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R9 > Chapter 33 - Intraoperative management > Flashcards

Chapter 33 - Intraoperative management Flashcards

1
Q

Anesthesia three components

A

1) analgesia 2) amnesia 3) relaxation

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2
Q

Analgesia definition

A

Absence of pain

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3
Q

Amnesia goal

A

block consciousness and memory formation

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4
Q

Relaxation goal

A

Block voluntary motor activity and suppress autonomic reflexes

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5
Q

Depth of sedation

A

TABLE 33.1

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6
Q

Clinical features of individual local anesthetic drugs

A

TABLE 33.2

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7
Q

Define Bier block

A

high dose of local anesthetic given IV in isolated limb with tourniquet to keep it contained

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8
Q

Clerance of ester and amide anesthetics

A

Ester = plasma cholinesterase Amide = liver metabolism

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9
Q

Toxic symptoms of local anesthetic

A

1) vertigo 2) tinnitus 3) anxiety/fear 4) tremors 5) seizure 6) coma 7) arrhythmia and myocardial depression

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10
Q

Drug that might mask early side effects of local anesthetic toxicity

A

Benzodiazepines

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11
Q

Reversal agents for moderate sedation

A

Naloxone = counter opiates Flumazenil = counter benzodiazepines

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12
Q

Things to monitor in moderate sedation

A

1) level of consciousness 2) oxygenation with pulse oximetry 3) arterial pressure with automated oscillometry q5 min 4) respiration for apnea monitor 5) ecg

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13
Q

common drugs for moderate sedation

A

TABLE 33.3

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14
Q

Dexmedetomidine key points

A

1) centrally acting 2) alpha 2 adrenergic agonist 3) decrease anxiety 4) provide pain relief and sedation 5) half life 2-3 hours 6) sympatholytic effects atropine standby as reversal

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15
Q

Ketamine key points

A

1) NMDA receptor antagonist 2) dissociative anesthetic 3) increase systemic and pulmonary pressure, HR, CO, myocardial oxygen requirement 4) avoid in heart disease, heart failure, CVA, epilepsy, psychotic illness, intracranial pressure

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16
Q

Initial dose of ketamine

A

0.5 mg/kg

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17
Q

Spinal and epidural anesthesia duration of action

A

lidocaine 60 min bupivacaine 100 min

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18
Q

Treatment of hypotension with spinal anesthesia

A

1) fluid resus 2) Tredelenburg position 3) inotropic/pressor

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19
Q

Complication of spinal anesthesia

A

1) postdural puncture headache 2) n/v with unopposed parasympathetic efferents 3) resp depression with COPD

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20
Q

Epidural anesthetic catheter duration

A

3-4 days

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21
Q

Spinal/epidural recommendation on holding anticoagulation and antiplatelet

A

TABLE 33.4

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22
Q

General anesthesia and temperature

A

1) inhibit sympathetic autonomic regulation 2) loss of vasoconstriction in periphery 3) loss of thermoregulation 4) dependent on therapeutic interventions with fluid and inotropes

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23
Q

Succinylcholine key points

A

1) depolarizing muscle relaxant 2) rapid onset short action 3) can cause malignant hypertermia, sepsis, arrhythmia, elevated intracranial pressure, increase serum potassium

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24
Q

Contraindication to succinylcholine use

A

1) large surface area burns 2) spinal cord injury 3) neuromuscular disease 4) cerebrovascular accident 5) chronic debility

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25
Q

Treatment of malignant hyperthermia

A

Dantrolene 2.5 mg/kg via large bore IV Hyperventilation on 100% O2 Cool patient before 38C Bicarb to correct metabolic acidosis Calcium chloride or calcium gluconate Sodium bicarb glucose and insulin for hyperkalemia

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26
Q

Absolute contraindication to using NO

A

1) respiratory compromise 2) air filled cavities (pneumothorax, pulmonary blebs, bowel obstruction)

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27
Q

Causes of propofol-associated hypotension

A

1) inhibition of sympathetic nervous system 2) impairment on baroreflex regulatory mechanism 3) dose-dependent decrease in potassium-induced tone in veins and arteries

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28
Q

Etomidate benefit

A

Does not affect sympathetic and autonomic reflex as propofol

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29
Q

Two common sedative-hypnotic agents that decrease cerebral blood flow and metabolic oxygen requirements

A

propofol etomidate

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30
Q

Etomidate side effect

A

inhibit cortisol production

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31
Q

Benefit of epidural

A

lower post-op pain score shorter intubation and mechanical ventilation rates of MI, GI complication, renal complication lower

32
Q

Anesthesia in ruptured AAA key points

A

1) permissive hypotension 70-80 SBP 2) relaxation can relax tamponade 3) catch up needed once clamped 4) epidural for hemodynamically stable patients with contained ruptures

33
Q

Spinal anesthesia benefit for PAD surgery

A

1) less early failure 2) less return to OR 3) less cardiac morbidity 4) less pneumonia compared to general anes

34
Q

GALA study on carotid

A

General and local has similar outcome

35
Q

ECG intraop

A

5 electrode system with 4 limb and 1 precordial lead V5

36
Q

Normal gradient between end-tidal CO2 and PaCO2

A

5 mmHg affected by disease states

37
Q

Rate of ulnar artery as dominant

A

90%

38
Q

Reasons to avoid brachial catheters

A

1) poor collateralization 2) axillary sheath hematoma risk

39
Q

CO calculation

A

heart rate x stroke volume determined by myocardial contractility and LVEDV

40
Q

Central venous pressure key points

A

1) correlates with LV filling pressure in normal cardiopulm function 2) correlation weakened with positive pressure ventilation and patient positioning

41
Q

Flow-directed balloon-tipped PA catheter uses

A

1) measure pulmonary artery diastolic pressure (PADP) 2) measure pulmonary capillary wedge pressure (PCWP) 3) sample mixed venous blood to calculate total body oxygen delivery DO2 and total body oxygen consumption VO2

42
Q

Minimally invasive hemodynamic monitoring systems

A

1) FloTrac sensor 2) ProAQT sensor with Pulsioflex monitor 3) LidCO rapid system cold fluid or lithium dilution

43
Q

Strategies to reduce incidence of surgical site infection

A

1) give prophylaxis within 1 hour of incision 2) dose adjust for body weight 3) ensure redosing as needed 4) short post-op course < 24 hr 5) vancomycin and clindamycin were appropriate substitutes in beta-lactam allergy 6) not used in angiogram, angioplasty, bare metal stent, venous procedure, thrombolysis and closure device only

44
Q

Adrenergic agents around surgery

A

1) continue betablocker 2) start therapy at least 7 days prior to surgery and not day of surgery

45
Q

Contraindication to beta blocker

A

1) asthma 2) sick sinus syndrome 3) second-third degree heart block

46
Q

Normothermia definition

A

36-38 C

47
Q

Physiologic response to hypothermia in awake patient

A

1) sympathetic activation 2) increased norepinephrine 3) shivering 4) increased metabolic rate 5) increased oxygen consumption 6) increased MAP

48
Q

Post-op hyperglycemia and infection risk

A

30% for every 40 point increase from normal 110 mg/dl

49
Q

Goal target for post-op blood surgar

A

< 200 mg/dl

50
Q

Half life of heparin

A

30-90 min

51
Q

Protamine risk of anaphylaxis

A

3%

52
Q

Argatroban dose in HIT

A

350 mcg/kg over 3-5 min then infusion 25 mcg/kg/min

53
Q

Bivalirudin dose in HIT

A

0.75 mg/kg bolus then 1.75 mg/kg/hr

54
Q

Bivalirudin reversal

A

Factor VIIa hemodialysis

55
Q

Dabigatran Brand name MOA half life metabolism coag assay reversal

A

Pradaxa DTI 12-17 hours 85% renal excretion TT, ECT, aPTT Reversal: HD, activated charcoal, PCC, Factor 7a Specific: idarucizumab (Praxbind)

56
Q

Dose of praxbind

A

5 g IV humanized monoclonal antibody fragment

57
Q

Rivaroxaban Brand name MOA half life metabolism coag assay reversal

A

Xarelto Factor 10a block 5-9 hours 66% renal; 33% hepatic Anti-Xa assay, PT, aPTT Reversal: activated charcoal, 4 factor PCC, aPCC Specific: clinical trials only

58
Q

Apixaban Brand name MOA half life metabolism coag assay reversal

A

Eliquis Factor 10a block 7-14 hours 66% hepatic; 33% renal anti Xa assay aPTT Reversal: activated charcoal, 4 factor PCC, aPCC Specific: clinical trial

59
Q

Fondaparinux Brand name MOA half life metabolism coag assay reversal

A

Arixtra antithrombin III 17-21 hours renal only anti-factor Xa Reversal: rFVIIa, aPCC

60
Q

Reason for antiplatelet after stent

A

Endothelialization of stent 1 month after BMS 12 months after DES

61
Q

Desmopression key points

A

1) V2 receptor agonist analogue of arginine vasopressin 2) enhance platelet unction through stimulated release of vWF from endothelial cells 3) 2.4x risk of MI

62
Q

Initial physiologic response to anemia

A

1) increase stroke volume (less viscosity and less impedance to ventricular ejection) 2) increase venous return (less peripheral resistance)

63
Q

Transfusion related acute lung injury - diagnosis

A

1) hypoxemia with ratio of PaO2//FiO2 < 40 kpa (300 mmHg) 2) bilaterla lung infiltrates 3) pulmonary vascular overload

64
Q

Incidence of TRALI

A

1.12% per unit of blood can be as high as 8%

65
Q

Mortality of TRALI

A

5-45%

66
Q

Mechanism of TRALI

A

Donor antibodies to recipient leukocyte antigen –> activation and lung injury Possible two hit hypothesis due to sensitization by insult

67
Q

Treatment of TRALI

A

1) stop transfusion 2) resp support 3) lung protective ventilation

68
Q

Transfusion associated circulatory overload rate

A

1-8%

69
Q

TACO diagnosis

A

1) Hydrostatic pulmonary edema in presence of increased pulmonary and left atrial pressure 2) Bilateral infiltrates 3) elevated BNP (78%)

70
Q

Treatment of TACO

A

1) telemetry 2) O2 3) elevated head 4) noninvasive positive pressure ventilation 5) diuresis 6) vasodilation with nitrate 7) renal replacement

71
Q

Rate of bacterial contamination in platelets

A

1 in 1000-2000

72
Q

Rate of bacterial contamination in RBC and type of bacteria

A

Yersinia enterocolitica 1 in 1000000

73
Q

Hep B virus transmission rate

A

1 in 50000-150000

74
Q

Risk of ABO incompatible blood given

A

1 in 1000000

75
Q

Transfusion-related immunomodulation (TRIM)

A

downregulation of immune system response after transfusion

76
Q

Transfusion triggers on HGB

A

TABLE 33.6

77
Q

Strategies to limit transfusion

A

1) preoperative treatment with erythropoietin 2) preoperative autologous blood donation 3) acute normovolemic hemodilution 4) intraoperative autologous blood recovery and transfusion (if suspected > 5 unit loss 1.5L)

R9 (200 decks)

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