Basic and ADVANCED EXAM Flashcards
HYPOnatremia and MAC
Decreases MAC
Glucagon and cardiac cells
Increase intracellular cAMP, which results in increased inotropy
Transducer vs pt
- Raise the tranducer (lowering the pt)>>>lowers the pressure reading
- Lower the tranducer (raising the pt)>>raises the pressure reading
What happens when the BP cuff is raised 20cm above the heart? BP reading will be 15cm lower than reality
CBF: CMR ratio
Volatile agent >1 MAC:
- increase CBF
- decrease CMR
Volatile agent <1 MAC:
- minimal effect on CBF
- decrease CMR
IV anesthetic:
- decrease CMR
- decreases CBF
PLASMA VOLUME and body fluid:
-intracellular
- extracellular
- interstitial
- plasma
- intracellular: 2/3 of total body water
- extracellular: 1/3 of total body water
- interstitial fluid: 3/4 of extracellular
- plasma fluid: 1/4 of extracellular
CAUDAL epidural
Sacrococcygeal ligament, THEN epidural space
Pulmonary circulation does NOT degrade:
- dopamine
- epinephrine
- histamine
Laryngospasm reflex: afferent limb vs efferent limb
- Afferent limb: superior laryngeal nerve, internal branch
- Efferent limb: recurrent larygneal nerve
DOPAMINE infusion: receptors
Low dose: D1 receptors
High dose: B1 receptors
Highest dose: A1 receptors
*
Volume of liquid anesthetic
-iso 1% at 4L/min
3 * fresh gas flow * volume % anesthetic vapor = 12ml/hr
Sulfhemoglobinemia vs methemoglobinemia
Similar CP: cyanosis
Sulfhemoglobinemia: shifts curve right, hence better tolerated; no antidote
Methemoglobinemia: shifts cruve left, so poorly tolerated; txt is methylene blue; or ascorbic acid for G6PD pts
Artery of Adamkiewicz (The great radicular artery)
- Comes off aorta between T9-T12
- Supplies the LOWER anterior portion of the spinal cord
- Interruption results in ASA (anterior spinal artery) syndrome
Labs a/w ESRD (secondary hyperPARATHYROIDISM)
- HYPERphos
- Low calcium
COMPLIANCE equation
1/C (rs=respiratory system) = 1/C (lungs) + 1/ C (chest wall)
Conus medullaris and dural sac
Conus medullaris: terminal end of spinal cord
- ADULTS: ends at L1-L2
- Neonates: ends at L3
Dural sac: dura matter terminates distally as the dural sac
- ADULTS: ends at S1-S2
- Neonates: S3
CO2 is transported in blood in which 3 forms
- dissolved CO2
- bicarbonate
- carbamino compounds
2,3 DPG
- What increases?
- What decreases?
- Increases? HyperPHOSPHATEMIA
- Decreases? 1u pRBC; thus results in left shit;
vs anemia produces right shift
Crichothyroid muscle
- innervated by?
- role?
- innervated by the SLN, external branch
- tenses the vocal cords
First-line vasopressor for pts with TBI and increased urine output?
VASOPRESSIN
Onset of local anesthetic
- low pKA and high lipid solubility enables fast onset
- alfentanil has very low pKA, hence why has 4x faster onset than fentanyl
St. John’s wort
CYP inducer
Hence, warfarin breakdown will be enhanced>>increased risk for clot
Chronic steroids: metabolic abnormalities
A/w hyperglycemia, hypo K (corticosteroids act on the mineralocroticoid receptor), increased urinary uric acid/calcium (think kidney stones)
Burn patients and NDNMB
- Dosing requirements for NDNMB, including roc, is increased
- with the exception of mivacurium, which is metabolized by pseudocholinesterase, which exhibits decreased level in burn patients
-Plateaued INSPIRATORY curve
-think: vocal cord paralysis, dysfxn
Allergic rxn:
Esters vs amide
- Allergy to ester is more common: secondary to PABA metabolaite
- Allergy to amide is less common: secondary to methylparaben preservative
PaCO2 vs EtCO2
PaCO2 is typically slightly higher, owing to dead space
Lithium and NMB
Prolongs both depolarizing and nondepolarizing blockade
CBF
-directly propotional to:
- directly proportional to: body temp and PaCO2
- inversely proptional to: PaO2 when <50mmHg
R wave
Signifies the beginning of LV systole, when the MV closes and LV contraction begins
Sugammadex adverse effects
- Anaphylaxis
- Severe bradycardia
Factors that increase MAC
- Chronic alcohol
- Cocaine
- MAO inhibitors
- HyperNATREMIA
- Red hair
pRBC storage
- a/w decreased 2,3-DPG
- also, decrease in pH and hence increase in K to maintain electrochemical neutrality
Ischemic optic neuropathy
- Anterior neuropathy
- Posterior neuropathy
Anterior: think cardiac surgery
Posterior: think posterior spine surgery
NMDA antagonist
- Ketamine
- Nitrous oxide
- Methadone
Anticholinesterease to treat CENTRAL ANTICHOLINERGIC SYNDROME
PHYsostigmine
MYASTHENIA GRAVIS
==
LAMBERT EATON
MG
Autoimmune destruction of Ach channels
- resistant to succinylcholine
- very sensitive to rocuronium
==
Lambert Eaton
- Autoimmune destruction of presynpatic calcium channels
- senstiive to both succinylcholine and rocuronium
R to L shunt:
Inhalation induction vs IV induction
- Inhalational induction: slowed
- IV induction: hastened
MALIGNANT HYPERTHERMIA
Txt: dnatrolene 2.5mg/kg; should be repeated every 5-10 minutes
DIC vs ESLD
DIC: factor 8 will be decreased
ESLD: factor 8 will be preserved
Latex allergy:
who is at risk?
- Healthcare workers
- children with spina bifida and urogenital syndrome
- allergies to tropical fruit
Vd: which drugs have LARGE Vd
- Vd: the degree to which a drug is distributed in body tissue rather than plasma
- Large Vd: lipophilic drugs, drugs with a high amount of TISSUE PROTEIN binding
- Low Vd: drugs with high degree of plasma protein binding, low degree of tissue protein binding, hydrophilic nature
Depleting the O2 cylinder
Pressure/3. Gives rough estimate of volume in L remaining in the tank.
SO if 1500 psg, that’s 500L. If rate is 4L/min, that’s 125 min.
ACE enzyme
Converts angiotensin I to angiotensin II
NDNMB pretreatment of succinylcholine
-does NOT prevent increases in IOP
Liquified gases (eg nitrous oxide, CO2)
-Use cylinder weight to determine the amount of gas remaining
vs
Non-liquified gas:
-pressure in the tank will directly correspond to the amount of gas remaining
MORPHINE metabolites:
M3G: has no analgesic activity
M6G: in setting of RF, can cause respiratory depression
Etomidate
MOA:
Adrenal suppresion:
MOA: GABA agonist
Adrenal suppresion: 11-beta hydroxylase inhibitor
TOF twitches and ACh receptor blockade
0 twitches: 100% blockade
1 twitch: 90% blockade
2 twitch: 80% blockade
3 twitch: 75% blockade
SUCCINYLCHOLINE:
Phase 1 block:
Phase 2 block:
Phase 1 block (nl block):
- neostigmine results in NMB prolongation
- TOF ratio >0.7
Phase 2 block:
- can be partially reversed with neostigmine
- dosei s NO MORE than 0.03mg/kg for Phase 2 block
- TOF ratio <0.3
Rocuronium:
-TOF ratio <0.3
Low cardiac output state and volatile anesthetic
Soluble anesthestics are MOST AFFECTED.
-Less blood to take up anesthetic gas, miminzing the dilutional effect
Dibucaine 20
- very significant pseudocholinesterase deficiency
- succ action prolonged to 4-8 hrs
Pip and Pplateau
Pip (airway resistance problem:
- bronchospasm
- asthma attack
- mucus plug
Pplateau (compliance issue):
- abdominal insufflation
- pulm edema
- ptx
Forced exhalation
-Airway closure occurs first in the lung bases
ASA 4, 5, 6
5: won’t survive without surgery
6: braind-ead, organs are being removed for surgery
Citrate tox
-can lead to HYPOcalcemia and HYPOmagnesemia
Infant laryngoscopy and intubation
At risk for bradycardia d/t predominance of the parasympathetic nervous system
LMWH vs UFH
Both bind to antithrombin III
BUT, LMWH is more selective for Factor Xa inhibition
Saphenous nerve
Innervated medial lower leg
ASPIRIN OVERDOSE: metabolic derangements
First: respiratory alkalosis
Then: metabolic acidosis
Endobronchial intubation: which is slowed more
Insoluble anesthetic
Which local anesthetic is most CARDIOtoxic
Bupivicaine
Drug metabolism
- Morphine
- Warfarin
- Codein
- Morphine: MC1R
- Warfarin: CYP2C9
- Codeine CYP2D6
TTP
Etiology:
Txt:
Etiology: abx inhibit ADAMT13, thereby inhibiting breakdown of vWF
Txt: FFP, to replace ADAMT13
Laryngeal muscles INNERVATION
-recurrent laryngeal nerve, with the exception of the crithyroid muscle (inntervated by SLN, external branch)
Hepatic blood flow is MEDIATED BY?
Adenosine
SUPRACLAV block
- Risk for PTX is highest with SUPRACLAV BLOCK
- called the “spinal of the arm”
TRALI etiology
Donor abs attack host leukocytes, leading to lung inflammation and injury
->can cause leukopenia
What increases power?
Power=1-beta
-increasing sample size
- increasing alpha (the p-value)
- reducing population variability (choosing a homogenous population)
BOTULISM
txt
- IVIG for < 1 yoa
- Equine antitoxin for pts >1 yoa
MOA:
ACh release blocked
Fasting guidlelines:
- breast milk
- infant formula; non-human milk; light non-fatty meal
Breast milk: 4 hrs
Infant formula/non-human milk/light non-fatty meal: 6 hrs
Sufentanil vs fentanyl
Alfentnil vs fentanyl
Slightly faster than fentanyl; d/t very high lipid solubility (tho unionized fraction is low)
=
Alfentanil is very fast d/t low pKA; 4x faster onset, 1/4 as potent, 1/4 duration
DEAD SPACE
- Neck extension
- PPV
- Neck extension: tube follows the chin; increases dead space
- PPV: decreases CO and thus pulmonary perfusion, thereby increasing dead space
Trendelenburg position: DEAD SPACE or SHUNT?
THINK: shunt
CYANIDE TOX and SVO2
- Increased SVO2 2/2 decreased O2 extraction
- cyanide inhibits cytochrome oxidase, preventing utilization of O2
SIMV
- SIMV attempts to synchronize the mandatory breaths with a pt’s inspiratory effort
- therefore, the interval between mandatory breaths may be irregular
vs VCV
-breaths will be delivered at a set schedule
FFP and liver disease
No need to give FFP prophylactically to normalize INR in liver pts unless INR >3
Muscle relaxant potentiation:
Which gas?
Which immunosuppresant?
Which abx?
Gas? Desflurane
Immunosuppresant? Cylosporine
Abx? Aminoglycoside (getamicin) and tetracycline
Anaphylaxis vs anaphylactoid rxn
Anaphylaxis: IgE-mediated
Anaphylactoid: not IgE-mediated; histmaine is released independently
Worst CO2 absorbent
Barium hydroxide
- more fires
- more compound A with sevo
- more carbon monoxide
CVP:
A-
C-
Y-
A-atrial contraction
C-TV bulging into RA during RV isovolumetric contraction
V-systolic filling of RA
Y-atrial emptying into RV through open TV
Most commonly abused drug AMONGST anesthesiologists
Opioids, not MIDAZ
Epidural: midline vs paramedian approach
Paramedian approach:
skin>muscle>ligamentum flavum
Midline approach:
skin>supraspinous ligament>interspinous ligament>ligamentum flavum
ASPIRIN inhibits which enzyme?
Prevents the synthesis of thromboxane, which is responsible for platelet aggregation
Metocloproamide MOA
- Increases LES
- Increases gastric motility
Ketamine emergence rxn: who is most at risk?
Old lady
TEG:
- MA decreased
- R prolonged
- K prolonged
- MA decreased: give platelets
- R prolonged: give FFP
- K prolonged: give cryoprecipitate
vWF interacts with which factor
Factor 8
CRPS I and II
CRPS I: no history of injury to the area
Inhaled anesthetic and neuromonitoring
Brainstem are barely affected (auditory evoked potential)
Visual are very affected (visual evoked potential)
HYPERventilation and electrolyte abnormalities
HYPOeverything:
-hypocalcemia, hypokalemia, hypophosphatemia
Most common periop neuropathy
Ulnar neuropathy:
-weakeness with hand flexion, thumb adduction
Spinal anesthesia in INFANTS
- increased speed of onset
- lack of HD collapse (d/t immature sympathetic system)
- increased block spread (ie increased risk of high spinal)
==
SO first sign can be: respiratory depression or apnea
Neg pressure pulm edema
Pathophys:
- increases preload
- increases afterload
Capnogram of incompetent inspiratory valve
tracing is not quite normal;; inspiratory phase is shortened, has blunted downstroke
-vs capnogram of comptent expiratory valve
MI:
- BMS
- No intervention
- DES
- BMS: wait 30 days
- No intervention: wait 60 days
- DES: wait 180 days
Blood transfusion: most common cause of death
TRALI
Hemophilia A
Hemophilia B
Hemophilia C
Hemophilia A: deficiency in factor 8
Hemophilia B: deficiency in factor 9
Hemophilia C: deficiency in factor 11
Deep sedation
- Purposeful response to repeated or painful stimulation
- Airway intervention may be required
What prolongs rocuronium?
(5 things)
- hypocalcemia
- hypothermia
- lithium
- volatile anesthetic
- abx (gentamicin, doxycycline)
MANNITOL:
-what happens if given too quickly
-contraindication:
- given too quickly: cerebral vasodilation>>causing engorgement and increased ICP
- should be given over 10 to 15 minutes
- produces an increase in plasma volume; hence think twice before giving in HF
CORONARY VENOUS ANATOMY
- Great cardiac vein: travels with LAD
- Anterior cardiac vein: travels with RCA
Efficacy vs potency
- Efficacy is MAX effect
- Potency: relative dose required to achieve effect
HD goals for aortic stenosis
- Maintain afterload and sinus rhythm
- Avoid tachycardia
Capnogram: (inspiration vs expiration)
Phase 3-4: end of exhlation
Phase 4-1: inspiration
Low FRC menmonic
PANGOS:
- pregnancy
- ascities
- neonatal
- supine position
- general anesthesia
- obesity
CCB in naive patients and NMB
Potentiates both depolarzing AND nondepolarizing muscle relaxants
(HYPOcalcemia also prolonged NMB)
Also desflurane; cyclosporine; aminoglycosides (gentamicin); tetracycline
Carotid chemoreceptors (carotid and aortic bodies)
Responsive to PaO2
Neostigmine:
-effect on depolarizing vs nondepolarizing block
-Effect on depolarizing block:
potentiates, by partialling inhibiting pseudocholinesterase
-Effect on nondepolarizing block:
inhibits
Brachial artery cannulation:
injury to which nerve?
median nerve
Volatile anesthetic:
- Which causes the least amount of airway irritation?
- Which causes plenty of airway irritation?
- Which is the most potent?
- Which causes the least amount of airway irritation? Sevoflurane
- Which causes plenty of airway irritation? Desflurane
- Which is the most potent? Halothane
Opioid-induced biliary colic
-Txt: naloxone and atropine
Transient neurologic syndrome (RISK FACTOR)
High dose lidocaine in the spinal mixture
Increases MAC
- Acute intoxication
- Chronic alcohol abuse
- Red hair
Zero-order kinetics
Rate of eliminiation is linear (phenytoin, ethanol, aspirin)
Cigarette smoking and P50
-Rightward shift in P50 is seen 48hrs AFTER smoking cessation
MOST ACCURATE sites for measuring core body temperature
- pulmonary artery
- distal esophagus
- tympanic membrane
- nasopharynx
CO poisoning vs methemoglobin
- CO monoxide: pulse ox 100%
- Methemoglobin: pulse ox 85%
Autonomic hyperreflexia: spinal cord transection
-Above lesion (VASODILATION):
nasal congestion; sweating; warm, flushed skin
- Below lesion (VASOCONSTRICTION):
- cool, pale skin
- acute HTN, cardiac arrhythmias
Which home meds to not take on day of surgery?
- ACE/ARB
- diuretics
- Metformin is ok
Sodium concentration in fluid:
-Plasmalyte
- LR
- NS
-Plasmalyte: 140
- LR: 130
- NS: 154
IO lines. Where to place?
- sternum
- humerus (proximal)
- tibia (distal and proximal)
What is this?
Single lung transplantation
- first peak: represents rapid exhalation from healthy, transplanted lung
- second peak: slower rate of rise of exhaled CO2 from diseased lung
Don’t reverse pregnant woman with neostigmine and glyco
Why?
Glyco does not cross the placenta. Rather, reverse with neostigmine and atropine.
ACE enzyme
Cleaves angiotensin I into angiotensin II
Pulmonary circulation does NOT degrade
- dopamine
- epinephrine
- histamine
Deep sedation vs GA
Deep sedation: purposeful response after repeated or painful stimulation
Succinylcholine and GI effects
-Succinylcholine increases BOTH LES tone and intragastric pressure
Lumbar epidural: pulm physiologic change
- Cough and PEP (peak expiratory pressure) are significantly reduced (10-40%)
- These parameters are more dependent on adominal musculature
Gag reflex: which CNs
CN9 for sensory
CN10 for cough
BP cuff
Point of maximal amplitude of oscillations corresponds to MAP
Laryngospasms results from:
-Sudden closure of both the true and false vocal cords
OR
-Sudden closure of the true cords only
Atelectasis
Lower lung segments are more prone to atelectasis than upper lung segments
BLOOD and ultrasound
- Reflects the LEAST amount of beam rays during ultrasound
- Has high water content>>thus is hypoechoic (dark)
Specificity
TF/TF+FP
SSRIs MOA
- inhibit CYP enzyme
- thereby, reduces the activation of many opioids to more potent forms
Liver disease: which factors are INCREASED
-Factor 8 and vWF are increased as they are produced extra-hepatically
MAC requirements by age
Highest btwn 1 month and 1 year of age
Mixed venous O2 sat; nl SvO2 is 75%
What causes mixed venous O2 sat to increase?
What causes mixed venous O2 sat to drop?
Increases:
- increases cardiac output (sepsis)
- increases Hgb concetnration
- decreases O2 consumption/extraction (eg cyanide tox, CO2 poisoning)
Decreases:
- decreased cardiac output (HF)
- decrease Hgb concentration
- increases O2 consumption/extraction
PAO2=
150-PACO2/0.8
Incompetent expiratory valve
-inspiratory segement does NOT return to zero
FRC increases with:
- height
- age
==
Decreases with (PANGOS):
- preg
- ascites
- neonatal
- general anesthesia
- obeisty
- supine
Why do infants have faster induction with volatile anesthetic compared to adult?
-infants have higher MV compared to FRC
Echothiophate and succinylcholine
- Echothiophate inhibits cholinesterase to cause miosis in glaucoma patients
- Systemic absoprtion of echothiophate can cause pseudocholinesterase deficiency, thereby PROLONGOINNG succinylcholine
Terbutaline
- Maternal effects
- Fetal effects
Maternal effect:
- tachycardia
- hyperinsulinemia but also hyperglycemia
==
Fetal effect:
-HYPOglycemia, tachycardia
Anticholinergic agent and cholinesteraes inhibitor:
-glycopyrrolate and ….
-atropine and …
- Glycopyrrolate and …neostigmine
- Atropine and edrophonium
Desflurane output and barometric pressure:
eg moving to Denver
Decreasing barometric pressure will INCREASE vaporizer output
Strong ion difference:
- Acidosis
- Alkalosis
- Acidosis decreases SID
- Alkalosis increases SID
- Nl strong ion difference is ~40
What muscle relaxes the vocal cords?
Thyroartyenoid muscles
EKG changes:
- HYPERMAGnesemia
- HYPERCALcemia
- HyperMAGNESEMIA: PR/QRS prolongation
- HyperCALCEMIA: PR prolongation, QT shortening
Posteriomedial papillary muscle
Anterolateral papillary muscle
Posteriormedial muscle: RCA alone
Anterolateral papillary muscle: LAD and LCx
Bellows ventilator
Rises during exhalation. Failure to rise would indicate a leak or disconnection.
Platelet trf
Associated with higher risk of rxn than other blood products
Stellate ganglion is a SYMPATHETIC GANGLION, located between C6-C7
Look out for predominance of parasympathetic sxs
Maternal cardiac output:
-when is it max?
-2nd to 3rd trimester
- Peak value is immediately folllowing delivery: 2.5 x prepregannt value
- 2nd to 3rd trimester: 50% increase over prepregnant state
LR vs NS infusion
NS infusion: metabolic acidosis
LR infusion: metabolic alkalosis (lactate is metabolized to bicarb)
ETIOLOGY of syndromes:
Febrile non-hemolytic transfusion rxn
Graft vs host disease
TRALI
Febrile non-hemolytic transfusion rxn:
cytokines from donor leukocytes
Graft vs host disease:
Donor lymphocytes reacting against recipient
TRALI:
Donor abs against HLA
Meperidine
Which receptor?
Which molecule structure?
Libby zion case?
- Effects are centered around the: kappa opioid receptor
- Meperidine is structurally similar to atropine
- Normeperidine: can cause seizure
- Meperidine + MAO-inhibitor=serotonin syndrome
Corneal reflex
CN5 (trigeminal nerve) and CN7 (facial nerve)
P50 hgb:
- when is it lowest?
- when is it highest?
-lowest: in newborns (ie hgb affinity for O2 is very high, thanks to hgb F)
Hetastarch vs tetrastarch
Hetastrach is a/w a higher risk of coagulopathy; compared to newer, tetrastarches
Hetastarch and PLATELET dysfxn:
causes a decrease in glycoprotein 2b-3a on the platelet surface, negatively affecting platelet aggregation
Bohr effect vs haldane effect
Bohr effect: maternal fetal interface; high CO2 environment; hgb has less affinity for O2
Haldane effect: deoxygenated hgb has greater affinity for CO2; oxygenated hgb has less affinity for CO2
- Boyle’s law
- Gay-Lussac’s law
-Boyle’s law
P*V=P*V
(hence why an O2 cyclinder can hold 660 liters of O2 despite having a volume of only 6.5L)
-Gay-lussac’s law:
P/T=P/T
Stress dose steroids: who to consider?
A person taking 20mg/day for more than 3 weeks are at high risk for HPAA supression
LAST: which routes increase likelihod
IICEBALLS:
IV>intercostal>caudal>epidural
COLORS:
Carbon dioxide cylinder
Helium cylinder
Carbon dioxide cylinder: gray
Helium: brown
Capnogram
-expiration vs inspiration
Obstetric surgery
- When should semi urgent surgery be done?
- When should elective surgey be done?
- When should it be done? 2nd trimester
- 2 to 6 weeks following delivery
Toxic metabolites:
- desflurane
- sevoflurane
- Desflurane: produces carbon monoxide
- Sevoflurane: produces fluoride
Sodium nitroprusside TOX
CP:
- elevated mixed venous O2 (cells cannot use O2 d/t impaired cellular oxidative phosphorylation)
- metabolic acidosis
- flushing
Methylene blue
- can treat cathecholamine-resistant shock
- happens to be a MAO-inhibitor, so can precipitate serotonin syndrome
- txt for methemoglobinemia
CAROTID and AORTIC bodies: increases minute ventilation through which nerve?
CN9 (glossopharyngeal nerve)
Aging
CV system?
Pulm system?
CV system: aging increases SANS activity
Pulm system: aging increases RV/FRC/closing capacity
Local anesthetic spread in the EPIDURAL space: which factor influences spread most
Volume
Which nerve is blocked at the palatoglossal fold?
The glossopharyngeal nerve (CN9)
Factors that decrease MAC of anesthetic agents
- Acute alcohol
- pregnancy
- metabolic acidosis
- anemia
- hyponatremia
- elderly age
Aspirin vs ticlopidine
- Aspirin implacts plt fxn for 7-10 days
- Ticlopidine impacts platelet fxn for 10-14 days
METHADONE MOA:
- Serotonin reuptake inhibitor
- NMDA antagonist
Action potentials:
Neuron
Cardiac Pacemaker
Cardiac mycotoes
Neuron: Na in, K out
Pacemaker: Ca in, K out
Mycocyte: Na in; Phase 1- K out; Phase 2- K out, Ca in; Phase 3- K out
A-line waveform
The farther from the aorta (ie dorsalis pedis):
- the higher the systolic peak
- the lower the diastolic peak
- the wider the pulse pressure
- the farther the dicrotic notch (marks: the closure of the aoritc valve)
Licorice
In excess can have a HYPERALDOSTERONISM effect
Superior laryngeal nerve injury PRESENTATION
-voice that tires easily
==
Recurrent laryngeal nerve injury is much more profound:
hoarseness/breathlessness/stridor
Low CO and inhalation induction
Very much hastened
- put low CO pts at risk of overdose
- Soluble anesthestics are most affected
BLOOD VOLUME
Premature infant:
Newborn infant:
Premature infant: 90-105cc/kg
Newborn infant: 80-90cc/kg
Pneumonectomy morbidity PREDICTORS
- max VO2 <15cc/kg/min
- predicted postop FEV1<35%
- predicted postopo DLDCO<35%
Duchenne’s muscular dystrophy
- must get EKG and ECHO
- not associated with MH; however, succinylcholine is associated with rhabdo and life-threatening K
SVT in WPW patients
Jump to procainamide
Lateral wall bladder tumor: what nerve?
Obturator nerve
Intraop MI: which lead is most senstive
V4
TRALI: highest risk blood product
FFP, not platelets
Safest and least safe local anesthesic to fetus
Safest: CPC (rapidly metabolized by pseudocholinesterase)
Least safe: 2% lido
Allodynia
Anesthesia dolorosa
Allodynia-pain from non-noxious stimulus (eg feather)
Anesthesia dolorosa-pain where there shouldn’t be pain sensation at all
Axillary nerve
“My useful rylan”
Txt of high spinal
CSF lavage
Aortic valve pressure gradient
4*(peak velocity)^2
Cardiac output thermodilator
- the faster the Tb return to baseline, the higher the cardiac output estimation
- the slower the TB return to baseline, the lower the cardiac output estimation
eg. if the injectate solution is cooler than what is preprogrammed, the cardiac output will be UNDERestimated
Cryo contains:
vWF, fibrinogen, factor 8 (think hemophilia A), Factor 13
TBI management
- Keep CPP btwn 50-70
- ICP<20
Pseudocholinesterase deficiency (3 drugs)
- Succinylcholine
- CPC
- Mivacurium
Neonate cardiac output
Very HR dependent (atropine is a good choice to augment CO)
Sugammadex dosing:
4mg/kg for 0-1 twiches
2mg/kg for 2+ twitches
Umbilical vascularture
1 umbilical vein (carries oxygenated blood)
2 umbilical arteries
==
Pulm artery and umbilical artery are the only ones thtat carry deoxygenated blood
Pyloric stenosis: medical optimization
Chloride normalized?->proceed with surgery
Nl Chloride is 100 btw
Knee surgery under MAC: blocks which nerves
Femoral and sciatic nerves
Peribulbar block (vs retrobulbar block)
- requires more local
- time to onset is longer
- less likely to have complete akinesia
BUT SAFER :)
Retrobulbar hemorrage vs posterior globe puncture
- Retrobulbar hemorrhage-expect INCREASE in IOP
- Posterior globe puncture-nl IOP
Protamine rxns
Type 1: hypotension (mast cell granulation, histamine)
Type II: anaphylaxis (IgE-mediated)
Type III: pulm HTN (thromboxane A2 mediated)
Cisatracurium metabolism
-Hoffman degradation
Peds resuscitation bolus
20-30cc/kg of isotonic solution; no dextrose, no potassium
Prerenal azotemia vs ATN
Prerenal: FENa<1%, UOSM (high), BUN:CR >20:1
ATN: Fena>1%, BUN:CR<20:1, UOSM (low)
When do troponins peak?
24 hrs
Infant diaphgram muscle fiber
Type 2 fibers, thus rendering them more prone to resp fatigue or failure
Electromagnetic interference
BIPOLAR electrocautery is safer!
Compared to the proximal aorta, arterial waveforms at more distal sites..
-delayed dicrotic notch (marks closure of the aortic valve)
Neonates and infants at risk of postop apnea: best form of anesthesia
-Spinal anesthesia
Klippel-Field syndrome
-cervical spine infusion->difficult to intubate
Saphenous nerve
Branch of the femoral nerve! (not sciatic)
Sickle cell disease: Hgb managment
Keep Hgb btwn 10-13
Centrifugal vs roller pumps
Centrifugal is preferred, however…flow will vary with alterations in pump preload and afterload
Nausea with neuraxial block: normotensive?
-Give glyco or atropine
Nenonatal resusciation
HR <100 BPM: PPV should be initiated
HR <60bpm: chest compressions
GCS scale: mild, mod, severe
Mild: 13-15
Mod: 9-12
Severe: <9
UE vs LE tourniquet
- Inflate UE to at least 50mmHg above SBP
- Inflate LE to at least 100mmHg above SBP
Nl PCWP
4-12mmHg
>20, think HF
GCS scale:
Eye-opening:
- Spontaneous: 4
- to sound: 3
- to pain: 2
- nil: 1
Verbal response
-Oriented: 5
-Approriate words: 4
- Inappropriate words: 3
- Moans: 2
- Nil: 1
Motor response:
- Obeys commands: 6
- Localizes to pain: 5
- Withdraws to pain: 4
- Flexion: 3
- Extension: 2
- Nil: 1
PEEP physiology
- decrease preload
- increase RV afterload
What covers both MRSA and gram-neg bacteria?
Tigecycline
Ultrasound Probes
Lower frequency: better depth perception
High frequecny: better resolution
ECT and CBF
ECT is known to increase CBF and ICP, which is why space-occuping lesions are CONTRAINDICATIVE
Myasthenic gravis—predictors of needing postop mechanical ventilation?
- VC <2.9L
- Pyridostigmine>750mg daily
- duration of disease >6yrs
Sodium deficit
sodium deficit=(140-serum sodium) x total body water
total body water=kg * 0.6
Laparoscopic surgery physiology
- increased afterload
- decreased preload
- increased ICP (by decreasing cerebral venous return)
HCM management
- avoid tachycardia
- maintain preload
- maintain afterload
eg neo is good, epi is not
Autonomic hyperreflexia: which anesthesia is better?
Both general and neuraxial anesthesia are ok
qSOFA
0-3
- altered mental status (GCS <15)
- RR >22
- SBP<100
TPN electrolyte abnormality
Watch out for HYPOphosphatemia
Vasopressin receptors (ADH)
- the V1 unit is vascular
- the V2 unit is on the kidney
Fetal blood gas post delivery
pH: 7.24 / paCO2 52 / PaO2 22
Beckwith-Wiedmann CP
hypoglycemia, omphalocele, and large tongues
Refractory hypotension 2/2 ACE-i/ARB
NOREPINEPHRINE is the pressor of choice
Ped oral midaz dosing
0.5mg/kg (ie 10x the IV dose)
Pregnancy and HR
HR and SV increase, causing an increasein CO
Child-Pugh score: what goes into it?
“Pour another beer at eleven”
- PT
- Ascities
- Biliriubin
- Albumin
- Encephalopathy
DKA: type 1 or type 2
Type 1
MS patients: anesthesia flare ups with…
- general and spinal anesthesia
- not epidural anesthesia
NL anion gap acidosis
- gut bicarb loss
- renal tubular acidosis
- chloride-containing acid administration (NaCl)
Refractory hemophilia
Context: hemophiliac patients with antibodies to their deficient factor
-txt is Kcentra or recombinant factor VIIa
Pregnancy clotting factors
-Most clotting factors increase
-EXCEPTION is Factor XI and XIII; they decrease
Stage I labor dermatomes
Stage II labor dermatome
Stage I labor dermatome: cover T10-L1
Stage II labor dermatome: cover T10-L1 AND S2-S4
Hepatopulmonary syndrome vs portopulmonary HTN
- Hepatopulmonary syndrome is associataed with nl PVR, platypnea, excess nitric oxide
- Portopulmonary HTN is associated with elevated PVR
Peds patients undergoing elective surgery: fluid management
-give 20-40cc/kg of isotonic fluid over 2 to 4hrs
Alveolar partial pressure of oxygen
PAO2 = FiO2 * (Patm – PH2O) – (PaCO2 / R)
***FiO2=0.21; PH20=47
Neuraxial anesthesia opioid MOA
impairing afferent input at receptors in the substantial gelatinosa at the dorsal horn of the spinal cord
