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Anesthesia > CA1 > Flashcards

CA1 Flashcards

1
Q

What does NIBP measure?

A

MAP

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2
Q

What is SaO2 and how is it calculated

A

Fractional Oxygen O2Hb/(O2Hb + COHb+MetHb)

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3
Q

What at high levels cause SpO2 to be 85% and what happens at different levels of SaO2?

A

Methemoglobinemia; SaO2 >85% falsely low reading and SaO2 <85% falsely high reading

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4
Q

What does CO reading do to SpO2?

A

Creates a falsely high SpO2 reading due to similar absorbance to O2Hb

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5
Q

When does cyanosis appear?

A

@ Hgb of 15 SaO2 of 80% and Hgb of 9 SaO2 of 66%

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6
Q

How sensitive is using two leads II and V5 in predicting ischemic events?

A

80%

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7
Q

How do you calculate Systolic and Diastolic BP with MAP?

A

MAP = (SBP +2DBP)/3 = DBP + (pulse pressure)/3

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8
Q

How does blood pressure change with change in height?

A

pH 7.410 for every 10 cm of height change 7.4 mmHg

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9
Q

How does EtCO2 change when patient goes apneic

A

Will increase 6 mmHg first minute and 3 mmHg every minute after that

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10
Q

What is gold standard of temperature source?

A

Pulmonary artery temperature

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11
Q

For inhalation agents what measure effect of the gas?

A

Partial pressure not concentration therefore atmospheric pressure matters => higher altitude = less effective at the same concentration

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12
Q

What does high cardiac output do to anesthetic reaching the CNS

A

You need more, there is more in the “tank”

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13
Q

How do different shunts effect volatile anesthetics

A

Right to left shunt (and mainstem) causes dilution of volatile gas.

Left to right shunt doesn’t do anything

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14
Q

Explain the second gas effect

A

The effect of a second agent increases the concentration of the other gas (i.e nitrous)

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15
Q

Potency of volatile anesthetic is linked to what?

A

Lipid solubility

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16
Q

What are the effects of volatile agents on neuro

A

Decreases CMRO2 and CVR but increases CBF and ICP

Nitrous Increases CMRO2 and CVR

0.5 mac of sevo/iso/des decrease CMRO2 and CBF is okay

1 mac of sevo/iso/des decreases CMRO2 substantially and CVR decreases therefore CBF increases

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17
Q

What are the effects of volatile agents on cardiac

A

Decrease in SVR and MAP, but maintains CO except halothane decreases contractility

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18
Q

Effects of volatile agents on Pulm

A

Decrease tidal volume, increased RR in order to maintain minute ventilation

Bronchodilation

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19
Q

Effects of volatile agents on renal

A

Decrease renal blood flow and decrease in GFR

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20
Q

Effects of volatile agents on MSK

A

increases muscle relaxation except N2O

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21
Q

Pros of N2O

A

Pros:
Quick on and off
NMDA antagonist
No malignant hyperthermia

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22
Q

Cons of N2O

A

Cons:

  • Mac of 104% only adjunct, low potency
  • PONV
  • If pulmonary cavities or blebs can cause tension pneumo
  • Pulm HTN for prolonged exposure
  • Bone marrow suppression with prolonged exposure
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23
Q

Pros of Iso

A

Pros:
Second most potent
Least expensive
Mac of 2 causes silent EEG

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24
Q

Cons of ISO

A

Cons:

  • Coronary vasodilator => coronary steal syndrome
  • Decreases BP and increases CBF @ mac 1.6 and ICP mac above 1
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25
Q

Things to know about Sevo and the carbon dioxide desicator

A

Can create CO

Can create Compound A and found to be nephrotoxic in rats therefore keep flows atleast 2 L/min so rebreathing does not happen.

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26
Q

Things to know about desflurane

A
  • Low potency
  • high vapor pressure
  • Very pungent => When given to awake patient => Can cause breath holding, bronchospasm, laryngospasm, cough, salivation
  • Can cause increase HR and BP when increased rapidly
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27
Q

At what MAC does 95% of patients no respond to incision?

A

MAC 1.3

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28
Q

What is MACaware

A

MAC necessary to prevent response to tactile or verbal response

volatile = 0.4 and N2O = 0.6

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29
Q

MAC movement

A

MAC 1.0 prevents movement

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30
Q

MAClaryngoscope,LMA,intubation

A

MAC 1.3

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31
Q

MACBar

A

MAC to reach blunted autonomic response to noxious stimulus

MAC 1.6 with use of opiate and nitrous

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32
Q

When is MAC highest and how does it depreciate?

A

Highest at 6 mo old

after 40 y/o decreases 6% for every decade

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33
Q

What factors require higher MAC?

A
  • Amphetamine, ephedrine, L-Dopa, and TCA => Inhibition of catecholamine reuptake
  • Chronic alcohol abuse
  • <6 mo yo
  • Hyperthermia
  • Hypernatremia

-Gingers

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34
Q

What pathophysiological conditions causes requiring less MAC

A
  • Hypothermia
  • Hypoxia
  • Hypercarbia
  • Severe anemia Hgb<5
  • Sepsis
  • Hyponatremia
  • Acute EtOH intoxication
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35
Q

Propofol Induction dose

A

1.5-2.5 mg/kg

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36
Q

Propofol effects on Neuro

A

Decrease CMRO2, CBF, ICP

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37
Q

Propofol effects on CV

A

Decreases SVR, direct myocardial depressant

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38
Q

Propofol effect on Pulm

A

Dose-dependent respiratory depression

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39
Q

Propofol things to know

A
  • Pain on injection
  • Antiemetic properties
  • Anticonvulsant
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40
Q

Etomidate induction dose

A

0.2-0.3 mg/kg

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41
Q

Etomidate effects on neuro

A

Decreases CMRO2, CBF, ICP

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42
Q

Etomidate effects on CV

A

Maintains hemodynamic stability (minimal cardiac depression)

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43
Q

Etomidate effects on pulm

A

Minimal respiratory depression (no histamine release)

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44
Q

Etomidate things to know

A
  • Pain on injection
  • High PONV
  • Myocolonus
  • Inhibits adrenocoritical axis (inhibits 11-beta-hydroxylase)
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45
Q

Ketamine induction dose

A

1-2 mg/kg

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46
Q

Ketamine effects on neuro

A

Increases CMRO2, CBF, and ICP

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47
Q

Ketamine effects on CV

A

Cardio-stimulating effects (negatively effects mycoardial supply-demand)

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48
Q

Ketamine effects on pulm

A

Minimal respiratory depression; bronchodilation, most likely protect airway reflexes

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49
Q

Ketamine things to know

A
  • Analgesic effects
  • NMDA antagonist
  • Can be used in chronic pain patients
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50
Q

Midazolam induction dose

A

1-2 mg

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51
Q

Midazolam effects on neuro

A

Decreases CMRO2, CBF, and ICP; does not cause burst suppression on EEG

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52
Q

Midazolam effects on CV

A

Decreases SVR and BP

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53
Q

Midazolam effects on Pulm

A

Dose-dependent respiratory depression

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54
Q

Midazolam reversal drug

A

Flumazenil

  • Very short acting
  • Can see re-sedation as benzo is eliminated more slowly compared to effects of flumazenil
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55
Q

Dexmedetomidine target

A

selective alpha2-adrenergic agonist (primarily central)

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56
Q

Dexmedetomidine main side effect

A

Bradycardia, heart block, and hypotension

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57
Q

What drug can you use to awake FOB intubations for sedation

A

Dexmedetomidine

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58
Q

What part of the brain is effected by the mu receptor agonism?

A

Periaquaductal gray matter

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59
Q

What part of the spinal cord is effected by the mu receptor agonism?

A

Substantia gelatinosa

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60
Q

Side effects of opiates

A
  • Sedation, Respiratory depression, chest wall rigidity
  • Bradycardia, hypotension (when given with other agents)
  • Itching, nausea, ileus, urinary retention
  • Miosis
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61
Q

What does opioids do to MAC of volatile anesthetics?

A

Reducses MAC required

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62
Q

Fentanyl peak onset and duration

A

Peak onset: 3-5 minutes

Duration of action: 30-60 minutes

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63
Q

Things to know about fentanyl

A
  • Very long context-sensitive half-life limits therefore:
    1) Cut dose in half every 2 hours
    2) prolonged duration of action with repeated boluses intraop
64
Q

Things to know about remifentanil

A
  • Max does 0.3 mcg/kg/min
  • Rapid metabolism and will last 5-10 min regardless of infusion duration due to almost no context-sensitivity of half-life
  • Useful to use for neuromonitoring and NMBA cannot be used to have the patient not move
  • Bradycardia is the most common: Have some glyco or atropine
65
Q

Things to know about Sufentanil

A
  • Has some context-sensitive half-life with some accumulation
  • Typical infusion dosing: Divide case into thirds

0.3 mcg/kg/h -> 0.2 -> 0.1 and turn off 15-30 minutes before end of surgery

66
Q

What to watch out for meperidine (demerol)

A

-Toxic metabolite (normeperidine) lowers seizure threshold

  • Anticholinergic side effects
  • Avoid using with MAOIs
  • Libby Zion Law: interacts with Haldol

-Common use is for Postop shivering common in younger patients

67
Q

What are some opioids to consider for ENT cases

A

Remifentanil or Sufentanil for narcotic wake up with less bucking and good post-op analgesia

68
Q

Which opioids do you want to avoid in renal patients?

A

Demerol (meperidine) and morphine due to active metabolites.

69
Q

How to calculate SVR with CO and how to calculate CO

A 
MAP-CVP = CO x SVR or V=I x R
CO = HR x SV
70
Q

How to calculate SVR and normal range

A

SVR = [(MAP-CVP)/CO]x80 normal range 800-1200 dynes

71
Q

Differential for narrow pulse pressure

A

<25 mmHg

  • Aortic stenosis
  • Coarctation of the aorta
  • Tension pneumothorax
  • Myocardial failure
  • Shock
72
Q

Differential for wide pulse pressure

A

> 40 mmHg

  • Aortic regurgitation
  • Atherosclerosis
  • PDA
  • Thyrotoxicosis
  • AVM
  • Pregnancy
  • Anxiety
73
Q

Intraoperative HTN ddx

A
  • Light anesthesia
  • Pain
  • Chronic HTN
  • Illicit drug use
  • Hypermetabolic state (MH, thyrotoxicosis, NMS)
  • Elevated ICP (Cushing’s triad => HTN, bradycardia, irregular respirations)
  • Autonomic hyperreflexia
  • Endocrine
  • Hypervolemia
  • Iatrogenic (epi + local)
  • Hypercarbia
74
Q

DDX of intraop hypotension

A
  • Measurement error
  • Hypovolemia
  • Drugs
  • Regional anesthesia
  • Surgical events
  • Cardiopulmonary problems
  • Acidosis and hypocalcemia must be treated before giving vasoactive drugs
75
Q

Mechanism of action for succinylocholine

A

ACh receptor agonist depolarizing NMBA

76
Q

Succinylocholine intubation dose

A

1-1.5 mg/kg

77
Q

Onset of succinylocholine

A

30-60 seconds

78
Q

How long does succinylocholine last?

A

~10 minutes

79
Q

Contraindications for Succinylocholine

A
  • HyperK and usual induction dose increases K ~0.5 mEq/L.
  • Avoid in burn patients, muscular dystrophy, myotonias, prolonged immobility, crash injury, upper motor neuron insults from stroke and tumors
  • MH
  • Open globe
80
Q

Mechanism of action of nondepolarizing NMBA

A

-Competitive inhibition of nicotinic Ach receptor at NMJ

81
Q

RSI and normal intubating dose for ROC

A

1.2 mg/kg and 0.6 mg/kg

82
Q

What NMBA do you use for renal or hepatic patients? and why?

A

Cisatracurium

Eliminated by Hofmann reaction

83
Q

When do you know when NMBA is fully reversed?

A

TOF of 0.9 when comparing the 4th to the 1st twitch or 5 seconds of sustained tetanus @ 50-100 Hz wi/o fade

84
Q

Where do you check for twitches to assess different muscles?

A

Diaphragm => corrugator supercilii

Pharyngeal muscles and readiness for extubation => adductor pollicis

85
Q

Side effects of neostigmine

A

Muscarinic vagal side effects (bradycardia, GI stimulation, bronchospasm)

86
Q

How do you dose neostigmine with glyco

A

40-50 mcg/kg never more than 70 mcg/kg

and give 1/5 of the amount of glyco with the neostigmine

87
Q

When do you not use sugammadex

A
  • Hormonal contraceptives for next 7 days will not work
  • Severe renal insufficiency
  • PTT and PT prolonged by 25% for 60 mins
  • Do not mix with Zofran, verapamil and ranitidine

Anaphylaxis

88
Q

Things to worry about for difficult or impossible face mask ventilation

A

MaMaBOATS:

  • Mallampati III or IV
  • Mandibular protrusion decreased
  • Beard
  • Obesity/OSA
  • Age >57-58
  • Teeth lacking
  • Snoring
89
Q

How to ramp?

A

Tragus is aligned with sternum and parallel to the floor

90
Q

What are the three axis you want to line up for intubation?

A

Oral axis,
Pharyngeal axis
Laryngeal axis

91
Q

How do you know a patient is volume responsive when using pulse pressure variation?

A

If their PPV > 10%

92
Q

Total body water for males and females

A

Males: weight x 60%
Females: weight x 50%

93
Q

Total body water components

A

67% intracellular + (25% interstitial + 8% intravascular)=extracellular

94
Q

Total body water weight distribution

A

5% of weight intravascular- 15% interstitial - 40% intracellular

5-15-40

95
Q

What does aldosterone do to fluid status

A

Sodium reabsorption and increase intravascular volume

96
Q

What does ADH/Vasopressin do?

A

Water reabsorption

97
Q

What does atrial natriuretic peptide do?

A

Sodium and water excretion

98
Q

NS advantages

A

Preferred for brain injury/swelling due hyperosmolar

99
Q

NS disadvantages

A

Hyperchloremic metabolic acidosis

100
Q

LR advantages

A

more “balanced”

101
Q

LR disadvantages

A

Potassium for renal patients

Ca maybe interferes with citrate’s chelating properties in pRBCs

102
Q

What type of patients should you use colloids?

A
  • Cirrhotics
  • Burn patients
  • Hemorrhagic shock with no blood => 1cc of colloid per cc of blood loss
103
Q

half life of colloid and crystaloid intravascular

A

colloid => 3-6

Crystaloid => 20-30 mins

104
Q

Fluid management rules

A

4-2-1 rule = 40+weight

105
Q

How to give fluid deficits back

A

1/2 over 1st hour
1/4 over 2nd hour
1/4 over 3rd hour

106
Q

How much evaporative loss happens in minimal tissue trauma (hernia repair)

A

0-2 ml/kg/hr

107
Q

How much evaporative loss happens in Moderate tissue trauma (open cholecystectomy)

A

2-4 ml/kg/hr

108
Q

How much evaporative loss happens in severe tissue trauma (bowel resection)

A

4-8 ml/kg/hr

109
Q

How to calculate blood loss

A

1 lap = 100-150 ml
4x4 = 10 ml each
Suction canister

110
Q

How to replete volume to burn patients

A

Parkland Formula
Give 2cc/kg x %BSA over first 8 hours
Give 2cc/kg x %BSA over next 16 hrs

111
Q

How to calculate %BSA?

A

Rule of nines

112
Q

Minimum UOP during surgery

A

0.5 cc/kg/hr

113
Q

How to calculate IBW

A

46 + 2.3 inch above or below 5 ft = females

50 + 2.3 inches above or below 5 ft = males

114
Q

Arterial O2 content equation

A

CaO2 = HbO2 + Dissolved O2

=(Hb x 1.36 x SaO2) + (PaO2 x 0.003)

NL = 20 cc O2/dl

115
Q

Estimated blood volume for Male and female adult

A

70 cc/kg = male

65 cc/kg = female

116
Q

Complications to think about with giving blood

A

1) Hypothermia => give it in a warmer
2) Coagulopathy (dilutional)
3) Citrate toxicity => Ca chelator
4) Acid-base
5) Hyperkalemia (K moves out of pRBCs during storage)
6) Impaired O2 delivery capacity (2,3 DPG)

117
Q

How to think about transfusion reactions according to fever or no fever and acuity

A

Fever:
Acute: Acute hemolytic, Febrile Non-hemolytic, Transfusion -related sepsis, Trali

Delayed: Delayed hemolytic, TA-GVHD

No Fever:
Acute: Allergic, hypotensive, TACO

Delayed: Delayed serologic, post-transfusion purpura, Iron overload

118
Q

What type of patient usually get anaphylactic rxn to blood products?

A

-IgA deficiency get washed blood

119
Q

What is TACO?

A

Tranfusion associated circulatory overload => get volume reduced blood for CHF patients

120
Q

Dyspnea, hypoxemia, hypotension, fever, PE post transfusion

A

TRALI => Transfusion Related Acute Lung Injury

4-6 hours post transfusion

121
Q

Causes of hypoxemia

A 
Low FiO2
Hypoventilation
Diffusion impairment
Shunt
V/Q Mismatch or Deadspace
122
Q

What is Alveolar gas equation?

what is normal partial pressure of arterial O2

A

PAO2 = FiO2 (760-47) - (PaCO2/0.8) = 100 mmHg

normal PaO2 = 103 - age/3

123
Q

Normal A-a gradients

A

<10 mmHg on RA
<60 mmHg on 100% O2
< (age/4) + 4
a/A ration > 0.75

124
Q

Steps to think about during hypoxemia

A

1) Listen to Lungs
2) Check ETT
3) Check Circuit
4) Check machine
5) Check monitors

125
Q

How to manage hypoxemia

A

1) Patient on 100% FiO2
2) Recruitment maneuver 30 sec at 30 mmHg and add PEEP
3) ETT placement by auscultation
4) Suction airway and ETT
5) CV issues with CO
6) Send ABG/VBG

126
Q

Mixed Venous O2 content

A

CvO2 = O2 Hb + Dissolved O2

PvO2 = 40

CvO2 = 15 cc O2/dl

127
Q

O2 Delivery equation

A

CO x CaO2
= 5 L/min x 20 cc O2/dl
=1 L O2/min

128
Q

O2 consumption

A

Fick equation
VO2 = CO x (CaO2 -CvO2)
=5 L/min x 5 cc O2/dl
250 cc O2/min

129
Q

Hyperkalemia effect on EKG

A

Peaked T waves with prolonged PR segment to drop of P wave with widening to QRS to sine waves

130
Q

Treatment for hyperK

A

Stabilize cardiomyocyte by giving calcium

Shift K intracellular Sodium bicarb, insullin, albuterol

Remove potassium: kayexalate, sorbitol, diuretics, and dialysis

avoid acidosis and treat acidosis

131
Q

EKG changes for hypokalemia

A

U wave

132
Q

Signs and symptoms of hypermagnesemia

A

EKG (wide QRS, long PR, bradycardia)

Hypotension (vasodilation, mycoardial depression)

133
Q

Signs and symptoms of hypomagnesemia

A

EKG (long QT, PACs, PVCs, afib)

Seizures

134
Q

Drawbacks of hypothermia

A

1) infection x 3 fold
2) wound healing
3) Coagulopathy

135
Q

Patient related risk factors for PONV

A

Young, female, non-smoker, with hx of PONV or motion sickness

136
Q

Which drugs give you PONV

A

1)Volatile anesthetics
2 Post-op Narcotics, neostigmine
3)Aggressive hydration causing gut edema

137
Q

Surgery related things for PONV

A

> 2 hours

138
Q

What is the mechanism of action of zofran and what is a common side effect

A

5-HT3 antagonists and headache

139
Q

What does promethazine (phenergan) do?

A

Dopamine antagonist as well as H1 antagonism

140
Q

What does metoclopramide (Reglan) do and who to avoid in?

A

Dopamine antagonist, can cause extrapyrammidal SE therefore do not give it to Parkinson’s patient

141
Q

Larynx innervations

A

Recurrent laryngeal (CNX) most of the motor

Superior Laryngeal

  • internal branch
  • External branch: motor of cricothyroid
142
Q

What nerve mediates laryngospasm?

A

-superior laryngeal nerve

143
Q

How to manage laryngospasm

A

1) Jaw thrust, head tilt, oral or nasal airway
2) Suction oropharynx
3) CPAP => bag mask
4) Propofol or IV lidocaine
5) Sux
6) Reintubate vs surgical airway
7) Monitor for post-obstructive negative pressure pulmonary edema

144
Q

NPO guidelines

A 
Clears 2 hrs
Breast milk 4 hrs
Formula 6 hrs
non-human milk 6 hrs
Light meal 6 hrs
Fatty meal 6-8 hrs
145
Q

Anaphylaxis epi dose

A

10-100 mcg IV boluses

0.3-0.5 mg IM

146
Q

What is the biggest cause of anaphylaxis in the OR

A

NMBA

147
Q

Lidocaine max dose

A

4.5 mg/kg

w/ epi 7 mg/kg

148
Q

Bupivacaine max dose

A

2.5 mg/kg with epi 3 mg/kg

=> 0.25%

149
Q

What are the CNS effects of Local Anesthetic toxicity

A

-Lightheadedness, tinnitus, tongue numbness, metallic taste -> CNS excitation -> CNS depression, seizure -> coma

150
Q

What are the CV effects of LAST

A
  • Bupi worse than lido
  • Dose dependent blockade of Na channels -> bradycardia, ventricular dysrhythmias, decrease contractility, CV collapse, circulatory arrest

-3x the amount of local is required to produce CV toxicity than CNS

151
Q

Treatment of LAST

A

Intralipid kit

-1.5 cc/kg bolus 20% intralipid

152
Q

Triggers of Malignant hyperthermia

A

Inhalational agents and sux

153
Q

Sx of MH

A

1) increased HR and BP
2) tachypnea
3) increased temperature 1-2 degrees C every 5 minutes

first signs are trismus, but often hypercarbia will be first sign

154
Q

Treatment for MH

A

-Dantrolene or ryanodex

155
Q

When should abx prophylaxis be ideally given?

A

within 60 minutes of surgical incision ideally 15-45 minutes

Anesthesia (1 decks)

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