APEX : ANES. FOR SURGICAL PROC. Flashcards
2 Blocks for knee arthorscopy
Femoral nerve Block
Fascia Iliaca BLock
What is SAMTER syndrome or triad?
ANA
Asthma
Nasal polyps
Aspirin allergy
SAMTER syndrome patients are at increased risk of
Intraoperative bronchospasm
Femoral nerve supplies the
ANTERIOR THIGH from the inguinal ligament to the knee
It is a modified femoral nerve block
Fascia Illiaca
Most blood loss associated with spinal surgery occurs during what phase?
Decortication phase.
Meta_____for wrist; meta ____for ankle
Carpal ; tarsal.
Dorsum of foot is innervated by the ______What area is missed?
Superior Peroneal nerve ; ONLY AREA MISSED is the interdigit cleft between 1 and 2nd toe
Type specific partially cross matched blood takes
1-5 minutes in the lab, and is the best in emergency
2 blood transfusion to consider when in an emergency situation
Type specific partially cross matched blood
O- blood
Stellate ganglion is located
just anterior to the tubercle of C6 and distal to the carotid artery
A successful stellate ganglion block leads to
Horner’s syndrome
Horner’s syndrome
Anhidrosis Nasal stuffiness Facial vasodiation Increased skin temperature PTOSIS Miosis
Block to treat PDPH
Sphenopalatine block
What is the plexus block to treat UPPER abdominal pain in regions such as stomach, color, esophagus
Celiac Plexus block
What comes together to form the stellate ganglion?
Inferior Cervical ganglion FUSES with the 1st thoracic ganglion
What is the plexus block to treat LOWER abdominal pain
Hypogastric block
Performed for patient with pituitary tumor
Transphenoidal Hypophysectomy
Total Thyroidectomy most significant immediate issues
RLN injury
Acute Hypocalcemia
Hypocalcemia on QT
Prolonged QT
Hypocalcemia on BP; response to beta agonist
Hypotension; decreased
When does HYPOCALCEMIA most commonly occur after total thyroidectomy?
6-12 hours after
When performing a paravertebral block the needle should
needle should pass medially below the TP, and it should never advance more than 2cm beyond the transverse process
The surgeon has dissected the neck and is between the 4th and 5th tracheal rings during an airway procedure, what should be your FIRST ACTIONS?
Ask surgeon to change from cautery to a scapel.
The carotid sinus is a nexus of nerve endings carrying info
afferent information from the SINUS NERVE OF HERING, to the Glossopharyngeal nerve (CN 9) to the VASOMOTOR CENTER in the medulla
Surgical stimulation near the carotid sinus leads to
Elicit the standard baroreceptor, response of decrease HR and vasodilation.
Carotid body vs carotid sinus
Carotid body is a CHEMORECEPTOR, sinus is a baroreceptor, Primarily responsive to O2, secondary response to Co2 and pH
Pneumoperitoneum in the patient whose normovolemic
Increases venous return and cardiac filling however, because SVR is also increase, it opposes an increase in CO
What intraabdominal pressure decreases GFR and uO
> 5 mmHg
Procedure associated with emergency excitement
breast, abdominal surgery and preop administration of midazolam
Post op delirium incidence higher with
Total knee and hip arthroplasty
Rigid bronchoscopy most appropriate anesthetic plan
TIVA with propofol and remifentanil
Anesthesia for Testicular torsion surgery
General anesthesia OR
SPERMATIC CORD BLOCK AND*** GENITOFEMORAL BLOCK , OR illioinguinal block or Illiohypogastric block
Increasd number of B lines indicates
pulmonary edema.
Greatest risk for the patient undergoing lumbar spine surgery?
Central Retinal Artery Occlusion
What greatly increased the risk of Central Retinal artery occlusion
Horseshoe headrest.
Central Retinal artery occlusion is due to
External compression of the globe from improper head position.
Ischemic Optic neuropathy occur because of p
Poor ocular perfusion pressure NOT EXTERNAL COMPRESSION
Risk factors for ischemic optic neuropathy?
Male Obese Long duration High blood loss Low colloid administration Wilson frame
CABG and TEE best view for evaluating LV filling and contractile function.
Transgastric Short Axis View (TG SAX)
Transgastric Short Axis View (TG SAX) how do you get ?
advance 4-6 cm in the stomach
Preload changes are easier to identify when viewing LV in the information is better
Cross section rather than Long axis view
IN prone position, the abdomen should be freely hanging why?
So that venous pressure is not elevated.
Pt with hypothyroidism are sensitive to
Sedatives, narcotics > consider awake fiberoptic intubation,
What is the most important initial consideration for a patient undergoing pancreatectomy for ductal pancreatic cancer?
Aspiration precautions at induction
Palliative phase of pancreatic cancer block
celiac plexus block
Benign intracranial hypertension aka
pseudotumor cerebri
Treatment of intracranial htn include
Drainage with a ventriculostomy
To maintain CBF even though they will decrease CMRO2
VA at 0.6 to 1 MAC
Hyperventilation during the initial treatment only of increase ICP
PaCo2 30-35mHg
What is temporary occlusion during aneurysm clipping surgery? How long should it last?
A clamp to halt blood flow through the aneurysm is applied while resectting it. It should last less than 10 minutes
Pt post radiation therapy issue
Irradiated tissue become
Friable tissue prone to bleeding
soft tissue bed stiff and fibrotic
Key anesthetic consideration with face transplant
Avoidance of vasopressors.
Facial surgeries treat hypotension with
Fluid and blood products
Most serious post op risk of transphenoidal hypophysectomy is
Cerebral spinal fluid leak. (can become chronic or cause meningitis)
The most serious complication of stereotactic surgery is the development of
Intracerebral hematoma
Large dose of vitamin____ associated with bleeding
E
Herbal that inhibit platelet aggregation leading to bleeding
G'S Ginkgo Ginseng Garlic Saw Palmetto
Guidelines for cardiac surgery blood glucose control
Below 180 during CPB
Below 150 if > 3 days of ICU are necessary
Video Assisted thoracoscopy vs open thoracic surgery
Rib spreading not required
Improved pulmonary function
Downside of VATS
Increased difficulty with access to centrally located tumors. Dissection of chest wall adhesions is also more difficulty
Still required after VATS
Post operative chest tube
Albumin half life is
3 weeks
Late indicator of hepatic synthetic function
Albumin
What is a better indicator of hepatic synthetic function? Albumin vs prothromin
Prothrombin because it reflects the presence of factor VIIa with a half life of 4 hours
Release as a result of hepatocyte injury
Alanine Aminotransferase )ALT_
Chemo drugs associated with pulmonary toxicity
Bleomycin
Chemo drugs associated with cardiac toxicity
Doxorubicin
Chemo drugs associated with renal toxicity
Cisplastin
Anesthetic considerations in lung CA patients 4
Mass effects
Metabolic effects
Metastases
Medications
Nd: YAG laser, what do you apply to the eyes?
Green gloggles
Wet 4x4 followed by green goggles. (everyone should be wearing green goggles, for the profession)
Laser and goggles color
CRAG CO2 --- CLEAR Ruby --> RED Argon --> AMBER Nd:YA"G" --> GREEN
In a patient with intracranial tumor and headache, which preop medication is not recommended. and why>
Fentanyl, because of the resp depression which lead to increase CO2 which would further increase ICP
Retrograde approach to cardioplegia cannulation of
Cannulation of the coronary sinus.
If coronary sinus is cannulated prior to arresting heart you can get____? If becoming unstable?
Afib; synchronized cardioversion
During retrograde cardioplegia, the cardioplegia solution travels from
RVC the veins from the capillary beds , protect myocardium distal to the occlusion
Protect myocardium distal to the occlusion
Retrograde cardiooplegia.
Anterograde approach involves cannulation of the
Aortic root
Anterograde cardioplegia, the cardioplegia solution travels from the
arteries to the capillary beds (AAC)
What has been proven to reducing the chance of surgical site infection
High Fraction of Inspired oxygen
Tissue oxygenation is dependent on
Dissolved O2 in the blood and is NOT dependent on the presence of Hemoglobin
2 that causes vasoconstriction and decrease peripheral blood flow, which are detrimental to the tissues
Hypovolemia
Hypothermia
Tests to be drawn after induction for CABG
ABGs
ACT
Electrolytes
What is A thymoma?
Thymoma is a thymus tumor, usually found in the upper chest,, It is an anterior mediastinal mass.
After induction of a patient with thymoma, SBP falls to 50 mmHg, why is that ? You can ventilate, what is the causes
Once muscle tone is lost by deep anesthesia, or neuromuscular blockade, the weight of the tumor, can compress the SVC, and /or PA causing CV collapse
Thymoma mass may compress
Trachea.
If patient with thymoma mass can be ventilated , what is the most likely cause?
Vascular compression
Which lab has to be ABNORMAL to diagnose FAT EMBOLISM?
FAT MICROGLOBULINEMIA
CRITERIA that must be present to formally diagnose fat embolism syndrome
One major and 4 minor criteria, plus fat microglobulinemia,
Gurd’s Diagnostic Criteria: FAT EMBOLISM SYNDROME
Major and minor criteria.
Major Criteria
Respiratory insufficiency
Cerebral involvement
Petechial rash
Minor Criteria Tachycardia Fever Jaundice Retinal changes Renal changes
Superior hypogastric plexus extends from
L5 to S1
Drugs that can reduce the Efficacy of IVF
MORPHINE SEVOFLURANE DESFLURANE NSAIDS Droperidol Metoclopramide
Prerenal Failure urine sodium and urine osmolarity
Low urine sodium
High urine osmolarity
Crepitus (Subcutaneous emphysema ) indicates
Air leak
Steps to take when there is crepitus during Laparoscopic case : 5 first steps
øDecrease intraabdominal pressure , Terminate pneumoperitoneum if possibleD/C Nitrous (It can øincrease SC emphysema)
øPlace on a 100% FiO2
øEvaluated for a pneumothorax
øIncrease MV to treat hypercarbia
Even this can cause air leak during long cases
Low insufflation pressure
In the patient with SCOLIOSIS, what is STRONGEST PREDICTOR of the need for POSTOP VENTILATION
Vital capacity < 40% of predicted
Used to predict Post op respiratory complications in thoracotomy patients undergoing lung resection procedures.
FEV1, and DLCO
In the absence of formal exercise testing , the _____Test can be used
stair climbing test (2-3 flights)
With the stairs climbing test, what indicates an increase of morbidity and mortality for lung resection patients?
A fall of 4% or more in SPO2
Surgical Procedures with its unique considerations–: TOTAL THYROIDECTOMY
POSTOP Hypocalcemia
Surgical Procedures with its unique considerations–: Shoulder Arthroscopy
Hypotensive bradycardic event
Surgical Procedures with its unique considerations–: HIP ARTHROPLASTY
Bone Cement Implantation syndrome
Surgical Procedures with its unique considerations–: LUMBAR FUSION
Ischemic optic neuropathy.
COPD patients lung recoil and FRC
Increase FRC, poor, recoil
PEEP and COPD
Can cause overdistention and pulmonary capillary compression, impairing gas exchange
Initial vent setting for OLV include
VT, RR, PIP, PEEP, and PP
Vt 5-6 ml/kg of ideal body weight RR 12 bpm PIP < 35 PP <25 PEEP +5 (O peep for COPD patients)
Details to be included for a patient undergoing a kidney transplant?
Time of last dialysis
Euvolemic body weight.
How to avoid Acute lung injury and hypoxia during one lung ventilation? FiO2, TV, PEEP, Recruitment maneuvers, CPAP, CO2
FiO2< 1.0
Low TV
use of PEEP
Permissive hypercapnia,
OLV and CPAP
Apply CPAP to Nondependent lung.
Why is patient having right sided lung surgery most likely to desat?
Right lung is larger than the left, thus proportionally there is a greater amount of perfusion to the right lung.
VATS and allowable anesthesia techniques?
Local
Regional
General
VATS performed under local anesthesia, what should not be attempted?
Lung deflation
VATS for minor transthoracic biopsy is
Intercostal nerve blocks, 2 levels above and below the incision is sufficient
HIGH FIO2 to treat V/Q mismatch
Drugs that should be administered to prevent the initial CV response to ECT?
Initial response is bradycardia and excess salivation, so GLYCOPYRROLATE (It is antimuscarinic, and does not cross the BBB)
The only antiplatelet agent not contraindicate a neuraxial anesthetic?
ASA
Lidocaine with epi for SAB lasts for approximately
1.5 h
Tetracaine with epi for SAB lasts for approximately
2-3 hours
What is the most important airway assessment for patient with oropharyngeal CA undergoing neck dissectoin
Diagnostic images of the airway (because external exam may not reveal significant impediments to tracheal intubation.
Auricular lobule aka
Ear lobe
Ear lobe is innervated by ____-? What block this nerve.
Greater auricular nerve
Blocking the superficial Cervical plexus will cover this nerve
Hysteroscopic sterilization aka
Essure system
Hysteroscopic sterilization aka essure system should not be performed in office
High anxiety
Cervical os stenosis
Advantage of US when it comes to paravertebral block?
Allow to measure depth of the transverse process
US guided recommended for patient with
Scoliosis and Obesity.
Patient is undergoing large volume liposuction with a total of 55mg/kg of lidocaine, When will peak serum lidoacaine levels occur?
12-14 hours
Maximum recommended dose for lidocaine used for tumescent anesthesia is
55 mg/kg
What is the most important facet of anesthesia care for a patient undergoing endovascular treatment of a posterior cerebral artery arteriovenous malformation>
BLOOD PRESSURE (May need both deliberate hotn, and deliberate htn)
What is the Arnold-Chiari malforatiom
result of the hindbrain being displaced downward into the FORAMEN MAGNUM, resulting in hydrocephalus.
Fournier Gangrene
Critically ill, will need GETA with vascular monitoring
Fournier gangrene shock
Septic shock
Features of AICD that should be disabled prior to surgery
Anti-tachycardia
Shock therapy
EMI monopolar vs bipolar
Monopolar most likely to cause EMI
If you won’t have access to pacemaker settings and stuff
Place external pads
Ear probe vs finger probe alert for low sat1
Ear 10-20 seconds
Finger 20-50 seconds
What is TIPS and what does it treat?
Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat ascites.
What is done during TIPS procedure?
Stent placed between the portal vein and hepatic vein, in an effort to bypass increased hepatic vascular resistance.
3 complications of TIPS procedures
Hemorrhage
Pneumothorax
Dysrhythmias
Most common comorbidities for patient presenting for VASCULAR surgery is
CAD
Nerve courses laterally around the knee
Common peroneal nerve
Flexed lateral decubitus position
Common peroneal neuropathy
Cervical plexus stretch
Brachial plexus compression
Flank positioning for abdominal surgery is associated with
significant respiratory embarassment, including dependent atelectasis and pneumothorax.
What should be placed for the Flexed lateral decubitus position and why?
Chest roll under the thorax (Caudad to the axilla), and NOT TO THE AXILLA because weight of thorax can cause compression of the injury to the IPSILATERAL brachial plexus
Hazards with CT
Radiation exposure
Hazards with MRI
Remote monitoring
CT doses of radiation compared to a chest XRAY
Xray 0.1mSv. vs. 7-8 mSv
CLOT with Afib will be most likely be present where
Left atrial appendage
The best view to visualize the left atrial appendage is the
Mid-ESOPHAGEAL LAX
When selecting an IV catheter most important factors are
Size and length of the catheter
Flow is directly proportional to the
Radius to the fourth power.
What is the most likely reason for postoperative airway obstruction in a patient with previous radiation therapy for head and neck cancer?
Impaired lympatic drainage.
Radiation to the head and neck can damage the
Extensive nexus of lymphatics in the neck, leading to impaired drainage and accumulation of lymph
Is usually the result of a mouth gag
Lingual edema
May result from the anterior approach to the cervical spine surgery??
Palatal edema
Airway hematoma is associated with this vascular procedure
CEA
Deep hypothermia requires patient’s core temperature to be____For how long, max _____
12-20 degrees C; 20-30 minutes, 80 max.
Meds for cerebral protection include
SAD LiMa Steroids Antegrade Cerebral perfusion Drugs that reduced CMRO2 (Propofol, barbiturates, etomidate) Lidocaine Mannitol.
Another example of CNS protection is placement of
lumbar spinal catheter to drain CSF, in patients at risk for hypoperfusion of the spinal cord such as THORACOABDOMINAL AORTIC ANEURYSM.
Risk of airway or laryngeal edema one should ascertain whether airway edema may
Significantly decrease airway patency in the absence of an ETT.
Important step for any case with Risk of airway or laryngeal edema make sure you check
For an air leak. The absence of an air leak with the cuff fully deflated indicates significant airway edema, with the risk of partial or complete airway obstruction after extubation.
Full recovery and TOF ratio?
A TOF ratio >0.9 at the adductor pollicis suggests full recovery from NMB. A sustained headlift for 5 seconds is an acceptable end point (50% may still be blocked though)
During a TIPS procedure, the shunt is introduces via the
JUGULAR Vein, threaded through the RIGHT ATRIUM –> IVC, hepatic vein.
During the TIPS procedure, what could occur with catheter placement?
Pneumothorax or IJ injury, passage through the RA can cause cardiac arrhythmias, If the portal vein is punctured rather than cannulated, hemorrhage can occur.
Hepatic cryotherapy is associated with complications of
Hypothermia
Hepatic resection complications
Venous air embolism due to aspiration through open hepatic veins
Adverse effect of hepatic resection since regenerative liver utilizes
phosphate to synthesize new cells.
Drugs that decrease the peripheral conversion of T4 to T3 are
Dexamethasone
Propranolol
Propothiouracil (via NGT)
Drugs that inhibits the SYNTHESIS of thyroid hormone
Potassium iodide
Methimazole.
Patients with grave’s disease remember to treat hypotension with
Direct-acting agents such as Phenylephrine because catecholamines may cause sudden sympathetic surges in the patient with hyperthyroidism
Several hours following endoscopic sinus surgery , a patient presents with severe pain and pressure in his left eye, with a progressive risk in intraocular pressure. What is the BEST treatment for this complication?
Lateral Canthotomy
Bleeding into the retrobulbar space thrusts the eye anteriorly (PROPTOSIS) leading to
Compression of the optic nerve, reduces blood flow through the orbital vasculature
Causes of retrobulbar hematoma?
Ocular orbital and sinus procedures, retrobulbar anesthesia, AV malformaitons.
What is the minimum recommended ACT for the patient undergoing Carotid Artery Angioplasty stenting?
250
Compared to Carotid endarterecomty, what is a less invasive way to treat carotid stenosis?
Carotid artery angioplasty stenting
The patient for Carotid artery angioplasty stenting is anticoagulation with
Heparin 50-100 units/kg to achieve a minimum ACT Of 250
One major concern for the patient undergoing Carotid artery angioplasty stenting is
The balloon will inflate the carotid artery, which will activate the baroreceptor reflex, which will manifest with bradycardia and hypotension.. Give glycopyrrolate or atropine prophylactically.
What is the most common complication of Carotid artery angioplasty stenting?
Stroke
The immediate CV response to aortic cross-Clamping is an ______What is the most appropriate treatment?
increase in afterload and myocardial work; Treat with vasodilators with the goal of decreasing SVR and cardiac work.
Caveat to giving vasodilators during cross-clamping of aorta.
Circulation distal to the cross-clamp is dependent upon perfusion pressure. The pressure must be maintained at adequate levels to prevent renal and mesenteric ischemia.
What is LVAD?
mechanical device that unloads the failing heart by pumping blood from the left ventricle to the aorta. The inflow cannula is inserted into the apex of the left ventricle. From here, blood flows through the LVAD pump and is returned to the aorta through the outflow cannula.
LVAD, Optimization of what is critical?
intravascular volume is critical, because an imbalance between preload and pump speed can lead to complications. For instance, the combination of low preload with a relatively high pump speed can produce a suction event (LV suck down). This is where part of the LV is sucked into the LV cavity, where it occludes the inflow cannula.
LVAD Pump flow is highly dependent on
adequate LV preload pump speed (RPMs), and the pressure gradient across the pump (afterload).
LVAD, Consequences of a suction event include 2
hypotension and ventricular dysrhythmias.Additionally, a leftward shift of the interventricular septum alters RV geometry, which reduces RV contractility and compliance.
As an aside, LVAD patients are at high risk for____What is the management?
developing GI bleeding.Management includes fluid administration (to increase preload) and reducing pump speed.
When compared to LAPAROTOMY (open approach) , Laparoscopy is associated with
Improved surgical outcomes minimal stress response Lower opioids requirements Less Fluid shifts Less post op resp dysfunction
Disadvantages of laparoscopic procedures
Gas embolism
referred pain from insufflation
PONV
Regional eye block complications are
Intra-arterial injection
Globe penetration
Retrobulbar hemorrhage
Superficial hemorrhage.
Regional eye block complications: Intraarterial injection would lead to
Seizure activity
Regional eye block complications: Globe penetration would lead to
Retinal detachment
Regional eye block complications: Retrobulbar hemorrhage would lead to
Circumorbital hematoma
Regional eye block complications: Superficial hemorrhage would lead to
Globe proptosis
While it may not be possible to ascertain whether one has punctured the globe during a block, the provider must be highly aware of the conditions under which this risk is prominent. This includes a childhood history of
myopia, a deeply recessed globe, or an axial length of > 26 mm (typically available on the surgeon’s preoperative US report)
Superficial hemorrhages are demonstrated as the so-called
“black eye” or circumorbital hematoma.
In a retrobulbar hemorrhage, __________ is common along with an entrapped lid, both causing rapid and significant increases in IOP. These patients may require a.
proptosis of the globe;
lateral canthotomy to relieve intraocular hypertension
Methods recommended to reduce blood loss during Endoscopic sinus procedure?
Elevate head of the bed
Mucosal vasoconstriciton (cocaine, epinephrine, phenylephrine)
Total IV anesthesia
4 intraoperative MONITORING techniques for carotid endacterectomy?
EEG
SSEP, and MEPs
NIRS
Transcranial doppler
4 intraoperative MONITORING techniques for carotid endacterectomy? cerebral oximetry
NIRS
4 intraoperative MONITORING techniques for carotid endacterectomy? EEG
Electrical activity
4 intraoperative MONITORING techniques for carotid endacterectomy? Transcranial doppler measures
Blood flow in large vessels
4 intraoperative MONITORING techniques for carotid endacterectomy? SSEP and MEPs monitors
Overall cerebral functional integrity.
The purpose of neurological monitoring during CEA is to determine the
integrity of cerebral perfusion and to help decide the need for carotid shunting.
The gold standard for neuromonitoring for CEA is an
awake patient with whom you can directly communicate.
Intercostal block: order of intercostal structures.
The order of intercostal structures is VAN (cephalad to caudad); similar to the order in the femoral canal—VAN—from medial to lateral.
Key considerations when performing the block (to minimize the risk of pneumothorax) include:
The needle should enter along the caudal rim of the rib at an 80° angle to the skin.
The needle can also be walked off the inferior edge of the rib 3 to 5 mm before injection.
The intercostal space is triangular:
Lateral border = external and intercostal muscles
Medial border = posterior and inner intercostal muscles
Posterior border = upper border of the next rib
The order of intercostal structures is VAN (cephalad to caudad); s
imilar to the order in the femoral canal—VAN—from medial to lateral.
An intercostal block is not considered safe in what kind of patients and why>?
outpatients due to the risk of pneumothorax.
Key considerations when performing the block (to minimize the risk of pneumothorax) include:
The needle should enter along the caudal rim of the rib at an 80° angle to the skin.
The needle can also be walked off the inferior edge of the rib 3 to 5 mm before injection.
Surgeries that are associated with the GREATEST risk of
developing POST-OP Chronic pain syndromes?
SAPHENOUS VEIN STRIPPING
MASTECTOMY WITH IMPLANTS
LIMB AMPUTATION
Expected adverse effects of gas insufflation during colonoscopy include
Decrease Heart rate
Increased Gastric secretion.
GI distension (due to gas insufflation) evokes.
peristalsis and increases secretions along the entire GI tract. This includes increases in salivary secretions that can increase the risk of laryngospasm in the patient with an unprotected airway (which is MOST patients in the endoscopy suite).
Enteric nervous system fibers (non-adrenergic, non-cholinergic) migrate to the
GI tract along the vagus nerve, and every vagal fiber may connect to up to 8000 neurons within Auerbach’s plexus. The vagal response to stretch of this smooth muscle layer often causes bradycardia or AV block, but typically not tachydysrhythmias.
The most IMPORTANT Guiding principle of “damage control” resuscitation is
Minimize crystalloid administration
Damage control resuscitation is designed to prevent
pulmonary edema, ARDS, coagulopathy, and multiple organ failure due to the administration of large volumes of crystalloid during fluid resuscitation.
The immediate goals of damage control resuscitation are to
minimize crystalloid administration and infuse RBCs, plasma, and platelets in a 1:1:1 ratio.Conceptually, the patient bleeds whole blood. Therefore resuscitation should revolve around delivering the equivalent of whole blood back to the patient.
Thawed plasma and liquid plasma contain only how much clotting factors?
30% of normal clotting factor activity,
FFP and clotting factors,; important consideration has but
100% of normal clotting factor activity; it takes 45 minutes to thaw.
May be given in hemorrhagic patient to control bleeding
Txa
Intraabdominal hypertension is measured with a
Patients who are mechanically ventilated on presentation to the OR should be placed on the closest possible settings to their ICU settings. These patients require sufficient muscle relaxation so that skeletal muscle tension does not contribute to a rise in IAP.
bladder manometer.
IAB > 10 mmHg
IAB > 10 mmHg reduces hepatic blood flow
IAP > 15 – 20 mmHg
reduces renal blood flow (enough to cause oliguria)
Patients who are mechanically ventilated on presentation to the OR should be placed on the closest possible settings to their ICU settings. These patients require sufficient muscle relaxation so that
skeletal muscle tension does not contribute to a rise in IAP.
What partial pressure of carbon monoxide is required to achieve 100% hemoglobin saturation
0.4 mmhg
The point to understand is that extremely small concentrations of carbon monoxide are capable of
completely saturating the patient’s hemoglobin. It’s important to understand that even if the patient has a normal PaO2, the patient with carbon monoxide poisoning can suffocate at the cellular level!
To review, the P50 of hemoglobin is_____mmhg; that is, at a dissolved oxygen level of 26-27 torr (mmhg) normal Hb is ___%saturated with oxygen.
26.5 mmHg: 50%
At a PaO2 of 60 mmHg, hemoglobin is about_____% saturated. At a PaO2 100 mmHg, hemoglobin is about saturated___%. It’s always good to remember the science behind the clinical scene.
90; 97.5%
What is the minimum target systolic BP for a 65-year old trauma victim in order to reduce mortality?
110 mmHg
Civilian trauma patients > 65 years of age maintained with a SBP ≥
110 mmHg had lower mortality than those maintained at lower SBP.
The anesthesia provider should elicit what information during the preoperative assessment of a pacemaker patient?
Manufacturer and model
Pacer impulse causes mechanical systole
Patient’s underlying rhythm
There are very clear recommendations on preanesthetic evaluation related to pacemaker and ICD management. Key information includes:
The patient’s underlying rhythm (if the pacemaker fails, will the patient be in cardiac arrest?)
Manufacturer and model (PRN contact information)
Assurance that a generator stimulus effectively triggers myocardial contraction (no loss of capture)
When relevant - lead location/s (will placement of a central line or PA catheter potentially dislodge a lead?)
Why are current electrolytes (not CBC) important for patients with a PM
because alterations in serum potassium can change the triggering threshold for capture (this leads to failure to capture).
It’s imperative that beat-to-beat verification of mechanical systole be monitored by
plethysmography or an arterial line waveform (NOT just an EKG tracing).
In which emergency anesthetic should hyperventilation to a PCO2 < 35 be avoided? (Select 2)
Traumatic brain injury
Arteriovenous malformation
Anesthetic management of a thoracic aneurysm repair should focus on avoidance of:
Hypertension and tachycardia
Anesthetic management of a thoracic aneurysm repair should focus on avoidance of:
Hypertension and tachycardia. An aneurysm is most likely to burst when the patient is hypertensive (think law of Laplace), and myocardial ischemia is most likely to occur when the heart rate is rapid. Thus, avoidance of these conditions is paramount to a successful outcomes
A healthy patient is undergoing laparoscopic hysterectomy with a carbon dioxide pneumoperitoneum in the Trendelenburg position. How many minutes after insufflation is complete does an increase in PaCO2 indicate pathology versus normal CO2 equilibration?
15 to 30
After abdominal insufflation is complete, the PaCO2 reaches a plateau after
15 – 30 minutes. EtCO2 also plateaus at this time.
After insufflation, If there’s a significant rise in PaCO2 or EtCO2 after this time (again 15 – 30 minutes), then you should
investigate for an air leak (a key sign is subcutaneous emphysema).
A patient has been intubated with an 8.5 mm endotracheal tube for a 7-hour procedure. He met extubation criteria and was subsequently extubated. He is awake, stridorous, using accessory muscles, and has SpO2 of 85% on a humidified O2 face mask. The next IMMEDIATE step is to:
Nebulize 0.5 mL of 2.25% solution racemic epinephrine. This patient has post-extubation croup—inflammation and edema of the glottis and subglottic trachea.
Immediate treatment includes humidified oxygen and aerosolized racemic (levo- and dextrorotary) epinephrine.
Which risk factor for peripheral vascular disease is MOST likely to elicit progression to limb ischemia or amputation?
SMOKING
Select the MOST appropriate intraoperative monitors for a 75-year old patient with end-stage liver disease and COPD undergoing emergent intra-abdominal surgery. (Select 2.)
Transesophageal echocardiography
Intra-arterial blood pressure
ESLD (End Stage Liver Disease) is associated with
Systemic vasodilation and hypotension, which warrants intra-arterial blood pressure monitoring.
Poor predictors of fluid status or responsiveness, while
CVP and the pulmonary catheter
TEE is a sensitive monitor of
preload, contractility, and regional wall motion.
TEE has been safely used in patients at risk for esophageal varices as long as the
transgastric view is avoided.
Which patient condition is a contraindication for craniotomy in the sitting position?
Patent Foramen Ovale
Venous air embolism
venous sinuses open coupled with low venous pressure
PFO is a ___to ____shunt
Right to left
% of patients with probe PFO
20%
Patent PFO causing
Aspirated air can pass directly from the central veins to RA to the LA/LV this is called a Paradoxical air embolism. Can lead to devastating stroke or death
Paramount importance patient’s ability to understand and cooperate with a surgeon is paramount. A patient with a neurological condition that cannot be consciously controlled generally requires GA (i.e., restless leg syndrome).
Inability to lay flat
Limited language ability
Open eye injury
Restless leg syndrome
Required in any open globe injury
General anesthesia
Regional ophtalmic anesthesia and AC
It’s generally accepted that regional ophthalmic anesthesia can be safely administered to anticoagulated patients.
Which option initiates HPV?
Alveolar hypoxia
Systemic HYPOXIA causes _______while alveolar hypoxia causes
Vasodilation; vasoconstriction
HPV increases V/Q matching by
Reducing shunt.
Shunt occurs when
Pulmonary blood perfuses unventilated alveoli
Pulmonary HTN is defined as a mean pulmonary arterial pressure of at least
25 mmHg
Pulmonary HTN PAOP of no more than
15 mmHg
When properly placed distal tip of the LMA will sit at the
Cricopharyngeus muscle (Upper esophageal spincter)
Disposable Proseal LMA version is
LMA supreme
Classic LMA max pressure is
20cm
Proseal LMA max pressure is
30 cm
Which LMA has a gastric tube opening for easy gastric decompression?
Proseal LMA
IN this condition , supplemental oxygen is least likely to increase arterial oxygenation
Pulmonary edema
Right to Left shunt and oxygenation
A right to left shunt that exceeds 50% typically won’t respond to further increases in FiO2
Fiver Primary causes of Hypoxemia and examples
Low FiO2 -High altitude Hypoventilation - opioid overdose Diffusion impairment - Pulmonary fibrosis V/Q mismatching - COPD Shunt - Pulmonary edema.
Acute intrinsic lung disease
Pulmonary disease
Aspiration pneumonia
ARDS
How long do you wait to repeat clear non particulate antacid ?
1 hour
Use Alveolar gas equation and your knowledge of the A-a gradient to estimate PaO2.
PAO2 = FiO2 x (Pb - PH2O) - (PaCO2 / RQ)
PAO2 = 0.28 x (760 - 47) - (80 / 0.8)
PAO2 = 200 - 100 = 100 mmHg
The A-a gradient is the difference between alveolar oxygen and arterial oxygen. If the A-a gradient is 35, then we subtract this value from PAO2 to arrive at PaO2
100 mmHg - 35 mmHg = 65 mmHg
During the administration of an inhalation anesthetic using 6.5% desflurane in oxygen, nitrous oxide is introduced into the gas mixture. The effect of the addition of nitrous oxide on the concentration of desflurane delivered is:
to cause a decrease in desflurane concentration
When a carrier gas other than 100% oxygen is used, a clear trend toward reduction in the desflurane vaporizer output is seen. This effect is thought to be secondary to the change in gas viscosity that occurs with the introduction of nitrous oxide and is most pronounced at low-flow rates. A reduction of as much as 20% may be produced.
The 3 major variables of the equation are the
atmospheric pressure
amount of inspired oxygen
and levels of carbon dioxide.
Normal A-a gradient =
(Age + 10) / 4
Laparoscopic surgery and LMA
Can be used in procedure is less than 15 minutes long
Muscarinic -2 stimulation causes
bradycardia
Muscarinic receptors are linked to G-proteins: M2, M2, M3
M2 and M3 causes bronchoconstriction, miosis and facilitates GI and GU function
Precedex and adenylate cyclase activity
Reduces
A-a gradient increases
5 to 7 for every 10% increase in FiO2.
Can aggrevate Left subclavian steal syndrome
Neck Flexion and exercise
Left subclavian steal happens when there is an occlusion of the
left subclavian proximal to the origin of the left vertebral artery. This results in reverse flow where blood in the left vertebral artery flows away from the brain and towards the left subclavian artery. This increases the risk of cerebral ischemia.
Left Subclavian steal Symptoms include
syncope, vertigo, ataxia and/or hemiplegia. Arm ischemia is also present. Neck flexion and exercise can exacerbate symptoms.
Signs of Left subclavian steal
The pulse is absent or significantly weaker in the affected arm and blood pressure can be 20 points lower than the contralateral arm.
What is the cardinal feature of myxedema coma?
Hypothermia
What laboratory finding is characteristic of acute pancreatitis?
Elevated serum amylase
Which of the following conditions can cause a decrease in the specific gravity of the cerebrospinal fluid?
Liver disease
What anesthetic type is the preferred alternative to performing a digital block in pediatric patients?
Transthecal block
The primary risk of a digital block is
nerve injury or disruption of the arteries at the base of the finger.
When performing a transthecal block no terminal arteries are close enough to the
injection site to risk disrupting the arterial supply to the distal finger. Also, a transthecal block only requires one injection instead of the multiple injections required to produce a digital block.
ou are called to the emergency room to evaluate a burn victim with an estimated 30% injury of body surface area. The patient’s SpO2 is 97% and respiratory rate 18 breaths per minute with evidence of singed facial hair, mild dysphagia, and an occasional cough. The FIRST intervention you should provide is:
high-flow oxygen by face mask.
Signs of inhalation injury
(singed facial hair, mild dysphagia, and cough). highest possible FiO2 via facemask to displace CO from the Hgb molecule.
The affinity of Hb is about
200 times higher for CO than it is for O2.
Pulse ox and COHgb
The pulse oximeter can’t identify COHb, so a normal SpO2 does not preclude a high carbon monoxide level.
What is required to measure COHb.
A co-oximeter
The surgeon has just transected the appendix during an emergent laparoscopic appendectomy when you note a sudden development of neck and facial flushing. Blood pressure is falling, and the peak inspiratory pressure during ventilation is rising. The suspected cause is:
carcinoid syndrome.
Two-thirds of carcinoid tumors originate in the______and half occur in the _____
GI tract, and almost half of these occur in the appendix.
Key characteristics of carcinoid syndrome include:
Cutaneous flushing of the head and neck (histamine and kinins)
Hypotension (histamine and bradykinin)
Bronchoconstriction (histamine and serotonin)
Carcinoid syndrome: Bronchoconstriction is due to
Histamine and serotonin
______is a unique risk of radical neck dissection.
Acute postoperative hypertension
Surgeries at risk for acute post-operative hypertension include
carotid endarterectomy, abdominal aortic surgery, and intracranial surgery.
Is a potential intra-operative complication of radical neck dissection.
Venous air embolism
Entrainment of room air into the systemic circulation is a risk whenever an
open vessel communicates with the atmosphere and the head is positioned above the heart.
Retraction of the vessels at the operative site (especially if the retractors are in place for a long time) can potentially contribute to
venous thrombosis.
Succinylcholine can increase serum K+ by_____ succinylcholine is safe to administer to an ESRD patient as long as
0.5 mEq/L
Succinylcholine is safe to administer to an ESRD patient as long as
They have been dialyzed within the last 24 hours.
The current serum K+ is ≤ 5.5 mEq/L.
NMB agent not be administered in renal patients for an RSI.
Pancuronium is 80% eliminated by the kidney (it’s also long-acting), so it should
Is an acceptable choice for RSI in patients with ESRD
Rocuronium (1.2 mg/kg)
When a fire is present, your first priority is to
stop ventilation and remove the endotracheal tube
stop the flow of airway gases
Remove the flammable material from the airway.
pour water or saline or water into the airway.
If this fails to extinguish the fire, then use a CO2 fire extinguisher.
Recurrent ascites can be managed with a.
Other
transjugular intrahepatic portosystemic shunt (TIPS procedure) that introduces a stent between the portal vein and hepatic vein to bypass an increased hepatic vascular resistance
Treatment of ascites includes
fluid restriction, sodium restriction, diuresis, and abdominal paracentesis. Keep in mind that removing a large volume of ascites can lead to hemodynamic instability. Aggressive fluid resuscitation may be required
Surgical management may be life-saving in which acute ischemic stroke situations? (Select 2.)
Acute cerebellar stroke
Malignant middle cerebral artery occlusion syndrome
A large hemispheric stroke can produce what and what does it lead to ?
malignant middle cerebral artery syndrome.In this situation, swelling of the infarcted brain tissue compresses flow through the anterior and posterior cerebral arteries, which leads to a secondary infarction.
Cerebellar stroke can produce a similar situation, where
edema of infarcted tissue occludes flow through the basilar artery.
What is the anticipated blood loss during a revision of a total hip replacement? (Enter your answer in mL)
1,000 – 2,000 mL
For revision of a total hip arthroplasty it can be a bloody procedure. The patient should be
typed and crossed for several units of PRBCs owing to a typical blood loss of 1 to 2 L.
By comparison, blood loss for a primary THA that utilizes a hypotensive technique (not suitable for all patients) can be as low as
200 mL.
What are the MOST important anesthetic considerations for microlaryngoscopy for laser removal of a vocal cord lesion? (Select 2.)
Sharing the airway
Maintaining vocal cord relaxation
Microlaryngoscopy for laser removal of a vocal cord lesion requires ________This is usually accomplished with a ____
immobile vocal cords; short- or intermediate-acting neuromuscular blocker or with remifentanil.
Sharing the airway with another provider necessitates good communication, planning, and a degree of finesse.
Microlaryngoscopy tube, The safest (and most effective method) to ensure adequate oxygenation and ventilation is to
secure the airway with a 5.0 or 6.0 mm MLT (microlaryngoscopy tube).
Like a standard ETT, the MLT is cuffed, however it is
longer than a comparatively sized pediatric ETT. This design helps to prevent inadvertent extubation, particularly if the patient’s head is extended.
Microlaryngoscopy for laser removal of a vocal cord , In some cases, the surgeon will request not to
intubate the airway. In these situations, TIVA with intermittent apnea or jet ventilation are suitable options.
The single MOST important task to perform when responding to a cardiac arrest event in which CPR is in progress is:
Activating the AED.
Most adult patients who suffer cardiac arrest have experienced either ______or _______? what is the best treatment for these rhythms.
ventricular tachycardia or ventricular fibrillation. Defibrillation is the best treatment for these rhythms.
For Afib and vtach , The best outcomes occur when the time from cardiac arrest to defibrillation is
less than 2 minutes. Ironically, this is more likely in a community setting than in a hospital!
The event response team must prioritize the application of the
AED defibrillator pads and activation of the AED.
Even when a traditional crash cart with a manual defibrillator is available, it is faster to
apply a portable AED unit for the initial analysis and shock. “CPR-AED”—everything else is secondary until the rhythm is analyzed and shock delivered (if necessary).
What is the MOST appropriate treatment for severe bradycardia in a brain-dead organ donor?
ISOPROTERENOL
Brain dead patients do not respond to_______ I
atropine, therefore treatment of significant bradycardia requires a direct-acting sympathomimetic agent.
A potent beta-1 agonist is the best choice for brain dead patient
Isoproterenol.soproterenol is a pure beta-agonist, making it more appropriate than epinephrine or norepinephrine, which have mixed alpha and beta effects.
Pure beta-1 agonist
ISOPROTERENOL
Anesthesia consideration in a dental setting include
Shared airway
High Risk for Airway Obstruction
Although most dental patients are______ intubated, this situation is still considered a
nasally; shared airway.
During dental procedures, what may create a potentioal for
Throat packs, dental equipment, and other dental materialsmay inadvertently be left in the airway creating the potential for airway obstruction.
Any patient undergoing sedation or GA requires medical evaluation whether the surgery is dental or not! Despite the risk of bleeding from the highly vascular dental mucosa,_____ is generally not a problem.
CV stability
Position for appendectomy
Trendelenburg with Left tilt
Position for appendectomy
Trendelenburg with Leftward tilt
Position for LEFT COLECTOMY
Trendelenburg with Rightward tilt
Position for gastric sleeve
Reverse Trendelenburg
Elective cardioversion in a stable patient is contraindicated in which scenario?
Digitalis-induced tachydysrhythmia
In the patient with a digitalis-induced tachydysrhythmia,
cardioversion can cause serious ventricular dysrhythmias. Instead of cardioversion, treatment should focus on correcting electrolyte disturbances, acid-base imbalance, and potentially administering digitalis-binding antibody to reduce serum levels and reduce toxicity.
Pharmacological effects of a denervation transplanted heart include
Absence of reflex tachycardia to hydralazine
Lack of response to atropine.
