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Board Prep Flashcards

1
Q

Decreased ETCO2

A 
Hypothermia
Hypothyroidism
Increased Dead Space (COPD)
Hyperventilation
Decreased Cardiac Output
Decreased CO2 production
Circuit leak or Occlusion
Pulmonary Embolism (air, thrombus, gas, fat, marrow, amniotic)
Increased muscle relaxation
Increased depth of anesthesia
Surgical manipulation of the heart or                thoracic vessels
Wedging of the PA Catheter
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2
Q

Increased ETCO2

A 
Increased CO2 production (MH, thyrotoxicosis, hyperthyroidism)
Hyperthermia
Shivering or convulsions
Sepsis
Rebreathing (valve prolapse, failed CO2 absorber)
Hypoventilation
Depression of the respiratory center
Reduction of ventilation
Increased or improving Cardiac Output
Right to left intracardiac shunt
Excessive catecholamine production
Administration of blood or bicarbonate
Release of aortic clamp/arterial clamp or tourniquet
Glucose in the IV fluid
Parenteral hyperalimentation
CO2 insufflation
Subcutaneous epinephrine injection
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3
Q

Minimal to zero ETCO2 or Sudden Drop

A 
Equipment Malfunction
ETT disconnect, obstruction, or total occlusion
Bronchospasm
No Cardiac Output
Cardiac Arrest
Bilateral PTX
Massive PE
Esophageal intubation
Application of PEEP
Cricoid pressure occluding tip of ETT
Sudden, severe hypotension
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4
Q

Determining source of decreased ETCO2

A

Call for help
Assess vital signs
Feel for a pulse
Take patient off ventilator and handbag listening for breath sounds

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5
Q

EKG interpretation

A 
Rhythm
Regularity
P wave (2.5 mm long and high) (Best viewed in Lead II)
PR interval (No longer than 0.2 seconds)
Q wave
QRS complex (up to 0.12 seconds) (R & R prime in V1 = RBBB, R & R prime in V6 = LBBB)
ST segment (V5 most sensitive lead)
T wave
Axis
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6
Q

ASA recommendations for preoperative EKG

A

Age >50 yo (good for one year if 50-69, good for 6 months if >69)
History of cardiovascular disease or HTN (mandatory if changes in symptoms)
History of DM (required if >40 yo or has had DM >10 years)
Central nervous system disease

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7
Q

Standard ASA Monitors

A

Oxygenation (pulse ox)
Ventilation (ETCO2, respiratory volumes, disconnect alarms)
Circulation (EKG, blood pressure, HR - every 5 minutes)
Temperature

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8
Q

Indications for arterial line

A

Continuous real time blood pressure monitoring
Planned pharmacological or mechanical cardiovascular manipulation
Repeated blood sampling (ABG, Hgb, Glucose)
Failure of indirect BP measurement
Supplementary diagnostic information from the arterial waveform (PPV)
Patient with end organ disease
Patient with large fluid shifts

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9
Q

Arterial line complications

A 
Distal ischemia (thrombosis, proximal emboli)
Pseudoaneurysm
AV fistula
Hemorrhage
Hematoma
Infection
Skin necrosis
Peripheral neuropathy
Misinterpretation of data
Cerebral air embolism from retrograde flow from flushing
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10
Q

Indications for central line

A 
CVP monitoring
Transvenous cardiac pacing
Pulmonary Artery Catheter
Temporary hemodialysis
Drug administration (vasoactive, hyperalimentation, chemotherapy, prolonged antibx)
Rapid infusion of fluids
Major surgery with large fluid shifts
Aspiration of a venous air embolus
Inadequate peripheral access
Sampling site for repeated blood testing
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11
Q

PA Catheter measurements

A 
Cardiac Output and Index (CO/CI)
Pulmonary Artery Pressure (PAP)
Central Venous Pressure (CVP)
Calculation of oxygen delivery
Assessment of cardiac work
Mixed Venous Oxygen Saturation (MVO2)
Pulmonary Capillary Wedge Pressure (PCWP)
Systemic Vascular Resistance (SVR)
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12
Q

Indications for PA Catheter

A

Cardiac (CHF, low EF, left sided valvular dz, CABG, aortic cross clamp)
Pulmonary (COPD, ARDS)
Complex fluid management (shock, burns, acute renal failure)
High risk obstetrical care (eclampsia, placental abruption)
Neurological (sitting craniotomy, venous air embolus)

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13
Q

Causes of Hypernatremia

A

Inadequate intake of fluid
Renal loss of hypotonic fluid (diuretics, DI, intrinsic renal disease)
Extrarenal (nonrenal loss of H20)
Primary Na gain (hypertonic tube feeds or fluids)

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14
Q

Clinical features of Hypernatremia

A 
Altered mental status
Lethargy
Confusion
Coma
Seizures
Pleural effusion
Ascites
Peripheral edema
Heart Failure
Thirst
Nausea and Vomiting
Neuromuscular irritability
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15
Q

Treatment of Hypernatremia

A

Determine volume status (diuresis if hypervolemic) (Free H2O deficit = {(plasma Na/140)-1} x kg x 0.6, replace half of water deficit in first 24 hours, then remainder over 2-3 days, use 5% dextrose in water or 0.45% NaCl)
Rate of Na correction should not exceed 0.5 mEq/L per hour

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16
Q

Treatment of Central Diabetes Insipidus

A

DDAVP (IV 2-4 mcg)(Nasal Spray 10-40 mcg)
Low Na Diet
Low dose thiazide diuretic
Carbamazepine (enhances vasopressin secretion)
NSAIDs

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17
Q

Treatment of Nephrogenic Diabetes Insipidus

A

Treat underlying cause

Treat symptomatic polyuria (Low Na diet, thiazide diuretic)

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18
Q

Causes of hypovolemic hyponatremia

A

Non renal (GI losses, integumentary losses, third spacing, cerebral salt wasting)

Renal (Diuretics, osmotic diuresis, hypoaldosteronism, salt wasting nephropathy, post obstructive diuresis, non-oliguric acute tubular necrosis, acute and chronic renal failure)

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19
Q

Causes of euvolemic hyponatremia

A

Polydipsia (psychogenic, exercise induced, medications)
Administration of hypotonic IV fluids
Beer potomania
SIADH (neurologic, pulmonary disease, malignant tumors, major surgery, pharmacologic)

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20
Q

Causes of hypervolemic hyponatremia

A 
Renal (acute or chronic failure)
Non renal (heart failure, hepatic cirrhosis, nephrotic syndrome)
Redistributive hyponatremia (hyperglycemia, mannitol)
Pseudohyponatremia (hyperlipidemia, hyperproteinemia, glycine solutions)
Endocrine disorders (adrenal insufficiency, hypothyroidism)
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21
Q

Causes of hyperkalemia

A

Pseudohyperkalemia (hemolysis, prolonged use of tourniquet, marked leukocytosis)
Endogenous K (tumor lysis, rhabdomyolysis, exercise induced, burns)
Exogenous K (increased intake, transfusions)
Renal (insufficiency, chronic failure, oliguria, nephropathy)
Acidosis (metabolic raises K 0.7/0.1 pH, resp raises K 0.1/0.1 pH, diabetic ketoacidosis)
Drugs (succinylcholine, Beta blocker, digitalis, ACEI, heparin, cyclosporine,
spironolactone, amiloride, triamterene)
Endocrine (primary adrenal insufficiency, pseudohypoaldosteronism)
Hyperkalemic periodic paralysis (excitement, cold, fasting, stress, infection, GA)
Chronic hyperkalemia (decreased renal excretion)

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22
Q

Clinical features of hyperkalemia

A 
Weakness, tingling, parathesias
Flaccid paralysis
Hypoventilation
Cardiac toxicity (increased T waves, flattened P wave, AV conduction delay, QRS 
       widening, v fib/flutter)
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23
Q

Treatment of hyperkalemia

A

Non emergent (reduce K intake, increase K output, IV loop and thiazide diuretics,
consider dialysis)
Emergent (calcium chloride centrally or calcium gluconate peripherally, sodium bicarb,
D50 plus insulin, albuterol)

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24
Q

Causes of hypokalemia

A 
Redistribution of K into cells
   Metabolic alkalosis (decrease K 0.3/0.1 pH)
   Medications (insulin, epi and selective beta2 agonists)
   Hypokalemic periodic paralysis
Potassium depletion
   Decreased dietary intake
   Extra renal (diarrhea, laxatives, intestinal bypass or fistula, vomiting and gastric suction)
   Renal (diuretics, steroids, PCN derivatives, renal tubular acidosis, diabetic keto, 
      mineralocorticoid excess - hyperaldosteronism)
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25
Q

Clinical features of hypokalemia

A

Non cardiac (fatigue, myalgia, weakness, constipation, polydipsia and polyuria,
hypoventilation, paralysis)
Cardiac (arrhythmias, a fib, PVCs, flattening T waves, prominent U waves, ST depression,
prolonged QT, prolonged PR, widening QRS)

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26
Q

Treatment of hypokalemia

A

Correct underlying disorder
Asymptomatic or minor (oral K, encourage K rich diet)
Cardiac manifestations or severe (IV K ideally through central access)
Address possible hypomagnesemia

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27
Q

Causes of hypocalcemia

A 
Parathyroid hormone deficiency
Vitamin D deficiency
Hyperphosphatemia (renal failure, tumor lysis, rhabdomyolysis)
Renal failure
Citrate toxicity
Acute alkalemia
Post cardiopulmonary bypass
Acute pancreatitis
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28
Q

Clinical features of hypocalcemia

A

Cardiovascular (dysrrhythmias, QT prolongation, heart failure, hypotension, impaired beta
adrenergic action)
Neuromuscular (tetany, muscle spasm, papilledema, seizure, weakness, fatigue,
paresthesias, irritability, mental status changes)
Respiratory (apnea, laryngeal spasm, bronchospasm)
Psychiatric (anxiety, dementia, depression, psychosis)

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29
Q

Treatment of hypocalcemia

A 
IV calcium
Magnesium
Correct metabolic and/or respiratory alkalosis
Oral calcium or oral vitamin D
Avoid hyperventilation
Avoid bicarbonate
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30
Q

Causes of hypercalcemia

A 
Malignancy (vast majority)
Hyperparathyroidism
Vitamin D intoxication
Sarcoidosis
Hyperthyroidism
Immobilization
Thiazide diuretics and lithium
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31
Q

Clinical features of hypercalcemia

A

Lethargy
Anorexia
Nausea
Polyuria
Neuromuscular (weakness, depression, impaired memory, emotional lability, lethargy,
stupor, coma)
Cardiovascular (hypertension, dysrhythmias, widening QRS, short QT, heart block, arrest)

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32
Q

Propofol infusion syndrome

A 
More common in critically ill children
Cardiomyopathy
Rhabdomyolysis
Severe metabolic acidosis
Hyperkalemia
Hepatomegaly
Lipemia
Renal Failure
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33
Q

Hypoxemia (pathophysiologic mechanism)

A

Decreased inspired oxygen (failure of anesthesia machine, disconnection, gas pressure
failure, crossing of tanks, etc)
Hypoventilation (esophageal intubation, ETT kinking, blockage, herniated or ruptured
cuff, right main stem intubation, respiratory depression)
Impaired diffusion
VQ mismatch
Right to left shunt (PFO, TOF)
Intrapulmonary derangements

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34
Q

Hypoxemia (structural anatomic)

A

Alveoli (pulmonary edema, acute lung injury, ARDS, pulmonary hemorrhage, PNA)
Interstitium (pulmonary fibrosis, viral PNA, allergic alveolitis)
Heart and pulmonary vasculature (PE, intracardiac or intrapulm shunt, CHF)
Airways (asthma, COPD, mucus plugging, right main stem intubation)
Pleura (PTX, pleural effusion)

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35
Q

Intraoperative Acute Hypoxia

A

Check color of patient
Check for a pulse
Check vital signs
Check for ETCO2
Take off ventilator and hand bag with 100% FIO2
Call for help
Check O2 monitor, peak airway pressure, and capnograph waveform
Listen to chest for bilateral breath sounds and chest rise
Evaluate ETT
Listen for wheezing
Bronchospasm - deepen anesthetic with volatile or give epi
Chest xray

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36
Q

Tension PTX

A 
Presentation
   Unilateral absence of breath sounds
   Tracheal deviation
   Unexplainable hypotension
   Distended neck veins
Treatment
   Find 2nd intercostal space
   Find midclavicular line
   Insert 14 gauge angiocath over top of the rib
   Listen for decompressive air rush
   Leave angiocath in place
   Place chest tube
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37
Q

Causes of hypercarbia

A 
Increased production of CO2
   Tourniquet release
   Aortic cross clamp release
   MH
   Sepsis
   Thyrotoxicosis
   Fever
Decreased removal of CO2
   Hypoventilation
   Airway Obstruction
   Increased Dead Space
Rebreathing of CO2 due to mechanical malfunction
Iatrogenic
   Sodium Bicarb administration
   Increased CO2 during laparoscopic procedure
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38
Q

Indications for Intubation

A 
Mechanical Function
   Respiratory Rate >35
   Vital capacity <15 ml/kg adult
   Vital capacity <10 ml/kg child
   Negative inspiratory force less than 20-25 cm H2O
Gas Exchange Function
   PaO2 <60 on FiO2 of 50%
   A-a gradient >350 on FiO2 of 100%
   PaCO2 >55 
   Dead Space Ventilation/Tidal Volume (Vd/Vt) ration >0.6
Unstable Vital Signs
Inability to protect airway
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39
Q

Indications for Extubation (subjective)

A 
Subjective
   Resolution of acute disease
   Adequate cough
   Awake, alert, following commands
   Cooperative
   GCS >13
   No sedation
   Sustained hand grip
   Sustained head lift >5 seconds
   Able to tolerate spontaneous ventilation
   Acceptable electrolytes
   Able to protect airway
   Clear oropharynx
   Adequate pain control
   Minimal end expiratory concentration of inhaled anesthetics
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40
Q

Indications for Extubation (objective)

A 
Objective
   Vital Signs
      RR <30-35
      Stable BP
      HR <140
      Afebrile
   Gas Exchange
      PaO2 >60
      PaCO2 <55
      PaO2/FiO2 >150-300
      Alveolar arterial PaO2 gradient <350 on 100% oxygen
      Maintenance of normal pH
   Mechanical
      FVC >10-15 ml/kg
      FEV1 >10 ml/kg
      TV >4-6 ml/kg
      Negative Inspiratory Force >20
      VC >15 ml/kg
      Dead Space ventilation/Tidal Volume (Vd/Vt) <0.6
      Rapid Shallow Breathing Index (RSBI) (f/Vt) <60-100 breaths/min
   Adequate hemoglobin
   No significant respiratory acidosis
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41
Q

Difficult Airway Algorithm

A

Look up Diagram

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42
Q

Pathological States that Predispose to Difficult Intubations

A

Congenital
Pierre-Robin (micrognathia, macroglossia, cleft palate)
Treacher-Collins (mandibular hypoplasia)
Down’s (macroglossia, atlantoaxial instability)
Kippel-Feil (restricted neck movement secondary to cervical vertebrae fusion)
Infection
Croup
Ludwigs angina
Abscess
Arthritis
Rheumatoid
Ankylosing spondylitis
Benign tumors
Malignancy
Injury (facial, cervical, laryngeal, tracheal, burns)
Diabetes
Scleroderma
Obesity
Pregnancy
Acromegaly
Anatomic abnormalities (micrognathia, limited jaw motion)

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43
Q

Criteria to Predict Difficult Airway

A

History (previous difficult, burns, edema, bleeding, airway stenosis, GERD, poor dentition,
radiation treatments)
Physical
General (obesity, cervical collar, traction device, external trauma, respiratory difficulty)
Patency of nares
Mouth opening (less than two finger breadths)
Teeth (prominent incisors, overbite, loose teeth)
Palate (high, narrow mouth)
Tongue
Prognathism
Thyromental distance <6cm
Neck (short and thick, limited extension, limited flexion)
Specific tests
Mallampati score of 3 or higher
Laryngoscopic grades III or IV
Radiographic assessments
Diabetic predictors (positive prayer sign - gap between palms)

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44
Q

Pediatric Airway - Differences

A

Larger occiput
Hypertrophied tonsil and adenoid tissue
More cephalad larynx (C2-3 premature, C3-4 infant, C4-5 adult)
More narrow and shorter epiglottis, angled into airway
Tongue larger in proportion to oral cavity
Cricoid cartilage is narrowest area (vocal cords in adult)
Obligate nasal breathers

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45
Q

Pediatric ETT selection

A

Uncuffed: Internal diameter (mm) = (16+age)/4

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46
Q

Pediatric Physiology - Pulmonary

A

Prone to peri-operative hypoxemia
High closing volumes
High MV/FRC ratio
Leads to rapid uptake of volatile
Faster inhalational induction (also greater cardiac output per kg)
Lower blood gas partition coefficient
Pliable rib cage
Diaphragm primary contributor to ventilation
If increased O2 demand
Increases RR
Increase respiratory excursion by diaphragmatic contraction
Leads to negative intra-thoracic pressure and retractions
Inefficient form of ventilation with high energy expense

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47
Q

Pediatric fluid maintenance and fluid deficit

A

Maintenance
4 ml/kg/hr for 1st 10 kg
2 ml/kg/hr for 2nd 10 kg
1 ml/kg/hr for each remaining kg

Deficit
Estimated = estimated hourly maintenance x number of hours NPO

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48
Q

Estimated Blood Volume

A 
Premature 90 ml/kg
Full term 85 ml/kg
Infant 80 ml/kg
Child 75 ml/kg
Adult 70 (male) and 65 (female) ml/kg
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49
Q

NPO guidelines

A 
Clear liquids: 2 hours
Breast milk: 4 hours
Formula: 6 hours
Nonhuman milk: 6 hours
Meal with fat: 8 hours
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50
Q

Risk Factors for Fetal Distress

A 
Maternal
   Diabetes
   Pregnancy induced hypertension
   Previous stillbirth
   Infection
   Substance abuse
   C-section
   General anesthesia
   Chronic HTN
   Previous Rh sensitization
   Bleeding in 2nd or 3rd trimester
Fetal
   Post term or preterm
   Poly or oligohydramnios
   Known fetal anomalies
   Abnormal fetal lie
   Non reassuring FHT
   Meconium stained amniotic fluid
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51
Q

Dyspnea - Differential Diagnosis

A

Obstruction to flow (asthma, emphysema, bronchitis, stenosis, malacia)
Resistance to lung expansion (fibrosis, restrictive disease
Resistance to chest expansion (pleural thickening, kyphoscoliosis, obesity, mass)
Weakness of pump (polio, neuromuscular disease)
PTX
Increased respiratory drive (hypoxemia, metabolic acidosis)
Psychological (anxiety, depression)

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52
Q

Dyspnea - Treatment Plan

A 
Reduce the sense of effort
Improve muscle function
Decrease respiratory drive
Alter CNS function
Exercise training and pulmonary rehab
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53
Q

Tachypnea - Causes

A

Airway obstruction (extra or intra thoracic)
Anxiety/pain
Acute circulatory failure (CHF, cardiomyopathy)
Intrapulmonary (COPD, restrictive disease, asthma, aspiration, atelectasis, edema, PTX,
PE, pHTN)
Disease of chest wall or musculature (polio, MG)
Systemic Disease (sepsis, acidosis, hypoxia, shock, fever, MH, infection,
hypophosphatemia)
Excessive post exercise oxygen consumption
Hypermetabolic state
Hyperthyroidism

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54
Q

Wheezing - Differential Diagnosis

A 
Bronchospasm
Asthma
COPD
Tracheobronchitis
Restrictive Pulmonary Disease
RA associated bronchiolitis
Extrinsic compression
Intrinsic compression
CHF
PE
Mechanical obstruction of ETT
Inadequate depth of anesthesia
Endobronchial intubation
Pulmonary aspiration and edema
PTX
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55
Q

Bronchospasm - Differential Diagnosis

A 
Kinked ETT
Solidified secretion or blood
Pulmonary Edema
Tension PTX
Aspiration Pneumonitis
PE
Endobronchial intubation
Persistent cough or strain
Negative Pressure Expiration
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56
Q

Bronchospasm - Intraoperative Treatment

A 
100% oxygen
Deepen anesthetic
Albuterol
IV or SQ epinephrine
Consider IV magnesium
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57
Q

Laryngospasm complications

A

Hypoxia
Noncardiogenic pulmonary edema
Cardiac arrest

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58
Q

Laryngospasm treatment plan

A 
100% oxygen
Remove irritating factor
Jaw thrust
Positive pressure ventilation
Increase depth of anesthesia
IV or topical lidocaine
Call for help
Succinylcholine (10-50 mg IV, IM, or SL)
Attempt intubation
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59
Q

Stridor differential diagnosis

A

Inspiratory: upper airway obstruction
Expiratory: lower airway obstruction
Biphasic: mid tracheal lesion

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60
Q

Stridor treatment plan

A 
Evaluate
Rule out need for emergent intubation
History
Physical exam
Chest Xray
ABG
Flexible bronchoscopy
Consider ENT consult
Oxygen - facemask
Head up position
Nebulized racemic epinephrine
IV Dexamethasone (4-8 mg every 8-12 hours)
Heliox
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61
Q

OSA - AHI index (Apena-hypoapnea)

A

Average number of apneas and hypoapneas per hour
Mild OSA: AHI 5-15
Moderate OSA: AHI 16-30
Severe OSA: AHI >30

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62
Q

OSA - Peri operative concerns

A 
Increased risk for difficult intubation
Post-operative hypoxemia
Post-operative airway obstruction
Myocardial Ischemia
Arrhythmia
Death
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63
Q

One Lung Ventilation - Indications

A

Absolute
Isolation to prevent spillage (infection, hemorrhage)
Control of ventilation (bronchopleural fistula, surgical opening of conducting airway,
cyst, tracheobronchial tree disruption, life threatening hypoxemia from unilateral
airway disease)
Unilateral bronchopulmonary lavage
Relative
Surgical exposure (thoracic aortic aneurysm, pneumonectomy, upper lobectomy,
mediastinal exposure, thoracoscopy, middle and lower lobectomies, esophageal
resection, thoracic spine surgery)
Severe hypoxemia from unilateral lung disease

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64
Q

One Lung Ventilation - Treatment of Hypoxia

A

Increase FIO2 to 100%
If severe, switch to two lung ventilation
Check position of DLT
Apply CPAP (5-10 cm H20) to nondependent lung
Apply PEEP to dependent lung
Intermittently ventilate both lungs
In emergency, have surgeon clamp pulmonary artery

65
Q

Hypotension - Differential Diagnosis

A

Pulmonary: hypoxia, hypercarbia, tension PTX
Hypovolemia: fluid deficit, acute blood loss
Cardiac: rate/rhythm, inotropic failure, myocardial ischemia, contusion, tamponade,
rupture, CHF, cardiomyopathy, valvular injury, lesion
Shock: hypovolemia, cardiogenic, septic
Surgical compression of the heart, aorta, IVC, or abdominal contents
Embolus: pulmonary, air, fat, amniotic
Electrolyte and hormonal abnormalities: hypoglycemia, hypocalcemia, adrenal
insufficiency, ADH suppression, hypermagnesemia
Anaphylaxis
Deep anesthesia, drug overdose, medications
Hypothermia
Sympathetic block, neuraxial block
Venodilation
Laparoscopic surgery: hypercarbia, dysrhythmia, increased vagal tone from peritoneal stretch, compression of IVC, venous gas embolism

66
Q

Hypotension - Preoperative treatment plan

A 
Recheck and validate
Evaluate - symptoms
Physical exam - auscultate, palpate pulses, mucus membranes, temperature, bleeding
Supplemental Oxygen
Increase IV fluids
Review history
Review medications
Determine baseline BP
Consider EKG
ABG, electrolytes, chest Xray
Treat
Consider postponement of elective surgery unless can be treated surgically
67
Q

Hypotension - Intraoperative treatment plan

A 
Confirm BP
Evaluate ABCs, vitals, temp, ETCO2
Place on 100% oxygen
Decrease volatile if tolerated
Increase IV fluids
Evaluate surgical field (bleeding, IVC compression)
Review history and physical exam
Consider invasive hemodynamic monitors and TEE
Stop vasodilating infusions
Start inotropic therapy
   Phenylephrine
   Ephedrine
   Epinephrine
   Norepinephrine
   Dopamine
   Dobutamine
   Milrinone
Place in Trendelenburg
68
Q

Hypertension - Differential Diagnosis

A

Pre-existing HTN
White coat HTN
Pulmonary: hypoxia, hypercarbia, pulmonary edema, OSA
Renal: renovascular disease, renal parenchymal disease, renin-secreting tumor,
polycystic kidney disease
Neurologic: elevated ICP, spinal cord injury, Guillan-Barre syndrome, dysautonomia
Cardiac: ischemia, stiff vessels, aortic coarctation, fluid overload
Endocrine: Cushing’s, pheochromocytoma, thyrotoxicosis, hyperaldosteronism,
hyperparathyroidism
Vascular: coarctation of the aorta, vasculitis, collagen vascular disease
Drugs: vasopressors, cocaine, MOAI inhibitors, TCAs, naloxone, glucocorticoids,
mineralocorticoids, OCPs, withdrawal
Pain, anxiety, inadequate anesthesia
Malignant hyperthermia
Hypothermia
Electrolyte abnormalities: hypercalcemia, hypoglycemia
Autonomic instability

69
Q

Hypertension - Preoperative treatment plan

A

Confirm BP
Evaluate patient (ABCs)
Review history and pharmacology
Postpone elective case if signs of target organ damage

70
Q

Hypertension - Intraoperative treatment plan

A 
Confirm BP
Evaluate ABCs, vitals, ETCO2
Verify oxygenation and ventilation
Consider 100% O2
Review history and physical
Consider placement of invasive monitors
Anti-hypertensive agents
   Beta blockers
   Alpha receptor blockers (hydralazine)
   Alpha receptor agonist (clonidine, dexmedetomidine)
   Vasodilators (nitroglycerin, sodium nitroprusside)
Monitor for myocardial ischemia
71
Q

Arrhythmia - intraoperative causes

A

General anesthetics
Local anesthetics (sympathectomy)
Abnormal ABG and electrolytes (ph, hypoxia, hypercarbia)
Sympathetic response to intubation
Reflexes: Vagal (brady, AV block, asystole), Carotid sinus stimulation (brady),
Oculocardiac (brady or asystole)
CNS stimulation
Autonomic nervous system dysfunction
Pre-existing cardiac disease: MI, CHF, Cardiomyopathy, Valvular dz, Conduction
abnormalities
Central Venous Cannulation
Surgical manipulation (atrial, venous bypass cannulas)
Location of surgery: dental, trigeminal)
Pain
Hypovolemia
Hypotension
Anemia
Endocrine abnormalities: hyperthyroidism, pheochromocytoma
Temperature abnormalities

72
Q

Arrhythmia - assessment

A 
Best evaluated in Lead II
Rate? 
Regular?
One P wave for each QRS?
QRS normal?
Rhythm dangerous?
Hemodynamic disturbance?
Is treatment required? 
How urgently does it need to be treated?
73
Q

Asystole and PEA - Causes

A 
Hypovolemia
Hypoxia
Acidosis
Hyper and hypokalemia
Hypoglycemia
Hypothermia
Toxins/Tablets
Tamponade
Tension Pneumothorax
Thrombosis
Trauma
74
Q

Asystole and PEA - Treatment

A

Call for help
CPR
Oxygen
Attach monitor/defibrillator
Epinephrine 1 mg IV/IO, repeat every 3-5 minutes
Atropine 1 mg IV/IO, repeat every 3-5 minutes
Look for and treat underlying causes

75
Q

Sinus Bradycardia - Causes

A 
Hypoxia/hypercarbia
Drug effects: beta blockers, opioids, succinylcholine, anticholinesterase inhibitors, 
   anesthetics
Acute inferior MI
Vagal stimulation: oculocardiac, visceral
High sympathetic blockade
Acidosis
Allergic reaction
Hypertension
Increased ICP: Cushing's
Baseline bradycardia
76
Q

Sinus Bradycardia - Treatment

A

Check all vital signs
Check baseline HR
Ensure secure airway with adequate oxygenation and ventilation
Obtain 12 lead EKG
Treatment if hypotension, ventricular, or signs of poor perfusion
Atropine 0.5-1 mg IV/IO, may repeat every 3-5 minutes up to 0.04 mg/kg
Ephedrine 5-10 mg IV
Isoproterenol 2-10 mcg/minute IV infusion
Temporary transcutaneous or transvenous pacing

77
Q

Sinus Tachycardia - Causes

A 
Hypoxia/hypercarbia
Pain/anxiety
Inadequate anesthesia
Fever/MH/Sepsis
CHF
Drug effect: catecholamines, pancuronium, anticholinergics, vasodilators
Endocrine: hyperthyroidism, thyrotoxicosis, pheochromocytoma
Electrolyte: hypoglycemia
Surgery
PE
Pacemaker malfunction
Drug withdrawal
Bladder distension
78
Q

Sinus Tachycardia - Treatment

A 
Stable
   Check vital signs
   Check EKG
   Check baseline HR
   Check oxygenation and ventilation
   Treat underlying disorder
   Consider beta blockers
Unstable with a pulse
   Support airway, breathing, circulation
   Oxygen
   Check vital signs
   IV access
   Synchronized cardioversion: 100, 200, 300, then 360 joules
79
Q

Paroxysmal Supraventricular Tachycardia (PSVT) - Etiology

A 
Intrinsic heart disease
Systemic illness
Thyrotoxicosis
Digitalis toxicity
Pulmonary embolism
Pregnancy
Changes in autonomic nervous system
Drug effect
Intravascular volume shifts
80
Q

Paroxysmal Supraventricular Tachycardia (PSVT) - Treatment

A

Vagal maneuvers
Adenosine 6 mg (may be repeated)
Verapamil 2.5-10 mg IV
Amiodarone 150 mg IV over 10 minutes
Esmolol 1 mg/kg bolus and 50-200 mg/kg/min infusion
Edrophonium 5-10 mg
Phenylephrine IV if hypotensive
Digoxin 0.5-1.0 mg
Rapid overt pacing in attempt to capture ectopic focus
Synchronized cardioversion: 50, 100, 200, 300, and 360 joules

81
Q

Atrial Flutter/Fibrillation - Causes

A 
Severe heart disease
Coronary artery disease
Mitral valve disease
Pulmonary embolism
Hyperthyroidism
Cardiac trauma
Cancers of the heart
Myocarditis
82
Q

Atrial Flutter - Treatment

A

Stable
Rule out thrombotic event
Synchronized cardioversion
Pharmacologic cardioversion
Control ventricular rate by slowing conduction through AV node
Beta blockers: esmolol, propranolol
Calcium Channel blockers: verapamil, diltiazem
Unstable
Start synchronized DC cardioversion: 100 joules, gradually increasing to 360 joules
Procainamide 5-10 mg/kg loading dose with a 0.5 mg/kg/minute infusion
Rapid atrial pacing from within atrium

83
Q

Atrial Fibrillation - Treatment

A

Acute
IV Diltiazem or esmolol
Synchronized cardioversion: 100-200 joules, then 300, then 360
If present >48 hours, consider TEE to rule out thrombus
Long-term therapy
Coumadin
Beta blockers, calcium channel blockers, digitalis (all for HR control)
Electrode catheter ablation of AV junction and permanent pacer placement
Implanted atrial defibrillator
Prevention of Recurrence: quinidine, flecainide, sotalol, amiodarone, dofetilide

84
Q

Ventricular Tachycardia - Treatment

A

Amiodarone 150 mg IV over 10 minutes

Synchronized cardioversion: 100-200 joules, then 300, then 360

85
Q

Ventricular Fibrillation

A 
Causes
   Myocardial Ischemia
   Hypoxia
   Hypothermia
   Electric shock
   Electrolyte imbalance
   Drug effect
Treatment
   CPR
   Oxygen
   Monitors/Defibrillator
   Asynchronized Cardioversion: 120-200 joules biphasic, 360 joules monophasic)
   Epinephrine 1 mg every 3-5 minutes
   Consider Amiodarone (300 mg followed by 150 mg), Lidocaine (1-1.5 mg/kg, then 0.5- 
      0.75 mg/kg), Magnesium (1-2 grams for torsades)
86
Q

Cardiac Ischemia - Lead changes and associated artery

A 
V1-V2
   Left Coronary (LAD)
   Septum, AV bundle, bundle branches
V3-V4
   Left Coronary (LAD and diagonal)
   Anterior wall of LV
V5-V6 plus I and aVL
   Left Coronary (Circumflex)
   High lateral wall LV
II, III, aVF
   Right Coronary (Posterior Descending)
   Inferior wall LV and posterior wall LV
V4R
   Right Coronary (proximal branches)
   RV, inferior wall LV, posterior wall LV
V1-V4 (marked depression)
   Left Coronary (circumflex) or Right Coronary (posterior descending)
   Posterior wall LV
87
Q

Cardiac Tamponade - Induction

A

Ketamine first line agent (etomidate second choice)
Neuromuscular blocker
No Midaz (systemic vasodilation)
Avoid Narcotics (bradycardia)
Reduce inspiratory positive pressure (to allow for cardiac filling)

88
Q

Cardiac Evaluation - Major clinical risk predictors

A 
Unstable Coronary Syndromes
   Unstable or severe angina
   Recent MI
Significant Arrhythmia
Severe valvular disease
Decompensated Heart Failure
89
Q

Cardiac Evaluation - Revised Clinical Risk Predictors (stable conditions)

A

Ischemic Heart Disease: history of MI, history of positive treadmill test, use of
nitroglycerine, current complaints of chest pain, EKG with abnormal Q waves
Congestive Heart Failure: history of heart failure, pulmonary edema, paroxysmal
nocturnal dyspnea, peripheral edema, bilateral rales, S3 heart sound
Cerebral Vascular Disease: history of TIA, history of stroke
Preoperative Insulin Treatment
Preoperative Creatinine higher than 2 mg/dL

90
Q

Cardiac Evaluation - Minor predictors of risk

A 
Age greater than 70
Abnormal EKG
   LVH
   LBBB
   ST-T abnormalities
Abnormal rhythm: non-sinus
Uncontrolled systemic HTN
91
Q

Cardiac Risk Stratification for Non-Cardiac Surgical Procedures

A 
Vascular (High Risk - 5% risk)
   Aortic and other major vascular surgery
   Peripheral vascular surgery
   Emergency surgery
   Anticipated long procedures with fluid shifts or larger estimated blood loss
Intermediate Risk (1-5% risk)
   Intraperitoneal and intrathoracic surgery
   Carotid Endarterectomy
   Head and Neck surgery
   Orthopedic surgery
   Prostate surgery
Low Risk (<1% risk)
   Endoscopic procedures
   Superficial procedures
   Cataract surgery
   Breast surgery
   Ambulatory surgery
92
Q

Indications for Pacemaker/AICD placement

A

Pacemaker
Sick Sinus Syndrome
3rd degree AV block
Symptomatic 1st or 2nd degree block
Non-ischemic, exercise induced block
Bradycardia associated with syncope or near syncope
Bradycardia associated with ventricular arrhythmia
Dilated Cardiomyopathies
Hypertrophic Cardiomyopathies
AICDs
Patients at high risk for fatal ventricular arrhythmias (ventricular tachycardia/fibrillation)
High risk for sudden cardiac death
Prior MI with ventricular tachycardia or ventricular fibrillation
Moderate to severe cardiomyopathies

93
Q

Pacemaker nomenclature

A 
Position 1 - Chamber being paced
Position 2 - Chamber being sensed
Position 3 - Response of device to a sensed event
   O - no response
   T - trigger device
   I - inhibit device
   D - dual, triggered and inhibited
Position 4 - Programmability and rate modulation
   O - no programmability
   R - rate modulation activated
Position 5 - Multi-site pacing
94
Q

Aortic Valve area

A

Normal: 1.6 - 2.5 cm2
Mild AS: 1.0 - 1.5 cm2 (peak gradient <20)
Moderate AS: 0.8 - 1.0 cm2 (peak gradient >50)
Severe AS: <0.8 cm2 (peak gradient >50)

95
Q

Aortic Stenosis - Management

A

Rhythm: sinus rhythm important to maintain atrial systole
Heart Rate: maintain normal HR (tachycardia and bradycardia harmful)
Preload: euvolemic, need adequate preload but too much can lead to pulmonary edema
Contractility: avoid decreases in contractility
Afterload: maintain SVR, drops can lead to profound hypotension and drop in coronary
perfusion pressure

96
Q

Aortic Insufficiency - Management

A

Rhythm: slight tachycardia aids with forward cardiac output
Heart Rate: slight tachycardia aids with forward cardiac output
Preload: euvolemic, decreased preload leaves the dilated LV empty, too much fluid can
lead to pulmonary edema
Contractility: dilated LV can lead to decreased contractility
Afterload: slight drop in afterload can aid with forward flow

97
Q

Mitral Stenosis - Management

A

Rhythm: sinus rhythm ideal to maintain EDV, however many of these patients have atrial
fib due to increase in atrial pressure and atrial stretch
Heart Rate: normal HR to allow for adequate diastolic filling time
Preload: maintain preload, a drop in preload leads to a significant drop in LV filling
Contractility: progressive disease can lead to drops in contractility
Afterload: maintain afterload, can’t increase cardiac output across fixed stenosis with
drops in SVR

98
Q

Mitral Insufficiency - Management

A

Rhythm: mild tachycardia and sinus, prone to a fib
Heart Rate: mild tachycardia to promote LV filling
Preload: normal levels
Contractility: advanced disease leads to ventricular dysfunction and worsening MI
Afterload: slight reduction in SVR allows forward flow, elevations in SVR can lead to
pulmonary edema

99
Q

Cardiopulmonary Bypass - Anticoagulation

A

Heparin: 300 units/kg
Goal ACT: >400 seconds
Protamine reversal: 1 mg per 100 U of heparin
Heparin enhances anti-thrombin III - enhanced destruction of thrombin
If anti-thrombin III deficient (recent heparin treatment), need to replace AT-III for heparin
to be effective (FFP)

100
Q

Protamine Reactions

A
  1. Anaphylactic: based on prior exposure, fish allergies, diabetics using NPH, prior
    vasectomy
    Profound Vasodilation and cardiovascular collapse
  2. Pulmonary Vasoconstriction: not well understood, lead to right heart failure
  3. Histamine reaction: due to too rapid administration
    Decrease in intravascular calcium
    Decrease in SVR and hypotension
101
Q

CEA - Neuromonitoring techniques

A

EEG
Advantages: available, reliable, correlates with cerebral ischemia
Disadvantages: Needs trained technician, possible anesthetic agent influences,
inability to detect subcortical ischemia
Processed EEG (BIS)
Advantages: available, identify severe cerebral ischemia, ease of use
Disadvantages: reliability, inability to detect focal ischemia
Somatosensory evoked potentials
Advantages: equivalent efficacy to EEG, detects deep brain structure injury
Disadvantages: complex, need for technician, can’t use inhalational anesthetic
Transcranial Doppler
Advantages: ability to monitor cross clamp hypoperfusion and shunt malfunction,
ability to assess cerebral blood flow and embolic phenomena
Disadvantages: technical complexity, may require trained personnel
Cerebral Oximetry
Advantages: simple
Disadvantages: low sensitivity and specificity
Carotid Stump Pressure
Advantages: simple, lack of expense
Disadvantages: lack of validation, lack of critical CSP value

102
Q

Cerebral Perfusion Pressure

A

CPP = MAP - ICP or CVP (whichever is greater)

103
Q

Anesthetic Effects on Brain Physiology

A

Volatile: increase CBF, can lead to increase ICP due to vasodilation
Propofol: decreases CMR, CBF, and ICP, but can decrease MAP and thus CPP
Etomidate: decreases CMR, CBF, likely decreases ICP (mild vasoconstriction)
Benzodiazepines: decreases CMR, CBF, may decrease ICP
Opioids: minor reduction or no effect on CMR and CBF
Barbiturates: decreases CMR, CBF, ICP but can decrease MAP and thus CPP

104
Q

Treatment of elevated ICP- step one

A

Positional therapy: elevated HOB to 30 degrees
Support hemodynamics: SBP >110 with goal MAP >90, CPP should be at a minimum of 70
Analgesia and Sedation: avoid increase in ICP from agitation
Avoid hypoxemia
Hyperventilation: PaCO2 30-35
Goal hematocrit >30%
Normothermia

105
Q

Treatment of elevated ICP - step two and three

A

Drainage of CSF by surgeon
Osmotic therapy: Mannitol 0.25-1.0 g/kg. Furosemide 1 mg/kg. Hypertonic saline
Decrease IVF after replaced for diuresis from osmotic therapy

106
Q

Treatment of elevated ICP - steps four and five

A

Barbiturate coma (for intractable elevations in ICP)
Neuromuscular blockade (only for short term)
Corticosteroids (reduces cerebral edema)
Decompressive craniotomy

107
Q

Pathophysiology of Venous Air Embolism

A

Mechanical obstruction of pulmonary vasculature
Leads to hypoxemia, vasoconstriction, V/Q mismatch, increased pulmonary artery
pressure, and reduced cardiac output.
Release of vasoactive mediators - increased vascular permeability, pulmonary edema
Increased filling pressures, decreased cardiac output, hypotension, mill-wheel murmur
Airlock

108
Q

Intracranial Hypertension Management (elevated ICP)

A

Hyperventilation
Osmotic diuresis
Barbiturates
CSF drainage

109
Q

Cerebral Aneurysm - Intraoperative Goals

A

Avoid aneurysm rupture, maintain CPP, maintain transmural aneurysm pressure
Blunt sympathetic response to laryngoscopy
IV access: large bore IV, consider central line, avoid excessive fluids
Monitoring: standard ASA, arterial line, consider CVP or PAC
Avoid hypertension to avoid aneurysm rupture
Intracranial hypertension treatment: hyperventilation, osmotic diuresis, CSF drainage
Neurophysiologic monitoring
Induced hypotension

110
Q

Subarachnoid hemorrhage and cerebral vasospasm

A

Develops 3-12 days after SAH, peak days 6-7
Diagnosis via angiography, transcranial doppler, or clinical progression
Prophylaxis and treatment
Nimodipine
Triple H therapy: hypertension, hypervolemia, hemodilution (not as common anymore)

111
Q

Glasgow Coma Scale

A 
Eyes open
   Spontaneous      4
   To Speech          3
   To Pain                2
   None                   1
Best Verbal Response
   Oriented                                5
   Inappropriate words             4
   Incomprehensible sounds    3
Best Motor Response
   Follows commands    6
   Localizes pain             5
   Withdrawal to pain     4
   Flexion to pain            3
   Extension to pain       2
   None                           0
112
Q

SIADH - Etiology

A

Idiopathic
Post-operative
Central Nervous Disease: head trauma, tumors, CVA, delirium tremens
Neoplastic: lung, pancreas, ovary, lymphoma, thymoma
Endocrine: glucocorticoid insufficiency, hypothyroidism
Pulmonary: PNA, PPV, COPD
Medications: TCAs, SSRIs, Nicotine, MDMA
Infectious: CMV, mycobacteria, brain or lung abscess

113
Q

SIADH - Signs and Symptoms

A 
Anorexia
Nausea and Vomiting
Malaise
Headache
Confusion, stupor, coma
Seizures
114
Q

SIADH - Differential Diagnosis

A 
Adrenal insufficiency
Cerebral Salt Wasting Syndrome
CHF
DM
Hypopituitarism
Hypothyroidism
Nephrotic Syndrome
Polydipsia
Simple hyponatremia
115
Q

SIADH - Testing and Diagnosis

A

Hyponatremia: <130 mEq/L
Plasma osmolality: <270 mOsm/kg
Urine sodium concentration: >20 mEq/L
Low: BUN, Cr, Uric Acid, Albumin

116
Q

SIADH - Treatment

A

Treat underlying cause
Fluid (water) restriction: 800-1000 ml per day
IV Saline: for very symptomatic patients, hypertonic saline 200-300 ml over 3-4 hrs
Medications: diuretics, demeclocycline
Do not correct water balance rapidly

117
Q

Cerebral Salt Wasting Syndrome

A

Hyponatremic dehydration due to intracranial pathology
Excessive renal sodium excretion from central process
Dehydrated and hypovolemic (unlike SIADH)

118
Q

Cerebral Salt Wasting Syndrome - Testing

A

Hyponatremia
Dilute urine with high flow rate
Random urine sodium >40 mEq/L
Urine sodium excretion greater than intake

119
Q

Cerebral Salt Wasting Syndrome - Treatment

A

Fluids
Correction of low sodium
Medications: mineralocorticoid (fludrocortisone)

120
Q

Diabetes Insipidus

A

Hypernatremia with normal total body sodium concentration
Inability to concentrate urine
Renal resistance to ADH (nephrogenic)
Decrease in ADH secretion (central)
Excretion of large amounts of extremely dilute urine

121
Q

Diabetes Insipidus - Etiology

A 
Central
   Traumatic: surgical, accidental
   Neoplasm: lymphoma, craniopharyngioma
   Granulomatous disease: sarcoidosis
   Idiopathic
   Infectious: meningitis, encephalitis
   Vascular: cerebral aneurysms, Sheehans
Nephrogenic
   Metabolic: hypokalemia, hypercalcemia
   Infectious: pyelonephritis
   Post-renal obstruction release
   Vascular: sickle cell anemia
   Granulomatous: sarcoidosis
   Drug effects: lithium, amphotericin, demeclocycline, methoxyflurane
   Genetic: X-linked, polycystic kidney disease
122
Q

Diabetes Insipidus - Desmopressin Stimulation Test

A

Central: reduction in urine output and increased urine osmolality
Nephrogenic: no change in urine output and urine osmolality

123
Q

Diabetes Insipidus - Treatment

A 
Central
   Desmopressin
   Hydration
Nephrogenic
   Diuretic: HCTZ
   Indomethacin
   Hydration
124
Q

Oliguria - definition

A

Urine output <400 ml/day

<0.5 ml/kg/hr for 6 hours

125
Q

Acute Renal Failure - Risk Factors

A 
Co-existing Renal Disease
Advanced Age
CHF
Symptomatic Cardiovascular Disease
Major Operative Procedure: CABG, Abdominal Aneurysm Repair
Sepsis
Multiple organ system dysfunction
Iatrogenic Causes: inadequate fluid replacement, delayed tx of sepsis, drugs
Hypotension
126
Q

Acute Renal Failure - Prerenal

A 
Absolute decrease in renal blood flow
   Dehydration
   Acute hemorrhage: hypovolemia, hypotension
   GI fluid loss
   Trauma
   Surgery: mechanical restriction of renal blood flow (clamping)
   Burns
   Renal artery or vein thrombosis
   Excessive Diuretic Use
Relative decrease in renal blood flow
   Septic Shock
   Hepatic Failure
   Allergic reaction/transfusion reaction
   Vasoconstriction
   CHF
   Decrease cardiac output
127
Q

Acute Renal Failure - Renal

A 
Acute glomerulonephritis
   Goodpasture's
   Wegener's granulomatosis
   Acute lupus nephritis
   Post-infectious glomerulonephritis
   Berger's 
   Henoch-Schonlein purpura
   Drugs: allopurinol, hydralazine, rifampin
Interstitial nephritis
   Pyelonephritis
   Sarcoidosis
   Allergic drug reaction
Acute Tubular Necrosis
   Ischemia: hypotension, shock
   Embolic event or aortic cross clamp
   Mechanical Damage: trauma
   Nephrotoxic drugs
   Solvents
   Vasculitis
   Chronic kidney disease: diabetes, hypertension
   Multiple Myeloma
128
Q

Acute Renal Failure - Postrenal

A 
Upper urinary tract obstruction
   Renal pelvis
   Ureter
Lower urinary tract obstruction
   Bladder outlet
   Foley catheter
   Urethral
   Prostatic hypertrophy or cancer
   Cervical cancer
129
Q

Correction of sodium deficit

A

Dose = weight (kg) x (140-current Na concentration) x 0.6
Correct at rate of 0/6-1.0 mmol/L/hr until Na is 125 mEq/L
Replace half of the deficit over first 8 hours, rest over the next 1-3 days

130
Q

Fasting Guidelines

A 
Clear liquids: 2-3 hours
Breast milk: 4 hours
Infant formula and non-human milk: 6 hours
Light meals: 6 hours
Regular meals: 8 hours
Fried and fatty foods: >8 hours
131
Q

Pheochromocytoma: pre-operative

A

Identify tumor location
Alpha blockade
Beta blockade considered, needs to be started after alpha blockers
10-14 days of treatment, proceed with surgery when:
BP consistently below 160/90
No orthostatic hypotension
No ST-T changes on EKG
Consider pre-operative volume loading
Consider co-morbid conditions: cardiomyopathy

132
Q

Pheochromocytoma: intra-operative

A

Pre-operative sedation
General, regional, and combined techniques have been used
Judicious use of histamine releasing drugs and sympathomimetics
Pre-induction arterial line
Short acting hypotensive agents on hand: esmolol, nitroprusside, nicardipine
IV lidocaine to blunt laryngoscopy response
Magnesium: vasodilator and they are often depleted
Slow induction
Manipulation of tumor may cause spikes in BP
BP may fall precipitously when tumor blood supply ligated

133
Q

Thyroid Storm - treatment

A 
Propylthiouracil (PTU)
Supportive measures for fever: acetaminophen, cooling blankets
IV fluids
Sodium iodide
Hydrocortisone
Meperidine (for shivering)
Digoxin (for heart failure)
Propranolol or esmolol
134
Q

Hyperthyroidism - treatment

A 
Euthyroid before surgery
Non-emergent
   PTU, methimazole (both may take 6-8 weeks)
   Radioactive iodine
   Surgery
   Glucocorticoids
Emergent
   Beta Blockers
135
Q

RSI Indications

A 
Full stomach: <8 hours fasting
Unknown last oral intake
Morbid obesity
Severe GERD
Decreased GI motility
Intra-abdominal process
Trauma
Pregnancy
Decreased gag reflex or depressed mental status
136
Q

RSI Contraindications

A

Difficult Airway
Contraindication to succinylcholine
Cervical Spine Injury

137
Q

Delayed Emergence, Altered Mental Status - Differential Diagnosis

A

Hypoxia and Hypercarbia
Hypotension
Hypothermia
Residual medications and polypharmacy: muscle relaxants, volatiles, opioids, induction
drugs, pre-medications, scopolamine, ketamine, steroid psychosis, cardiac anti-
dysrhythmics, TCAs, antihistamines
Electrolyte abnormalities: DKA, hyper and hypoglycemia, hyponatremia,
hypermagnesemia, acidosis/alkalosis, hypercalcemia
Adverse neurologic outcome
Infections
Substance abuse
Endocrine abnormalities: Addison’s, Cushing’s, Hyper/hypothyroid
Renal abnormalities
Pain and anxiety

138
Q

Delayed Emergence, Altered Mental Status - Evaluation

A

Check oxygenation and ventilation
Check vital signs
Review medications
Investigate pre-operative level of consciousness
Check patient’s response to stimulus
Pharmacological reversal agents
Naloxone: 0.04 mg IV, repeat every 2 minutes up to 0.2 mg
Flumazenil: 0.2 mg IV per minute to total of 1 mg
Physostigmine: 1.25 mg IV
Reversal of neuromuscular blockers
Consider LAST
Check ABG, electrolytes, and blood glucose
Perform neurological check
Head CT scan and neuro consult

139
Q

Post Carotid Bleed - Causes of Respiratory Insufficiency

A

Recurrent laryngeal nerve injury
Hypoglossal nerve injury
Massive Hematoma
Deficient Carotid Body function - loss in ventilatory drive

140
Q

Nausea and Vomiting - Differential Diagnosis

A 
Hypoxia
Hypotension
Pain
Anxiety
Infection
Chemotherapy
GI obstruction
Narcotics, volatiles
Movement
Vagal Response
Pregnancy
Increased ICP
PONV
141
Q

Malignant Hyperthermia - Treatment Intraoperative

A

Call for Help, Call MH Hotline
Discontinue triggering agent
Change circuit
Hyperventilate with 100% O2
Dantrolene: 2-3 mg/kg IV bolus every 5 minutes up to 10 mg/kg.
Then start infusion of 1-2 mg/kg/hr.
Treat Acidosis: Sodium Bicarbonate
Cool patient
Monitor UOP: goal >1-2ml/kg/hr. Use IV fluids, furosemide, mannitol
Obtain labs: ABG, electrolytes, CK, hepatic functions, coag panel, CBC, glucose
Treat Hyperkalemia: Insulin 0.1-0.2 U/kg and Dextrose 500 mg/kg and calcium
Treat arrhythmias
Expedite or abort surgery
Consider arterial line and central line

142
Q

Malignant Hyperthermia - Treatment Postoperative

A 
Alkalinize the urine and diurese
Follow CK levels
Follow all labs
Watch for DIC
Follow CNS status
Continue dantrolene 1 mg/kg IV q 4-6 hours for up to 72 hours
143
Q

Interscalene Block

A

Indications: shoulder, upper arm, lower arm
Shortcomings: Can spare C8 and T1 (ulnar nerve), potentially harmful in COPD
Complications: PTX, spinal or epidural block, vertebral artery, hoarseness (more often in
right sided, 10-20%), phrenic nerve paralysis (near 100%), cervical plexus blockade,
Horner’s syndrome (Miosis, Ptosis, Nasal Stuffiness, Anhidrosis)

144
Q

Supraclavicular Block

A

Indications: upper arm, lower arm, NOT shoulder
Shortcomings: avoid bilateral due to risk of PTX and phrenic nerve injury
Complications: PTX, phrenic nerve block

145
Q

Infraclavicular Block

A

Indications: upper arm, lower arm, NOT shoulder
Shortcomings: may involve multiple injections to get musculocutaneous
Complications: PTX

146
Q

Axillary Block

A

Indications: forearm, wrist, hand
Shortcomings: may need multiple injections to get musculocutaneous and
intercostobrachial and medial brachial cutaneous, arm must be abducted to perform
Complications: none specific to this block

147
Q

Lumbar Plexus Block

A

Indications: femoral neck/shaft, anterior thigh, knee
Shortcomings: very vascular area
Complications: retroperitoneal hematomas, epidural spread, LAST, hip flexor weakness

148
Q

Femoral Nerve Block

A

Indications: knee
Shortcomings: need for sciatic (popliteal) and/or obturator (medial thigh) to completely
cover knee, quadriceps weakness
Complications: accidental puncture/injury of peritoneal space

149
Q

Sciatic Nerve Block (popliteal)

A

Indications: sole of the foot and below knee
Shortcomings: likely require lumbar plexus, femoral, or saphenous nerve blocks as well
Complications: no specific complications

150
Q

CRPS

A 
Type I: not associated with a major nerve injury, non-dermatomal distribution
Type II: associated with a major nerve injury, dermatomal distribution
Treatment: 
   1. Physical therapy
   2. NSAIDs
   3. Opioids
   4. Steroids (acute phase of condition)
   5. SSRIs and TCAs
   6. Lidocaine (IV), maybe patches
   7. Gabapentin
   8. Clonidine patches
   9. Ketamine
   10. Sympathetic blocks (stellate ganglion, lumbar)
   11. TENS unit
   12. Spinal Cord Stimulator
   13. Psychiatric Treatment
151
Q

Hyperthermia - Differential Diagnosis

A

Iatrogenic
Infectious
Pulmonary (aspiration pneumonitis, atelectasis, DVT/PE)
Metabolic (pheochromocytoma, thyroid, adrenal insufficiency)
Central Nervous System (status epilepticus, hypothalamus, Parkinson’s)
Drug induced (MH, Neuroleptic Malignant Syndrome, Anticholinergic effect, Cocaine,
TCAs, MOAIs)
Blood transfusion

152
Q

Hypothermia - Differential Diagnosis

A 
Environmental
Impaired Thermoregulation
Medical Conditions (hypothyroidism, large BSA burns, malnutrition, hypoglycemia, 
   hypothalamic, unconsciousness)
Iatrogenic
153
Q

Myasthenia Gravis - Anesthetic Implications

A

Resistant to depolarizing neuromuscular blockers (unless receiving treatment)
Sensitive to non-depolarizing neuromuscular blockers (unless receiving treatment)

154
Q

Sickle Cell Crisis Triggers

A 
Low oxygen saturation
Acidosis
Hypo/hyperthermia
Infection
Emotional Stress
Physical Exertion
Alcohol Consumption
Dehydration
Surgery
155
Q

Complications of Massive Transfusion

A

Hypothermia
Volume Overload
Dilutional Coagulopathy (decrease in fibrinogen, FII, FV, FVIII, platelets)
Left shift of Oxygen-Hgb dissociation curve (due to decrease in 2,3-DPG)
Citrate intoxication (hypotension, narrow pulse pressure, elevated CVP)
Hyperkalemia
Acid-base disturbances

156
Q

Remote Anesthesia Guidelines

A

Reliable oxygen source and back up E cylinder
Suction source
Waste gas scavenging system
Adequate monitoring that complies with ASA standards
Self-inflating resuscitator bag
Adequate anesthetic drugs and supplies
Sufficient safe electrical outlets
Adequate light and battery powered backup
Sufficient space
Emergency cart with defibrillator, emergency drugs and equipment
Means of reliable two-way communication
Compliance with safety and building codes
Adequately trained staff to support anesthesia team
Adequate equipment for transport
Post-anesthesia care facilities

157
Q

Remote monitoring guidelines

A

Qualified anesthesia personnel
Continuous monitoring of oxygenation, ventilation, circulation, temperature
Oxygen concentrations of inspired gas, low oxygen concentration alarm
Blood oxygenation: pulse ox
Ventilation: observation, ETCO2, disconnect alarm
Circulation: EKG, BP every 5 minutes, pulse ox

158
Q

MRI Anesthetic Equipment

A

Anesthesia cart (pediatric or adult)
Anesthesia machine/circuits (pediatric or adult)
Monitors for transport
End-tidal CO2 monitor
Temperature monitor
MRI-compatible monitoring equipment
Airway equipment (oral and nasal airways, nasal cannula, masks, LMAs, ETTs)
Long corrugated ventilation tubing
Self-inflating resuscitator bag
Syringe pump and extension sets
Medications (propofol, remifentanil, ketamine, midazolam, fentanyl, succinylcholine, non-
depolarizing muscle relaxants, ephedrine, other emergency drugs)
IV tubing and fluids
Charting supplies

Oral Boards (2 decks)

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