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SEE/NCE Boards CoreConcepts > APEX : ANES. FOR SURGICAL PROC. > Flashcards

APEX : ANES. FOR SURGICAL PROC. Flashcards

1
Q

2 Blocks for knee arthorscopy

A

Femoral nerve Block

Fascia Iliaca BLock

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2
Q

What is SAMTER syndrome or triad?

A

ANA
Asthma
Nasal polyps
Aspirin allergy

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3
Q

SAMTER syndrome patients are at increased risk of

A

Intraoperative bronchospasm

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4
Q

Femoral nerve supplies the

A

ANTERIOR THIGH from the inguinal ligament to the knee

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5
Q

It is a modified femoral nerve block

A

Fascia Illiaca

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6
Q

Most blood loss associated with spinal surgery occurs during what phase?

A

Decortication phase.

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7
Q

Meta_____for wrist; meta ____for ankle

A

Carpal ; tarsal.

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8
Q

Dorsum of foot is innervated by the ______What area is missed?

A

Superior Peroneal nerve ; ONLY AREA MISSED is the interdigit cleft between 1 and 2nd toe

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9
Q

Type specific partially cross matched blood takes

A

1-5 minutes in the lab, and is the best in emergency

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10
Q

2 blood transfusion to consider when in an emergency situation

A

Type specific partially cross matched blood

O- blood

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11
Q

Stellate ganglion is located

A

just anterior to the tubercle of C6 and distal to the carotid artery

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12
Q

A successful stellate ganglion block leads to

A

Horner’s syndrome

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13
Q

Horner’s syndrome

A 
Anhidrosis 
Nasal stuffiness
Facial vasodiation
Increased skin temperature 
PTOSIS
Miosis
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14
Q

Block to treat PDPH

A

Sphenopalatine block

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15
Q

What is the plexus block to treat UPPER abdominal pain in regions such as stomach, color, esophagus

A

Celiac Plexus block

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16
Q

What comes together to form the stellate ganglion?

A

Inferior Cervical ganglion FUSES with the 1st thoracic ganglion

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17
Q

What is the plexus block to treat LOWER abdominal pain

A

Hypogastric block

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18
Q

Performed for patient with pituitary tumor

A

Transphenoidal Hypophysectomy

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19
Q

Total Thyroidectomy most significant immediate issues

A

RLN injury

Acute Hypocalcemia

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20
Q

Hypocalcemia on QT

A

Prolonged QT

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21
Q

Hypocalcemia on BP; response to beta agonist

A

Hypotension; decreased

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22
Q

When does HYPOCALCEMIA most commonly occur after total thyroidectomy?

A

6-12 hours after

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23
Q

When performing a paravertebral block the needle should

A

needle should pass medially below the TP, and it should never advance more than 2cm beyond the transverse process

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24
Q

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?

A

Ask surgeon to change from cautery to a scapel.

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25
Q

The carotid sinus is a nexus of nerve endings carrying info

A

afferent information from the SINUS NERVE OF HERING, to the Glossopharyngeal nerve (CN 9) to the VASOMOTOR CENTER in the medulla

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26
Q

Surgical stimulation near the carotid sinus leads to

A

Elicit the standard baroreceptor, response of decrease HR and vasodilation.

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27
Q

Carotid body vs carotid sinus

A

Carotid body is a CHEMORECEPTOR, sinus is a baroreceptor, Primarily responsive to O2, secondary response to Co2 and pH

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28
Q

Pneumoperitoneum in the patient whose normovolemic

A

Increases venous return and cardiac filling however, because SVR is also increase, it opposes an increase in CO

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29
Q

What intraabdominal pressure decreases GFR and uO

A

> 5 mmHg

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30
Q

Procedure associated with emergency excitement

A

breast, abdominal surgery and preop administration of midazolam

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31
Q

Post op delirium incidence higher with

A

Total knee and hip arthroplasty

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32
Q

Rigid bronchoscopy most appropriate anesthetic plan

A

TIVA with propofol and remifentanil

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33
Q

Anesthesia for Testicular torsion surgery

A

General anesthesia OR

SPERMATIC CORD BLOCK AND*** GENITOFEMORAL BLOCK , OR illioinguinal block or Illiohypogastric block

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34
Q

Increasd number of B lines indicates

A

pulmonary edema.

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35
Q

Greatest risk for the patient undergoing lumbar spine surgery?

A

Central Retinal Artery Occlusion

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36
Q

What greatly increased the risk of Central Retinal artery occlusion

A

Horseshoe headrest.

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37
Q

Central Retinal artery occlusion is due to

A

External compression of the globe from improper head position.

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38
Q

Ischemic Optic neuropathy occur because of p

A

Poor ocular perfusion pressure NOT EXTERNAL COMPRESSION

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39
Q

Risk factors for ischemic optic neuropathy?

A 
Male
Obese
Long duration
High blood loss
Low colloid administration
Wilson frame
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40
Q

CABG and TEE best view for evaluating LV filling and contractile function.

A

Transgastric Short Axis View (TG SAX)

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41
Q

Transgastric Short Axis View (TG SAX) how do you get ?

A

advance 4-6 cm in the stomach

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42
Q

Preload changes are easier to identify when viewing LV in the information is better

A

Cross section rather than Long axis view

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43
Q

IN prone position, the abdomen should be freely hanging why?

A

So that venous pressure is not elevated.

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44
Q

Pt with hypothyroidism are sensitive to

A

Sedatives, narcotics > consider awake fiberoptic intubation,

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45
Q

What is the most important initial consideration for a patient undergoing pancreatectomy for ductal pancreatic cancer?

A

Aspiration precautions at induction

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46
Q

Palliative phase of pancreatic cancer block

A

celiac plexus block

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47
Q

Benign intracranial hypertension aka

A

pseudotumor cerebri

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48
Q

Treatment of intracranial htn include

A

Drainage with a ventriculostomy

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49
Q

To maintain CBF even though they will decrease CMRO2

A

VA at 0.6 to 1 MAC

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50
Q

Hyperventilation during the initial treatment only of increase ICP

A

PaCo2 30-35mHg

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51
Q

What is temporary occlusion during aneurysm clipping surgery? How long should it last?

A

A clamp to halt blood flow through the aneurysm is applied while resectting it. It should last less than 10 minutes

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52
Q

Pt post radiation therapy issue

A

Irradiated tissue become
Friable tissue prone to bleeding
soft tissue bed stiff and fibrotic

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53
Q

Key anesthetic consideration with face transplant

A

Avoidance of vasopressors.

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54
Q

Facial surgeries treat hypotension with

A

Fluid and blood products

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55
Q

Most serious post op risk of transphenoidal hypophysectomy is

A

Cerebral spinal fluid leak. (can become chronic or cause meningitis)

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56
Q

The most serious complication of stereotactic surgery is the development of

A

Intracerebral hematoma

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57
Q

Large dose of vitamin____ associated with bleeding

A

E

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58
Q

Herbal that inhibit platelet aggregation leading to bleeding

A 
G'S 
Ginkgo
Ginseng
Garlic
Saw Palmetto
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59
Q

Guidelines for cardiac surgery blood glucose control

A

Below 180 during CPB

Below 150 if > 3 days of ICU are necessary

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60
Q

Video Assisted thoracoscopy vs open thoracic surgery

A

Rib spreading not required

Improved pulmonary function

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61
Q

Downside of VATS

A

Increased difficulty with access to centrally located tumors. Dissection of chest wall adhesions is also more difficulty

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62
Q

Still required after VATS

A

Post operative chest tube

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63
Q

Albumin half life is

A

3 weeks

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64
Q

Late indicator of hepatic synthetic function

A

Albumin

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65
Q

What is a better indicator of hepatic synthetic function? Albumin vs prothromin

A

Prothrombin because it reflects the presence of factor VIIa with a half life of 4 hours

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66
Q

Release as a result of hepatocyte injury

A

Alanine Aminotransferase )ALT_

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67
Q

Chemo drugs associated with pulmonary toxicity

A

Bleomycin

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68
Q

Chemo drugs associated with cardiac toxicity

A

Doxorubicin

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69
Q

Chemo drugs associated with renal toxicity

A

Cisplastin

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70
Q

Anesthetic considerations in lung CA patients 4

A

Mass effects
Metabolic effects
Metastases
Medications

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71
Q

Nd: YAG laser, what do you apply to the eyes?

A

Green gloggles

Wet 4x4 followed by green goggles. (everyone should be wearing green goggles, for the profession)

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72
Q

Laser and goggles color

A 
CRAG
CO2  --- CLEAR
Ruby --> RED
Argon --> AMBER
Nd:YA"G" --> GREEN
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73
Q

In a patient with intracranial tumor and headache, which preop medication is not recommended. and why>

A

Fentanyl, because of the resp depression which lead to increase CO2 which would further increase ICP

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74
Q

Retrograde approach to cardioplegia cannulation of

A

Cannulation of the coronary sinus.

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75
Q

If coronary sinus is cannulated prior to arresting heart you can get____? If becoming unstable?

A

Afib; synchronized cardioversion

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76
Q

During retrograde cardioplegia, the cardioplegia solution travels from

A

RVC the veins from the capillary beds , protect myocardium distal to the occlusion

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77
Q

Protect myocardium distal to the occlusion

A

Retrograde cardiooplegia.

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78
Q

Anterograde approach involves cannulation of the

A

Aortic root

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79
Q

Anterograde cardioplegia, the cardioplegia solution travels from the

A

arteries to the capillary beds (AAC)

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80
Q

What has been proven to reducing the chance of surgical site infection

A

High Fraction of Inspired oxygen

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81
Q

Tissue oxygenation is dependent on

A

Dissolved O2 in the blood and is NOT dependent on the presence of Hemoglobin

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82
Q

2 that causes vasoconstriction and decrease peripheral blood flow, which are detrimental to the tissues

A

Hypovolemia

Hypothermia

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83
Q

Tests to be drawn after induction for CABG

A

ABGs
ACT
Electrolytes

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84
Q

What is A thymoma?

A

Thymoma is a thymus tumor, usually found in the upper chest,, It is an anterior mediastinal mass.

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85
Q

After induction of a patient with thymoma, SBP falls to 50 mmHg, why is that ? You can ventilate, what is the causes

A

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

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86
Q

Thymoma mass may compress

A

Trachea.

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87
Q

If patient with thymoma mass can be ventilated , what is the most likely cause?

A

Vascular compression

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88
Q

Which lab has to be ABNORMAL to diagnose FAT EMBOLISM?

A

FAT MICROGLOBULINEMIA

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89
Q

CRITERIA that must be present to formally diagnose fat embolism syndrome

A

One major and 4 minor criteria, plus fat microglobulinemia,

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90
Q

Gurd’s Diagnostic Criteria: FAT EMBOLISM SYNDROME

Major and minor criteria.

A

Major Criteria
Respiratory insufficiency
Cerebral involvement
Petechial rash

Minor Criteria
Tachycardia
Fever
Jaundice
Retinal changes
Renal changes
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91
Q

Superior hypogastric plexus extends from

A

L5 to S1

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92
Q

Drugs that can reduce the Efficacy of IVF

A 
MORPHINE
SEVOFLURANE
DESFLURANE
NSAIDS
Droperidol
Metoclopramide
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93
Q

Prerenal Failure urine sodium and urine osmolarity

A

Low urine sodium

High urine osmolarity

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94
Q

Crepitus (Subcutaneous emphysema ) indicates

A

Air leak

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95
Q

Steps to take when there is crepitus during Laparoscopic case : 5 first steps

A

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

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96
Q

Even this can cause air leak during long cases

A

Low insufflation pressure

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97
Q

In the patient with SCOLIOSIS, what is STRONGEST PREDICTOR of the need for POSTOP VENTILATION

A

Vital capacity < 40% of predicted

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98
Q

Used to predict Post op respiratory complications in thoracotomy patients undergoing lung resection procedures.

A

FEV1, and DLCO

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99
Q

In the absence of formal exercise testing , the _____Test can be used

A

stair climbing test (2-3 flights)

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100
Q

With the stairs climbing test, what indicates an increase of morbidity and mortality for lung resection patients?

A

A fall of 4% or more in SPO2

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101
Q

Surgical Procedures with its unique considerations–: TOTAL THYROIDECTOMY

A

POSTOP Hypocalcemia

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102
Q

Surgical Procedures with its unique considerations–: Shoulder Arthroscopy

A

Hypotensive bradycardic event

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103
Q

Surgical Procedures with its unique considerations–: HIP ARTHROPLASTY

A

Bone Cement Implantation syndrome

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104
Q

Surgical Procedures with its unique considerations–: LUMBAR FUSION

A

Ischemic optic neuropathy.

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105
Q

COPD patients lung recoil and FRC

A

Increase FRC, poor, recoil

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106
Q

PEEP and COPD

A

Can cause overdistention and pulmonary capillary compression, impairing gas exchange

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107
Q

Initial vent setting for OLV include

VT, RR, PIP, PEEP, and PP

A 
Vt 5-6 ml/kg of ideal body weight
RR 12 bpm
PIP < 35
PP <25
PEEP +5 (O peep for COPD patients)
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108
Q

Details to be included for a patient undergoing a kidney transplant?

A

Time of last dialysis

Euvolemic body weight.

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109
Q

How to avoid Acute lung injury and hypoxia during one lung ventilation? FiO2, TV, PEEP, Recruitment maneuvers, CPAP, CO2

A

FiO2< 1.0
Low TV
use of PEEP
Permissive hypercapnia,

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110
Q

OLV and CPAP

A

Apply CPAP to Nondependent lung.

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111
Q

Why is patient having right sided lung surgery most likely to desat?

A

Right lung is larger than the left, thus proportionally there is a greater amount of perfusion to the right lung.

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112
Q

VATS and allowable anesthesia techniques?

A

Local
Regional
General

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113
Q

VATS performed under local anesthesia, what should not be attempted?

A

Lung deflation

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114
Q

VATS for minor transthoracic biopsy is

A

Intercostal nerve blocks, 2 levels above and below the incision is sufficient
HIGH FIO2 to treat V/Q mismatch

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115
Q

Drugs that should be administered to prevent the initial CV response to ECT?

A

Initial response is bradycardia and excess salivation, so GLYCOPYRROLATE (It is antimuscarinic, and does not cross the BBB)

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116
Q

The only antiplatelet agent not contraindicate a neuraxial anesthetic?

A

ASA

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117
Q

Lidocaine with epi for SAB lasts for approximately

A

1.5 h

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118
Q

Tetracaine with epi for SAB lasts for approximately

A

2-3 hours

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119
Q

What is the most important airway assessment for patient with oropharyngeal CA undergoing neck dissectoin

A

Diagnostic images of the airway (because external exam may not reveal significant impediments to tracheal intubation.

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120
Q

Auricular lobule aka

A

Ear lobe

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121
Q

Ear lobe is innervated by ____-? What block this nerve.

A

Greater auricular nerve

Blocking the superficial Cervical plexus will cover this nerve

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122
Q

Hysteroscopic sterilization aka

A

Essure system

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123
Q

Hysteroscopic sterilization aka essure system should not be performed in office

A

High anxiety

Cervical os stenosis

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124
Q

Advantage of US when it comes to paravertebral block?

A

Allow to measure depth of the transverse process

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125
Q

US guided recommended for patient with

A

Scoliosis and Obesity.

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126
Q

Patient is undergoing large volume liposuction with a total of 55mg/kg of lidocaine, When will peak serum lidoacaine levels occur?

A

12-14 hours

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127
Q

Maximum recommended dose for lidocaine used for tumescent anesthesia is

A

55 mg/kg

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128
Q

What is the most important facet of anesthesia care for a patient undergoing endovascular treatment of a posterior cerebral artery arteriovenous malformation>

A 
BLOOD PRESSURE
(May need both deliberate hotn, and deliberate htn)
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129
Q

What is the Arnold-Chiari malforatiom

A

result of the hindbrain being displaced downward into the FORAMEN MAGNUM, resulting in hydrocephalus.

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130
Q

Fournier Gangrene

A

Critically ill, will need GETA with vascular monitoring

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131
Q

Fournier gangrene shock

A

Septic shock

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132
Q

Features of AICD that should be disabled prior to surgery

A

Anti-tachycardia

Shock therapy

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133
Q

EMI monopolar vs bipolar

A

Monopolar most likely to cause EMI

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134
Q

If you won’t have access to pacemaker settings and stuff

A

Place external pads

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135
Q

Ear probe vs finger probe alert for low sat1

A

Ear 10-20 seconds

Finger 20-50 seconds

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136
Q

What is TIPS and what does it treat?

A

Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat ascites.

137
Q

What is done during TIPS procedure?

A

Stent placed between the portal vein and hepatic vein, in an effort to bypass increased hepatic vascular resistance.

138
Q

3 complications of TIPS procedures

A

Hemorrhage
Pneumothorax
Dysrhythmias

139
Q

Most common comorbidities for patient presenting for VASCULAR surgery is

A

CAD

140
Q

Nerve courses laterally around the knee

A

Common peroneal nerve

141
Q

Flexed lateral decubitus position

A

Common peroneal neuropathy
Cervical plexus stretch
Brachial plexus compression

142
Q

Flank positioning for abdominal surgery is associated with

A

significant respiratory embarassment, including dependent atelectasis and pneumothorax.

143
Q

What should be placed for the Flexed lateral decubitus position and why?

A

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

144
Q

Hazards with CT

A

Radiation exposure

145
Q

Hazards with MRI

A

Remote monitoring

146
Q

CT doses of radiation compared to a chest XRAY

A

Xray 0.1mSv. vs. 7-8 mSv

147
Q

CLOT with Afib will be most likely be present where

A

Left atrial appendage

148
Q

The best view to visualize the left atrial appendage is the

A

Mid-ESOPHAGEAL LAX

149
Q

When selecting an IV catheter most important factors are

A

Size and length of the catheter

150
Q

Flow is directly proportional to the

A

Radius to the fourth power.

151
Q

What is the most likely reason for postoperative airway obstruction in a patient with previous radiation therapy for head and neck cancer?

A

Impaired lympatic drainage.

152
Q

Radiation to the head and neck can damage the

A

Extensive nexus of lymphatics in the neck, leading to impaired drainage and accumulation of lymph

153
Q

Is usually the result of a mouth gag

A

Lingual edema

154
Q

May result from the anterior approach to the cervical spine surgery??

A

Palatal edema

155
Q

Airway hematoma is associated with this vascular procedure

A

CEA

156
Q

Deep hypothermia requires patient’s core temperature to be____For how long, max _____

A

12-20 degrees C; 20-30 minutes, 80 max.

157
Q

Meds for cerebral protection include

A 
SAD LiMa
Steroids
Antegrade Cerebral perfusion
Drugs that reduced CMRO2 (Propofol, barbiturates, etomidate)
Lidocaine
Mannitol.
158
Q

Another example of CNS protection is placement of

A

lumbar spinal catheter to drain CSF, in patients at risk for hypoperfusion of the spinal cord such as THORACOABDOMINAL AORTIC ANEURYSM.

159
Q

Risk of airway or laryngeal edema one should ascertain whether airway edema may

A

Significantly decrease airway patency in the absence of an ETT.

160
Q

Important step for any case with Risk of airway or laryngeal edema make sure you check

A

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.

161
Q

Full recovery and TOF ratio?

A

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)

162
Q

During a TIPS procedure, the shunt is introduces via the

A

JUGULAR Vein, threaded through the RIGHT ATRIUM –> IVC, hepatic vein.

163
Q

During the TIPS procedure, what could occur with catheter placement?

A

Pneumothorax or IJ injury, passage through the RA can cause cardiac arrhythmias, If the portal vein is punctured rather than cannulated, hemorrhage can occur.

164
Q

Hepatic cryotherapy is associated with complications of

A

Hypothermia

165
Q

Hepatic resection complications

A

Venous air embolism due to aspiration through open hepatic veins

166
Q

Adverse effect of hepatic resection since regenerative liver utilizes

A

phosphate to synthesize new cells.

167
Q

Drugs that decrease the peripheral conversion of T4 to T3 are

A

Dexamethasone
Propranolol
Propothiouracil (via NGT)

168
Q

Drugs that inhibits the SYNTHESIS of thyroid hormone

A

Potassium iodide

Methimazole.

169
Q

Patients with grave’s disease remember to treat hypotension with

A

Direct-acting agents such as Phenylephrine because catecholamines may cause sudden sympathetic surges in the patient with hyperthyroidism

170
Q

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?

A

Lateral Canthotomy

171
Q

Bleeding into the retrobulbar space thrusts the eye anteriorly (PROPTOSIS) leading to

A

Compression of the optic nerve, reduces blood flow through the orbital vasculature

172
Q

Causes of retrobulbar hematoma?

A

Ocular orbital and sinus procedures, retrobulbar anesthesia, AV malformaitons.

173
Q

What is the minimum recommended ACT for the patient undergoing Carotid Artery Angioplasty stenting?

A

250

174
Q

Compared to Carotid endarterecomty, what is a less invasive way to treat carotid stenosis?

A

Carotid artery angioplasty stenting

175
Q

The patient for Carotid artery angioplasty stenting is anticoagulation with

A

Heparin 50-100 units/kg to achieve a minimum ACT Of 250

176
Q

One major concern for the patient undergoing Carotid artery angioplasty stenting is

A

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.

177
Q

What is the most common complication of Carotid artery angioplasty stenting?

A

Stroke

178
Q

The immediate CV response to aortic cross-Clamping is an ______What is the most appropriate treatment?

A

increase in afterload and myocardial work; Treat with vasodilators with the goal of decreasing SVR and cardiac work.

179
Q

Caveat to giving vasodilators during cross-clamping of aorta.

A

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.

180
Q

What is LVAD?

A

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.

​

​

181
Q

LVAD, Optimization of what is critical?

A

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.

182
Q

LVAD Pump flow is highly dependent on

A 
adequate LV preload
pump speed (RPMs), and the pressure gradient across the pump (afterload).
183
Q

LVAD, Consequences of a suction event include 2

A

hypotension and ventricular dysrhythmias.Additionally, a leftward shift of the interventricular septum alters RV geometry, which reduces RV contractility and compliance. ​

184
Q

As an aside, LVAD patients are at high risk for____What is the management?

A

developing GI bleeding.Management includes fluid administration (to increase preload) and reducing pump speed.

185
Q

When compared to LAPAROTOMY (open approach) , Laparoscopy is associated with

A 
Improved surgical outcomes
minimal stress response
Lower opioids requirements
Less Fluid shifts
Less post op resp dysfunction
186
Q

Disadvantages of laparoscopic procedures

A

Gas embolism
referred pain from insufflation
PONV

187
Q

Regional eye block complications are

A

Intra-arterial injection
Globe penetration
Retrobulbar hemorrhage
Superficial hemorrhage.

188
Q

Regional eye block complications: Intraarterial injection would lead to

A

Seizure activity

189
Q

Regional eye block complications: Globe penetration would lead to

A

Retinal detachment

190
Q

Regional eye block complications: Retrobulbar hemorrhage would lead to

A

Circumorbital hematoma

191
Q

Regional eye block complications: Superficial hemorrhage would lead to

A

Globe proptosis

192
Q

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

A

myopia, a deeply recessed globe, or an axial length of > 26 mm (typically available on the surgeon’s preoperative US report)

193
Q

Superficial hemorrhages are demonstrated as the so-called

A

“black eye” or circumorbital hematoma.

194
Q

In a retrobulbar hemorrhage, __________ is common along with an entrapped lid, both causing rapid and significant increases in IOP. These patients may require a.

A

proptosis of the globe;

lateral canthotomy to relieve intraocular hypertension

195
Q

Methods recommended to reduce blood loss during Endoscopic sinus procedure?

A

Elevate head of the bed
Mucosal vasoconstriciton (cocaine, epinephrine, phenylephrine)
Total IV anesthesia

196
Q

4 intraoperative MONITORING techniques for carotid endacterectomy?

A

EEG
SSEP, and MEPs
NIRS
Transcranial doppler

197
Q

4 intraoperative MONITORING techniques for carotid endacterectomy? cerebral oximetry

A

NIRS

198
Q

4 intraoperative MONITORING techniques for carotid endacterectomy? EEG

A

Electrical activity

199
Q

4 intraoperative MONITORING techniques for carotid endacterectomy? Transcranial doppler measures

A

Blood flow in large vessels

200
Q

4 intraoperative MONITORING techniques for carotid endacterectomy? SSEP and MEPs monitors

A

Overall cerebral functional integrity.

201
Q

The purpose of neurological monitoring during CEA is to determine the

A

integrity of cerebral perfusion and to help decide the need for carotid shunting.

202
Q

The gold standard for neuromonitoring for CEA is an

A

awake patient with whom you can directly communicate.

203
Q

Intercostal block: order of intercostal structures.

A

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.

204
Q

The intercostal space is triangular:

​

A

Lateral border ​ = ​ external and intercostal muscles
Medial border ​ = ​ posterior and inner intercostal muscles
Posterior border ​ = ​ upper border of the next rib

205
Q

The order of intercostal structures is VAN (cephalad to caudad); s

A

imilar to the order in the femoral canal—VAN—from medial to lateral.

206
Q

An intercostal block is not considered safe in what kind of patients and why>?

A

outpatients due to the risk of pneumothorax.

207
Q

Key considerations when performing the block (to minimize the risk of pneumothorax) include:

​

A

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.

208
Q

Surgeries that are associated with the GREATEST risk of

developing POST-OP Chronic pain syndromes?

A

SAPHENOUS VEIN STRIPPING
MASTECTOMY WITH IMPLANTS
LIMB AMPUTATION

209
Q

Expected adverse effects of gas insufflation during colonoscopy include

A

Decrease Heart rate

Increased Gastric secretion.

210
Q

GI distension (due to gas insufflation) evokes.

​

A

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).

211
Q

Enteric nervous system fibers (non-adrenergic, non-cholinergic) migrate to the

A

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.

212
Q

The most IMPORTANT Guiding principle of “damage control” resuscitation is

A

Minimize crystalloid administration

213
Q

Damage control resuscitation is designed to prevent

​

A

pulmonary edema, ARDS, coagulopathy, and multiple organ failure due to the administration of large volumes of crystalloid during fluid resuscitation.

214
Q

The immediate goals of damage control resuscitation are to

A

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.

215
Q

Thawed plasma and liquid plasma contain only how much clotting factors?

A

30% of normal clotting factor activity,

216
Q

FFP and clotting factors,; important consideration has but

A

100% of normal clotting factor activity; it takes 45 minutes to thaw.

217
Q

May be given in hemorrhagic patient to control bleeding

A

Txa

218
Q

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.

​

A

bladder manometer.

219
Q

IAB > 10 mmHg

A

IAB > 10 mmHg reduces hepatic blood flow

220
Q

IAP > 15 – 20 mmHg

A

reduces renal blood flow (enough to cause oliguria)

221
Q

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

A

skeletal muscle tension does not contribute to a rise in IAP.

222
Q

What partial pressure of carbon monoxide is required to achieve 100% hemoglobin saturation

A

0.4 mmhg

223
Q

The point to understand is that extremely small concentrations of carbon monoxide are capable of

​

A

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!

224
Q

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.

A

26.5 mmHg: 50%

225
Q

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.

A

90; 97.5%

226
Q

What is the minimum target systolic BP for a 65-year old trauma victim in order to reduce mortality?

A

110 mmHg

227
Q

Civilian trauma patients > 65 years of age maintained with a SBP ≥

A

110 mmHg had lower mortality than those maintained at lower SBP.

228
Q

The anesthesia provider should elicit what information during the preoperative assessment of a pacemaker patient?

A

Manufacturer and model
Pacer impulse causes mechanical systole
Patient’s underlying rhythm

229
Q

There are very clear recommendations on preanesthetic evaluation related to pacemaker and ICD management. Key information includes:

​

A

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?)

230
Q

Why are current electrolytes (not CBC) important for patients with a PM

A

because alterations in serum potassium can change the triggering threshold for capture (this leads to failure to capture).

231
Q

It’s imperative that beat-to-beat verification of mechanical systole be monitored by

A

plethysmography or an arterial line waveform (NOT just an EKG tracing).

232
Q

In which emergency anesthetic should hyperventilation to a PCO2 < 35 be avoided? ​ (Select 2)

A

Traumatic brain injury

Arteriovenous malformation

233
Q

Anesthetic management of a thoracic aneurysm repair should focus on avoidance of:

A

Hypertension and tachycardia

234
Q

Anesthetic management of a thoracic aneurysm repair should focus on avoidance of:

A

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

235
Q

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?

A

15 to 30

236
Q

After abdominal insufflation is complete, the PaCO2 reaches a plateau after

A

15 – 30 minutes. EtCO2 also plateaus at this time.

237
Q

After insufflation, If there’s a significant rise in PaCO2 or EtCO2 after this time (again 15 – 30 minutes), then you should

A

investigate for an air leak (a key sign is subcutaneous emphysema).

238
Q

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:

A

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.

239
Q

Which risk factor for peripheral vascular disease is MOST likely to elicit progression to limb ischemia or amputation?

A

SMOKING

240
Q

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.)

A

Transesophageal echocardiography

Intra-arterial blood pressure

241
Q

ESLD (End Stage Liver Disease) is associated with

A

Systemic vasodilation and hypotension, which warrants intra-arterial blood pressure monitoring.

242
Q

Poor predictors of fluid status or responsiveness, while

A

CVP and the pulmonary catheter

243
Q

TEE is a sensitive monitor of

A

preload, contractility, and regional wall motion.

244
Q

TEE has been safely used in patients at risk for esophageal varices as long as the

A

transgastric view is avoided.

245
Q

Which patient condition is a contraindication for craniotomy in the sitting position?

A

Patent Foramen Ovale

246
Q

Venous air embolism

A

venous sinuses open coupled with low venous pressure

247
Q

PFO is a ___to ____shunt

A

Right to left

248
Q

% of patients with probe PFO

A

20%

249
Q

Patent PFO causing

A

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

250
Q

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).

A

Inability to lay flat
Limited language ability
Open eye injury
Restless leg syndrome

251
Q

Required in any open globe injury

A

General anesthesia

252
Q

Regional ophtalmic anesthesia and AC

A

It’s generally accepted that regional ophthalmic anesthesia can be safely administered to anticoagulated patients.

253
Q

Which option initiates HPV?

A

Alveolar hypoxia

254
Q

Systemic HYPOXIA causes _______while alveolar hypoxia causes

A

Vasodilation; vasoconstriction

255
Q

HPV increases V/Q matching by

A

Reducing shunt.

256
Q

Shunt occurs when

A

Pulmonary blood perfuses unventilated alveoli

257
Q

Pulmonary HTN is defined as a mean pulmonary arterial pressure of at least

A

25 mmHg

258
Q

Pulmonary HTN PAOP of no more than

A

15 mmHg

259
Q

When properly placed distal tip of the LMA will sit at the

A

Cricopharyngeus muscle (Upper esophageal spincter)

260
Q

Disposable Proseal LMA version is

A

LMA supreme

261
Q

Classic LMA max pressure is

A

20cm

262
Q

Proseal LMA max pressure is

A

30 cm

263
Q

Which LMA has a gastric tube opening for easy gastric decompression?

A

Proseal LMA

264
Q

IN this condition , supplemental oxygen is least likely to increase arterial oxygenation

A

Pulmonary edema

265
Q

Right to Left shunt and oxygenation

A

A right to left shunt that exceeds 50% typically won’t respond to further increases in FiO2

266
Q

Fiver Primary causes of Hypoxemia and examples

A 
Low FiO2 -High altitude
Hypoventilation - opioid overdose
Diffusion impairment - Pulmonary fibrosis
V/Q mismatching - COPD
Shunt - Pulmonary edema.
267
Q

Acute intrinsic lung disease

A

Pulmonary disease
Aspiration pneumonia
ARDS

268
Q

How long do you wait to repeat clear non particulate antacid ?

A

1 hour

269
Q

Use Alveolar gas equation and your knowledge of the A-a gradient to estimate PaO2.

​
​

A

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

270
Q

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:

A

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.

271
Q

The 3 major variables of the equation are the

A

atmospheric pressure
amount of inspired oxygen
and levels of carbon dioxide.

272
Q

Normal A-a gradient =

A

(Age + 10) / 4

273
Q

Laparoscopic surgery and LMA

A

Can be used in procedure is less than 15 minutes long

274
Q

Muscarinic -2 stimulation causes

A

bradycardia

275
Q

Muscarinic receptors are linked to G-proteins: M2, M2, M3

A

M2 and M3 causes bronchoconstriction, miosis and facilitates GI and GU function

276
Q

Precedex and adenylate cyclase activity

A

Reduces

277
Q

A-a gradient increases

A

5 to 7 for every 10% increase in FiO2.

278
Q

Can aggrevate Left subclavian steal syndrome

A

Neck Flexion and exercise

279
Q

Left subclavian steal happens when there is an occlusion of the

​

A

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.

280
Q

Left Subclavian steal Symptoms include

A

syncope, vertigo, ataxia and/or hemiplegia. Arm ischemia is also present. Neck flexion and exercise can exacerbate symptoms.

281
Q

Signs of Left subclavian steal

A

The pulse is absent or significantly weaker in the affected arm and blood pressure can be 20 points lower than the contralateral arm.

282
Q

What is the cardinal feature of myxedema coma?

A

Hypothermia

283
Q

What laboratory finding is characteristic of acute pancreatitis?

A

Elevated serum amylase

284
Q

Which of the following conditions can cause a decrease in the specific gravity of the cerebrospinal fluid?

A

Liver disease

285
Q

What anesthetic type is the preferred alternative to performing a digital block in pediatric patients?

A

Transthecal block

286
Q

The primary risk of a digital block is

A

nerve injury or disruption of the arteries at the base of the finger.

287
Q

When performing a transthecal block no terminal arteries are close enough to the

A

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.

288
Q

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:

A

high-flow oxygen by face mask.

289
Q

Signs of inhalation injury

A

(singed facial hair, mild dysphagia, and cough). highest possible FiO2 via facemask to displace CO from the Hgb molecule.

290
Q

The affinity of Hb is about

A

200 times higher for CO than it is for O2. ​

291
Q

Pulse ox and COHgb

A

The pulse oximeter can’t identify COHb, so a normal SpO2 does not preclude a high carbon monoxide level.

292
Q

What is required to measure COHb.

A

A co-oximeter

293
Q

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:

A

carcinoid syndrome.

294
Q

Two-thirds of carcinoid tumors originate in the______and half occur in the _____

A

GI tract, and almost half of these occur in the appendix.

295
Q

Key characteristics of carcinoid syndrome include:

​

A

Cutaneous flushing of the head and neck (histamine and kinins)
Hypotension (histamine and bradykinin)
Bronchoconstriction (histamine and serotonin)

296
Q

Carcinoid syndrome: Bronchoconstriction is due to

A

Histamine and serotonin

297
Q

______is a unique risk of radical neck dissection.

​

A

Acute postoperative hypertension

298
Q

Surgeries at risk for acute post-operative hypertension include

A

carotid endarterectomy, abdominal aortic surgery, and intracranial surgery.

299
Q

Is a potential intra-operative complication of radical neck dissection.

A

Venous air embolism

300
Q

Entrainment of room air into the systemic circulation is a risk whenever an

A

open vessel communicates with the atmosphere and the head is positioned above the heart.

301
Q

Retraction of the vessels at the operative site (especially if the retractors are in place for a long time) can potentially contribute to

A

venous thrombosis.

302
Q

Succinylcholine can increase serum K+ by_____ succinylcholine is safe to administer to an ESRD patient as long as

A

0.5 mEq/L

303
Q

Succinylcholine is safe to administer to an ESRD patient as long as

A

They have been dialyzed within the last 24 hours.

The current serum K+ is ≤ 5.5 mEq/L.

304
Q

NMB agent not be administered in renal patients for an RSI.

A

Pancuronium is 80% eliminated by the kidney (it’s also long-acting), so it should

305
Q

Is an acceptable choice for RSI in patients with ESRD

A

Rocuronium (1.2 mg/kg)

306
Q

When a fire is present, your first priority is to

A

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.

307
Q

Recurrent ascites can be managed with a.

​

Other

A

transjugular intrahepatic portosystemic shunt (TIPS procedure) that introduces a stent between the portal vein and hepatic vein to bypass an increased hepatic vascular resistance

308
Q

Treatment of ascites includes

A

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

309
Q

Surgical management may be life-saving in which acute ischemic stroke situations? ​ (Select 2.)

A

Acute cerebellar stroke

Malignant middle cerebral artery occlusion syndrome

310
Q

A large hemispheric stroke can produce what and what does it lead to ?

A

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.

311
Q

Cerebellar stroke can produce a similar situation, where

A

edema of infarcted tissue occludes flow through the basilar artery.

312
Q

What is the anticipated blood loss during a revision of a total hip replacement? ​ (Enter your answer in mL)

A

1,000 – 2,000 mL

313
Q

For revision of a total hip arthroplasty it can be a bloody procedure. The patient should be

A

typed and crossed for several units of PRBCs owing to a typical blood loss of 1 to 2 L.

314
Q

By comparison, blood loss for a primary THA that utilizes a hypotensive technique (not suitable for all patients) can be as low as

A

200 mL.

315
Q

What are the MOST important anesthetic considerations for microlaryngoscopy for laser removal of a vocal cord lesion? ​ (Select 2.)

A

Sharing the airway

Maintaining vocal cord relaxation

316
Q

Microlaryngoscopy for laser removal of a vocal cord lesion requires ________This is usually accomplished with a ____

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.

317
Q

Microlaryngoscopy tube, The safest (and most effective method) to ensure adequate oxygenation and ventilation is to

A

secure the airway with a 5.0 or 6.0 mm MLT (microlaryngoscopy tube).

318
Q

Like a standard ETT, the MLT is cuffed, however it is

A

longer than a comparatively sized pediatric ETT. This design helps to prevent inadvertent extubation, particularly if the patient’s head is extended.

319
Q

Microlaryngoscopy for laser removal of a vocal cord , In some cases, the surgeon will request not to

A

intubate the airway. In these situations, TIVA with intermittent apnea or jet ventilation are suitable options.

320
Q

The single MOST important task to perform when responding to a cardiac arrest event in which CPR is in progress is:

A

Activating the AED.

321
Q

Most adult patients who suffer cardiac arrest have experienced either ______or _______? what is the best treatment for these rhythms.

A

ventricular tachycardia or ventricular fibrillation. Defibrillation is the best treatment for these rhythms.

322
Q

For Afib and vtach , The best outcomes occur when the time from cardiac arrest to defibrillation is
​

A

less than 2 minutes. Ironically, this is more likely in a community setting than in a hospital!

323
Q

The event response team must prioritize the application of the

A

AED defibrillator pads and activation of the AED.

324
Q

Even when a traditional crash cart with a manual defibrillator is available, it is faster to

A

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).

325
Q

What is the MOST appropriate treatment for severe bradycardia in a brain-dead organ donor?

A

ISOPROTERENOL

326
Q

Brain dead patients do not respond to_______ I

A

atropine, therefore treatment of significant bradycardia requires a direct-acting sympathomimetic agent.

327
Q

A potent beta-1 agonist is the best choice for brain dead patient

A

Isoproterenol.soproterenol is a pure beta-agonist, making it more appropriate than epinephrine or norepinephrine, which have mixed alpha and beta effects.

328
Q

Pure beta-1 agonist

A

ISOPROTERENOL

329
Q

Anesthesia consideration in a dental setting include

A

Shared airway

High Risk for Airway Obstruction

330
Q

Although most dental patients are______ intubated, this situation is still considered a

A

nasally; shared airway.

331
Q

During dental procedures, what may create a potentioal for

A

Throat packs, dental equipment, and other dental materialsmay inadvertently be left in the airway creating the potential for airway obstruction.

332
Q

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.

A

CV stability

333
Q

Position for appendectomy

A

Trendelenburg with Left tilt

334
Q

Position for appendectomy

A

Trendelenburg with Leftward tilt

335
Q

Position for LEFT COLECTOMY

A

Trendelenburg with Rightward tilt

336
Q

Position for gastric sleeve

A

Reverse Trendelenburg

337
Q

Elective cardioversion in a stable patient is contraindicated in which scenario?

A

Digitalis-induced tachydysrhythmia

338
Q

In the patient with a digitalis-induced tachydysrhythmia,

​

A

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.

339
Q

Pharmacological effects of a denervation transplanted heart include

A

Absence of reflex tachycardia to hydralazine

Lack of response to atropine.

SEE/NCE Boards CoreConcepts (49 decks)

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