

A

2 years before pregnancy

399
Q

What pre-existing neurologic disease’s medications are contraindicated during pregnancy?

A

Epilepsy - anti-seizure meds are contraindicated

400
Q

Risks associated with morbidly obese pregnant patient

A
  • Decreased blood volume per kilo
  • Increased risk of diabetes
  • Difficult epidural placement
  • Difficult vaginal delivery

Anesthesia Practice (9 decks)

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