CH6 GENERAL ANESTHESIA Flashcards
longest acting sulfonylurea
CHLORPROPAMIDE
DURATION 72 hrs
duration of regular insulin
peak 2-3 hrs
duration 6-8 hrs
a QUALITATIVE assesment of pseudocholinesterase
DIBUCAINE TEST
amide type LA
inhibit normal pseudocholinesterase by 80%
DIBUCAINE
amide ( 2 i)
ester (1i)
Normal PO2 in mixed venous blood is?
40mmHg
inc Venous arterial oxygen due to ?
inc CO sepsis left to right shunt impaired peripheral uptake dec o2 consumption
Tracheal capillary arteriolar pressure
25-35mmHg
if cuffed greater > ischemia> tracheomalacia
ET low pressure cuff recommended for intubation> 48 hrs
LMWH like enoxaparin dalterapin and ardeparin should be stop for __hrs prior to neuraxial.
at least 24 hrs
LMWH is 2-4 x longer than standard heparin
The most common peripheral nerve injury under GA?
ULNAR NERVE
compressed between medial epicondyle of the humerus
sharp edge of the operating table
leading to ISCHEMIA
CODEINE is metabolized to morphine by
CYP2D6
CYP2D6 metabolize (3 drugs)
oxycodone to oxymorphone
hydrocodone to hydromorphone
codeine to mso4
s/p pca or pci when to schedule elective case
2 week - baloon ca
6 weeks - BMS( bare metal)
12 mons - DES( Drug eluting)
DUAL THERAPY
ASPIRIN AND CLOPIDOGREL
when to stop?
continue aspirin
clopidogrel 7 days
emergency case on clopidogrel ? what to give?
platelet conc effective 4hrs after last dose but much better 24 hrs after
NALOXONE
competitive inhibitor all opioid receptors
greater affinity to mu receptor
duration :1hr
short can cause renarcotization
NALTREXONE
N cyclopropylmethyl of oxymorphone
long half life 8-12 hrs
oral form only
block euphoric effect
NALMEFEME
opiod antagonist
extremely long duration of action
oral and iv
most common cause postoperative hypoxemia
uneven v/q mismatch
atelectasis
AIRWAY obstruction after thyroidectomy cause by
hypocalcemia RLN damage tracheomalacia compression hematoma
airway symptoms of hypocalcemia can develop
as early as 1-3 hrs up to 24-72 hrs post op
laryngeal muscle is sensitive to hypocalcemia
tx
cal gluconate
ca chloride
weakness in abduction of the thumb inability to extend to metacarpophhalangeal joints wristbdrop numbness in the webbed space between thumb and index
what nerve?
RADIAL NERVE
can be comprrss around the humerus b/w middle and lower portions spiral groove
dystonic reaction about 1%
DROPERIDOL
TX
DIPHENHYDRAMUNE
BENZATROPINE ( can cross bbb)
most freq injured nerve in the antecubital fossa
MEDIAN NERVE
palmar surface of the lat 3 and 1 half fingers
motor:
abductor pollicis brevis
flexor pollicis brevis
opponens pollicis ms
diaphoresis
tachycardia
heache
htn
pheochromocytoma
average sized contains 100-800mg NE
pheochromocytoma +
medullary ca thyroid +
and neuroma of the oral mucosa
MEN Type IIb
dec hepatic gluconeogenesis
not hypoglycemia
METFORMIN
improve insulin sensitivity
no hypoglycemia effect
piolitazone
rosiglitazone
delay carbo absorption
no hypo gly
Acarbose
miglitol
stimulate insulin secretion
RISK of hypogly
glimeperide glipizide glyburide tolbutanidr tolazamide chlor
alcohol withdrawal
early symptoms?
life threatening ?
alcohol withdrawal
early symptoms? 6-8hrs
life threatening ?2-4days
HYPERCALCEMIA SIGNS AND SYMPTOMS
HTN dysrhythmia short qt kidney stoney seizure nause and vomiting weakness a depression psychosis
<12 no intervention
notmal 2.25-2.75mmol/l
red eyedrop?
green eyedrop?
white?
reD-myDriasis
green -MIOSis
white no pupillary size changes
wt in children how to compute?
newborn-3.5kg 5mons bw x 2 1year bw x 3 1-6 2kg/year 6-10 3kg/year
HYPERCALCEMIA SIGNS AND SYMPTOMS
HTN dysehythmia short qt kidney stoney seizure nause and vomiting weakness a depression psychosis
<12 no intervention
notmal 2.25-2.75mmol/l
red eyedrop?
green eyedrop?
white?
reD-myDriasis
green -MIOSis
white no pupillary size changes
wt in children how to compute?
newborn-3.5kg 5mons bw x 2 1year bw x 3 1-6 2kg/year 6-10 3kg/year
WHAT CBF ?
first sign of cerebral ischemia
no eeg sign
22ml/100g/min
What CBF?
eeg become isoelectric
15ml/100g/min
what CBF?
irreversible membrane damage an cellular death
6ml/100g/min
what CBF?
zone of ischemic penumbra
6-15ml/100g/min
PEEP increase?
arterial oxygenation
pulmonary compliance
FRC
by expanding prev collapsed but perfused alveoli»_space; dec shunt»_space; imp ventilatio
PEEP effect ok arterial blood pressure?
dec arterial blood pressure caused by dec in venous return , left ventricular filling and stroke volume and cardiac output
other adverse effect:
pneumothorax
pneumomediastinum
subq emphysema
clopidogrel MOA?
irrevesible inhibitor of plt p2Y12
block ADP
Inhibit platelet activation, aggregation
and degranulation
Glycoprotein 2b/3a inhibitor?
abcixima
eptifabatidr
tirofiban
inhibit cox1 ?
inhibit release of ADP by platelet and plt aggregation
aspirin
naproxen
ibuprofen
Direct thrombin inhibitor?
hirudin agratroban lepirudin desidurin bivalirudin DABIGATRAN
supress plt function
how to compute for oil/gas
coefficient
150/MAC
high - lipid soluble ( lower MAC)
HYPERNATREMIA
serum hyperosmolarity
polyuria
urine hypoosmolality
DIABETES INSIPIDUS
develop 4-12 hrs post op
txt desmopressin acetate
DDAVP
in alzheimer disease,
which anticholinergic drug should not be given
scopolamine
atropine
glycopyrolate
scopolamine and atropine
can pass the bbb
can cause confusion
administration of sux to any pt who has already received an anticholinesterase will result ina PROLONGED block ?
true or false
TRUE
because it can no longer be easily hydrolyzed
measurement of DIFFUSING capacity of the lung
DLCO
20-30ml/min/mmHg
DLCO influenced by ?
vol of blood hgb
dec DLCO:
dec oxygen toxicity
pulmonary edema
increased DLCO: supine position exercise obesity left to right cardiac shunt
Thyroidectomy
postoperative complication results in upper airway obstruction?
hemorrhage - compression
hypocalcemia- stridor – laryngospasm
recurrent laryngeal nerve
unilateral- hoarseness
bilateral - airway obstruction
sup laryngeal nerve sensory only
hoarseness only
MH
most early signs ?
TACHYCARDIA
nonspecific pulmonary function test that measures the ENDURANCE of ventilatory muscles and indirectly reflects compliance of the lung and thorax as airway resistance
MMB
MAXIMUM VOLUNTARY VENTILATION
dec- impairment to inspiration or rxpiration
FLOW VOLUME LOOP- confirmatory test
PADSS
what are the five criteria
stable vs walk w/o dizziness controlled pain absence of nausea and vomiting min sx bleeding
TOOL TO OBJECTIVELY assesing a patients readiness for discharge from the surgical center and includes 5 criteria
PADSS
post anethetics discharge
scoring system
MH
LATE finding
fever
test for MH
caffeine halothane contracture test
muscle biopsy
leukotriene pathway inhibitor
zileuton
leukotriene receptor antagonist
montelukast
Treatment of mild hyponatremia 120-135
water restriction
furosemide
no neuro symptoms
what level of na has neurologic symptoms
ecg changes
less than 120
hyponatremia ecg changes?
widening qrs
st elevation
ventricular tach
vfib
how to compute for na correction
TBW x ( desirrd- actual na )
rapid correction of na will lead to
demyelinating cns
MH
TRISMUS after sux
in how many % inpatient will develop MH
50 percent
KETAMINE demonstrate myocardial depressant when??
cathecholamines are depleted
under deep anesthesia
MH is due to ____ control of intracelluar _____
MH is due to DEC control of intracelluar CALCIUM STORE
tx dantrolene
blocks the release of calcium from sarcoplasmic reticulum
inc intracellular ca leads to muscle contraction ?
true or false
true
bleomycin
PULMONARY TOXICITY
increase risk of pulmonary toxicity ( in pt taking bleomycin)
radiotherapy
inc conc of 02 ( > 30percent)
head flexion or extension, how many cm?
1.9 cm towards the carina
turn head laterally will move the et tube ___cm?
0.7cm away from the carina
sulfur hexafluoride ppv
to prevent changes in size of the bubbles?
can nitrous be given?
prevention: 02. 15mins before injevtion
NO NITROUS FOR 10days
post thyroidectomy , hypocalcemia can occur ___hrs?
first 24 -96 hrs
manifest as laryngospasm and stridor
tx: cal gluconate and ca chloride
which confirms euthyroid state?
TSH
TURP:
fluid absorption rate ?
10-30ml/min
TURP:
inc rate of absorption can cause?
htn
bradycardia
pulmonary congestion
treatment:
diuretics
3% nacl
BURN:
after 24 hrs
sensitivity to depo? or non depo?
depo sensitive
non depo resistant
upregulation of extrajunctional recptor
nerve injured during parotidectomy
FACIAL NERVE
orbicularis oris
frontalis
close ehwlids
purse the kips
raise the eyebrows
how manu ml of 02 is ther per gram of hgb?
1gram hgb=1.34ml O2
allergic reaction is most likely secondary to
MUSCLE RELAXANT
latex allergy after 15-mins
HUNTINGTON CHOREA
effects on succinylcholine
PROLONGED
INC SENSITIVITY TO NON DEPO
because they have dec pseudocholinesterase
normal intraocular pressure
10-22mmHg
causes inc in iop
ketamine
elevation of PaCO2
sux
coughing and vomiting ( 35-50mmHg)
AHI
apnea-hypopnea index ?
used to QUANTIFY number of apnea or hypoapnea per hr
greater than 30»_space;> OSA
no ventilation for period of 10sec or more
APNEA
50% dec in airflow or a dec sufficient to cause dec oxygen saturation of 4%
HYPOPNEA
INCREASED operative risk for pneumonectomy?
what are the test?
RV/TLC >50 FEV1 < 0.8L mPAP >40mmHg PaCO2 60mmhg PaO2 <45 mmHg
for every degree Celsius decreased how many percent dec with PaO2
1 degre = 6 %
nonspecific pulmonary function test that measures the ENDURANCE of ventilatory muscles and indirectly reflects compliance of the lung and thorax as airway resistance
MMB
MAXIMUM VOLUNTARY VENTILATION
dec- impairment to inspiration or rxpiration
FLOW VOLUME LOOP- confirmatory test
PADSS
what are the five criteria
stable vs walk w/o dizziness controlled pain absence of nausea and vomiting min sx bleeding
TOOL TO OBJECTIVELY assesing a patients readiness for discharge from the surgical center and includes 5 criteria
PADSS
post anethetics discharge
scoring system
MH
LATE finding
fever
test for MH
caffeine halothane contracture test
muscle biopsy
leukotriene pathway inhibitor
zileuton
leukotriene receptor antagonist
montelukast
Treatment of mild hyponatremia 120-135
water restriction
furosemide
no neuro symptoms
what level of na has neurologic symptoms
ecg changes
less than 120
hyponatremia ecg changes?
widening qrs
st elevation
ventricular tach
vfib
how to compute for na correction
TBW x ( desirrd- actual na )
rapid correction of na will lead to
demyelinating cns
MH
TRISMUS after sux
in how many % inpatient will develop MH
50 percent
KETAMINE demonstrate myocardial depressant when??
cathecholamines are depleted
under deep anesthesia
MH is due to ____ control of intracelluar _____
MH is due to DEC control of intracelluar CALCIUM STORE
tx dantrolene
blocks the release of calcium from sarcoplasmic reticulum
inc intracellular ca leads to muscle contraction ?
true or false
true
bleomycin
PULMONARY TOXICITY
increase risk of pulmonary toxicity ( in pt taking bleomycin)
radiotherapy
inc conc of 02 ( > 30percent)
head flexion or extension, how many cm?
1.9 cm towards the carina
turn head laterally will move the et tube ___cm?
0.7cm away from the carina
sulfur hexafluoride ppv
to prevent changes in size of the bubbles?
can nitrous be given?
prevention: 02. 15mins before injevtion
NO NITROUS FOR 10days
post thyroidectomy , hypocalcemia can occur ___hrs?
first 24 -96 hrs
manifest as laryngospasm and stridor
tx: cal gluconate and ca chloride
which confirms euthyroid state?
TSH
TURP:
fluid absorption rate ?
10-30ml/min
TURP:
inc rate of absorption can cause?
htn
bradycardia
pulmonary congestion
treatment:
diuretics
3% nacl
BURN:
after 24 hrs
sensitivity to depo? or non depo?
depo sensitive
non depo resistant
upregulation of extrajunctional recptor
nerve injured during parotidectomy
FACIAL NERVE
orbicularis oris
frontalis
close ehwlids
purse the kips
raise the eyebrows
how manu ml of 02 is ther per gram of hgb?
1gram hgb=1.34ml O2
allergic reaction is most likely secondary to
MUSCLE RELAXANT
latex allergy after 15-mins
HUNTINGTON CHOREA
effects on succinylcholine
PROLONGED
INC SENSITIVITY TO NON DEPO
because they have dec pseudocholinesterase
normal intraocular pressure
10-22mmHg
causes inc in iop
ketamine
elevation of PaCO2
sux
coughing and vomiting ( 35-50mmHg)
AHI
apnea-hypopnea index ?
used to QUANTIFY nuper of apnea or hypoapnea per hr
greater than 30»_space;> OSA
no ventilation for period of 10sec or more
APNEA
50% dec in airflow or a dec sufficient to cause dec oxygen saturation of 4%
HYPOPNEA
INCREASED operative risk for pneumonectomy?
what are the test?
RV/TLC >50 FEV1 < 0.8L mPAP >40mmHg PaCO2 60mmhg PaO2 <45 mmHg
for every degree Celsius decreased how many percent dec with PaO2
1 degre = 6 %
causes of central cyanosis
dec arterial o2 saturation
hgb abnormality
what kind of heparin? immediate t1/2 .5 to 2hrs reversed by protamine aptt act
UNFRACTIONATED HEPARIN
what kind of heparin? 20-60 mins onset t1/2 4.5hr partially reverse by protamine LOWER INCIDENCE OF HIT
LMWH
relationship of gfr and crea ?
inversely proportional
MC chromosomal syndrome in congetinal hypothyroidism smaller tracheas occipito atlantaoaxial isntability subluxation congetinal heart disease
TRISOMY 21
Downs syndrome
anticholinergic like scopolamine can cause
mydriasis
cyclopedia
neuroleptic malignant syndrome vs MH DIFFERENTIATE?
Non depo NMB will cause FLACCID paralysis in NMS but not in MH
classic signs of fat embolism
tachycardia dyspnea confusion fever PETecHial rash on the upper part was
most common after LONG BONE sx
occurs 12-72 hrs after
REMIFENTANIL IS metabolized by
nonspecific pseudocholinesterasr
acceptable preductal oxygen saturation
1 min - 60-65 2 min 65 3min 70 4min 75 5 mins 80 10 min 85 a%
MOST common readin for unexpected admission post GA
nausea and vomiting
min alveolar concentration of anesthetic that will prevent movement of 50% of pt whwn skin incision is made
MAC 1
min alveolar concentration of anesthetic that will prevent movement of 95% of pt whwn skin incision is made
MAC 1.3
OBESE:
cardiac output increased or decreased?
increased by
100ml/min/kg
additional blood vessel> inc ventricular dilation inc sv and
resting hr not increased
alternative for Na nitroprusside for tx for severe htn?
FENOLDOPAM
Dopamine 1 agonist
no thiocyanate toxicity
no rebound effect
no coronary stral
contraindicated:
sulfite sensitivity
Hemophilia
how many percent of F8 is needed for major or
ideally 100 percent
F8 elimination t1/2 12 hrs
tx
F8 conc
cryoprecipitate
THE REASON 4 twitches are used in TOF instead of 5?
succesive twitches deplete ach syore
after 4th twitch ni affitional decrement in height
INFERIOR ISCHEMIA
complete heart block
what coronary artery
right RCA
AV NODE supplied by the RCA
INCREASE MAC
hyperthermia CHRONIC ETHANOL USE hypernatremia red hair natural infancy
DECREASE MAC
narcotics iv LA ACUTE ETHANOL USE hypothermia Hypoxia anemia inc age pregnancy hypoxia
NO EFFECT IN MAC
duration sc typr sx thyroid function gender hyperkalemia
long term lithium therapy can cause
hypothyroidism ( inhibit thyroid hormones)
sedative properties
associated nephrogenic DI
prolong osncu and sux but does not cause hyperkalemia
Carcinoid syndrome
tx
octreotide
synthetic somatostatin analog surpress serotonin
minimum dermatomal level for orchiectomy
T10
GCS ?
mild head injury
moderate and severe?
severe 3-8
mod 9-12
mild 13-15
e4 v5 m6
associated with FALSELY elevated SaO2 ?
CARBOCYHEMOGLOBIN
anticonvulsant
centrally acting active GABA
GABAPENTIN
most common cause of blindness post surgery?
ISCHIEMIA OPTIC NEUROPATHY
associated factors: prolonged hypotension anemia large blood loss prolonhed surgery favial edema
POVL may result form
corneal traume retinal artery occlusion retinal vein occlusion optic nerve ischemia cortical disease
postoperative shivering. can ..
inc metabolic rate and o2 consumption
inc co and mv
postoperative shivering treatment
suppl o2 rewarming meperidine clonidine mg sulfate ca chloride chlorpromazine droperidol
drugs: meperidine clonidine mg cacl chlorpromazine butorphanol
hyperkalemia ecg changes?
narrowed and peaked t wave ( earliest manifestation)
dec p wavr
prolonged pr interval
widened qrs
potentianed by hypocalcemia
s/p tss is Cpap contraindicated?
YES !
neutral protease stored in mast cell ?
TRYPTASE
should be measure 1-2 hrs
histamine level returns to normal after 30-60 mins
what enzyme is responsible to metablosim of fentanyl
sulfentanil
alfentanul
CYP3A4
LIVER TRANSPLANTATION
phase where the greatest degree of hemodynamics
REPERFUSION
Hypotension
dec cardiac contractilitcardiac arrythmia
hyperkalemia
PONV:
Strongest independent predictor
FEMALE
PONV:
risk factor
female non smoker hx of ponv migraine narcotics length of sx use of nitrous voltile anes
MH MUTAtion with what receptor
RYANODINE RECEPTOR
glycopyrrolate can pass the placenta? true or false?
FALSE
only ATROPINE AND SCOPOLAMINE
greatest predictor of OSA
neck circumference
>44cm
conversion of morphine iv to oral?
1:3
methadone
1:2
me2done
equilibrium with alveolar partial pressure is rapid , how many mins?
8-10mins
which compartment reach equilibrium last?
VPG
vessel poor group
hazards of oxygen administration
ROP
bronchopulmonary dysasia
adsorption atelectasis
what nerve arises from branches of c2-c3 spinal nerves and innervates the skin of the outer ear, the mastoid process and the parotid gland
GREAT AURICULAR NERVE
vasopasm
associated with SAH
OCCURS 4-12 days after bleed
treatment for hodgkin lumphoma and testicular tumor .
causing pulmonary toxicity
BLEOMYCIN
use low oxygen concentration
most common cardiac event in pediatrics
bradycardia
difficult mask ventilation
bmi >26 without teeth pt who snore beard age older than 55 facial tumor facial trauma
symptoms of compartment syndrome
pain
parethesias
paralysis
pulseless
treatment? fasciotomy
CSF IN NEONATES?
LA dose?
duration
4ml/kg
adult: 2ml/kg
increase dose
shorter duration
ET TUBE SIZE are measured according to
INTERNAL DIAMETER
colorless, odorless gas that bonds to hgb with affinity more than 200 times stronger than oxygen.
carbon monoxide
what nerve ?
weakness of all muscles below the knee
SCIATIC NERVE INJURY
what nerve ?
foot drop, loss of dorsal extension of the toes
common peroneal nerve
what nerve ?
weakness of the ms that exten the knee
obturator nerve injury
what nerve ?
inability to addduct the leg; diminished sensation over the medial side of the thigh
OBTURATOR NERVE INJURY
what nerve ?
mc caused by placement of pt into lithotomy position
common peroneal
what nerve ?
numbness over the lateral aspect of the thigh
lateral femoral cutaneous nerve injury
amount of air expired in 1 second
FEV1
normal FEV/FVC
75%- 80%