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COMP EXAM 15 > COMP 15 > Flashcards

COMP 15 Flashcards

1
Q

What are the ASA guidelines for pts taking 82 mg regarding neuraxial anesthesia?

A
  • Continue taking ASA
  • Proceed with neuraxial anesthesia

By themselves, ASA and NSAIDs do not increase the risk of spinal hematoma. This assumes a normal pt with normal coagulation profile

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2
Q

What is the waiting period to proceed with neuraxial anesthesia in a pt taking Plavix?

A

7 days

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3
Q

If the initial dose of warfarin was given > 24 hrs preop to a block or more than 1 dose was given, how should you proceed?

A

Check PT/INR and document

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4
Q

If a single dose of warfarin was given < 24 hours preop, how should you proceed?

A

It should be safe to proceed..but I would still check PT/INR

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5
Q

Minidose SQ heparin is a contraindicaion to neuraxial. True or false?

A

False

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6
Q

When should blocks be performed in pts receiving heparin therapy?

A

1 hr or more before scheduled dose

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7
Q

When should an epidural catheter be removed for pt receiving heparin treatment?

A

1 hour prior to treatment OR

4 hrs following treatment

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8
Q

When should needle placement for neuraxial be performed for pt receiving LMWH?

A

At least 10 hrs after dose

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9
Q

If a pt is receiving fibrinolytic drugs (tPA, streptokinase, urokinase), what should the protocol for receiving neuraxial anesthesia be?

A

Neuraxial is contraindicated in these pts

tPA = tissue plasminogen activator

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10
Q

How do you manage hypotension associated with epidural analgesia?

A

fluid administration and pressor therapy

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11
Q

What is the primary cause of hypotension associated with a high spinal?

A

decreased preload –> decreased CO

high spinal associated with sympathetic blockade and decreased HR associaed with cardioaccelerator fibers T1-T4 being blunted

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12
Q

What are ways to minimize the degree of hypotension?

A

Volume loading (10-20 cc/kg)

Left uterine displacment

Head-down position

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13
Q

If fluid administration is not suffient to treat hypotension in pt with neuraxial block, what pressors should be used?

A

Phenylephrine

Ephedrine

Epi (5 - 10 mcg IV)

For decreased HR, give atropine.

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14
Q

What is the order of loss of modalities with spinal anesthesia?

A

small fibers > large fibers

myelinated fibers> non-myelinated

sympathetic block > sensory > motor

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15
Q

Why may the paramedian approach to neuraxial be indicated?

A

pt cannot be positioned easily due to arthritis, kyphosis

calcified ligaments

thoracic epidural needed (longer spinous processes)

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16
Q

If a solution has a baricity ratio > 1, what does this mean?

A

Hyperbaric solution which means that it will sink with gravity in the CSF

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17
Q

Is LA + dextrose hyper or hypo-baric?

A

hyperbaric

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18
Q

Is LA + sterile water hyper or hypo-baric?

A

hypobaric

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19
Q

How does pregnancy affect CSF baricity?

A

decreases it

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20
Q

At what level does the iliac crests lie?

A

L3-L4

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21
Q

What is the physiological mechanism preceding asystole during spinal anesthesia?

A

High spinal sympathemectomy (blockade of cardioaccelerator fibers) leaves vagal tone unopposed

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22
Q

What are the advantages of neuraxial anesthesia?

A

Metabolic stress response to surgery is decreased

Pulmonary compromise is decreased

Less blood loss

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23
Q

What is the order of sensitivity of nerve fibers from most sensitive to least sensitive?

A

B fibers (myelinated but physically thicker than C fibers, responsible for sympathic tone)

C fibers (unmyelinated, responsible for pain)

A (delta) responsible for temperature

A (gamma) responsible for propioception-sense of movement

A (beta) responsible for touch, pressure

A (alpha) responsible for motor movement

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24
Q

What is the molecular form of injectable LA consist of?

A

benzene ring (lipophilic) with a tertiary amine (hydrophilic)

the bond between the two determines the class of LA, ester or amide

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25
Q

What are the amide LAs?

A

Ones with “i” before the “-caine”

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26
Q

How are the amide LAs metabolized?

A

Cyt 450 metabolism, i.e. liver

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27
Q

Which class of LAs are more stable?

A

amides

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28
Q

What LA is an exception to all the others and how?

A

cocaine is mostly metabolized in the liver

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29
Q

How are ester LAs metabolized?

A

plasma cholinesterases and are very unstable

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30
Q

What may cause allergies to ester LAs?

What may cause allergies to amide LAs?

A

PABA (para-aminobenzoic acid)

methylparaben similar to PABAs found in mulidose preparations

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31
Q

What does the onset time of LAs depend upon?

A

lipid solubility

relative concentration

pka –relative nonionized form (lipid) to ionized form (water soluble)

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32
Q

What happens when the pH < pka of LA?

A

Inflamed tissues have lower pH –>

base (LA) + acid (tissue) = increased ionized form of LA –>

Less non-ionized form –> less potent

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33
Q

How does bicarb increase effectiveness of LA?

A

Increases local pH –> less ionized form of drug –> faster onset

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34
Q

What should the pka be relative to pH in order to have the highest efficacy?

A

pka ~= pH

Most non-ionized form of drug exists under these conditions

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35
Q

What happens to LA onset if the pH >> pka?

A

Onset takes much longer since most of the drug is in lipophilic form

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36
Q

What does increased lipid solubility correlate to?

A

increased potency

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37
Q

What does the dissociation constant, or, pka a LAs correlate with?

A

time of onset

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38
Q

What type of LA molecules will not penetrate neurons?

A

Quarternary, water soluble state

Must be in tertiary lipid soluble state to penetrate cell membrane

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39
Q

What does the pka of LAs represent?

A

the pH of which 50% exists in quaternary form and 50% exists in tertiary form

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40
Q

What will occur to duration of amide LAs if hepatic flow is decreased?

A

longer duration of action

41
Q

What occurs to duration of action with increase protein binding?

A

longer duration of action

42
Q

How does epi effect the onset time?

A

It doesn’t

43
Q

What severe cardiotoxic reactions can bupivicaine cause?

A

arrhythmias

AV heart block

V-tach

V-fib

hypotension

44
Q

For what LA is intralipid administered?

A

bupivicaine

45
Q

*What is the initial bolus of intralipid (20%) to treat LA toxicity?*

A

1.5 mg/kg over 1 minute

46
Q

What should be the initial setting for a nerve stimulator need to be for peripheral nerve blocks?

A

0.2 - 0.5 mA

47
Q

What nerves are blocked for ankle blocks used in foot surgery? (5)

A
  • PT (posterior tibial)
  • Peroneal
  • Superficial peroneal
  • Saphenous
  • Sural
48
Q

Which regional anethesia will most likely produce ipsilateral diaphragmatic paresis or paralysis?

A

interscalene block because it can hit the phrenic nerve

49
Q

When is an interscalene block indicated?

A

shoulder surgery

50
Q

What nerve is commonly missed in an interscalene block?

A

ulnar nerve

51
Q

*How do you manage cuff pain 40 mins after the administration of a Bier Block?*

A

the most effective way is rotating the tourniquet by changing the site of tourniquet pressure from proximal to distal when the pressure is on the anesthetized portion of the arm

Answer: Inflate distal cuff THEN deflate proximal cuff

52
Q

During a Bier Block, what if the tourniquet pressure inflated to?

A

250 mmHg or 100mmHg above systolic pressure

53
Q

How much LA is injected while doing a Bier Block?

A

~50cc of 0.5% lidocaine

54
Q

What is the purpose of a femoral vent hole when methylmethacrylate is used?

A

to prevent increased intramedullary pressures –> fat embolism

55
Q

How do you manage tourniquet pain?

A
  • Deflate cuff for 10-15 minutes then reinflate cuff
  • give vasodilators to lower BP

Tourniquet pain occurs about 30-60 minutes after cuff inflation

56
Q

What is a compound fracture?

A

An open fracture that occurs when there is a break in the skin around a broken bone.

The bone does not need to be outside the skin, there just needs to be a break of the skin to open air

57
Q

Why does a compound fracture represent an emergent medical procedure?

A

It is at high risk for infection

58
Q

*Hypotension occurs post-op in a pt receiving epidural analgesia with infusion of bupi + meperidine. What actions should you take first?

A
  • Assess and manage IV volume
  • Measure hematocrit and manage blood volume
  • Change infusion to dilaudid
  • Last actions: stop epidural or add IV infusion of pressors
59
Q

*What is the first modality to be lost upon onset of spinal anesthesia?

A

sympathetic blockade

60
Q

*What is the advantage of spinal over GA for vaginal delivery?*

A

Reduced risk of aspiration

61
Q

*Which amide LA has the most rapid onset when used for spinals?*

A

Lidocaine

62
Q

*A Bier block on an upper extremity is appropriate for surgery lasting up to _____ minutes.*

A

60 minutes

63
Q

What problem is depicted?

A

Pneumothorax, collapsed lung on left

64
Q

What are the more common sizes for spinal needles?

A

22 - 27 gauge

65
Q

What is potency?

A

The amount of drug required to achieve a defined effect

66
Q

In what position do you place a pt for a Bier block?

A

supine

67
Q

What drug is used for a Bier block?

A

Lidocaine

68
Q

What does this CXR depict?

A

sub-q emphysema

69
Q

What is the rate and rhythm?

A

v tach rate 180…not in this pic though

70
Q

What is the most prevalent etiology of arterial hypoxemia?

A

low V/Q = shunt

high V/Q = deadspace

71
Q

What is depicted in the CXR?

A

pneumonic infiltrates

72
Q

What is the current output of the stimulator depicted?

A

0.5 mA

73
Q

What is normal CSF density?

A

1.003

74
Q

Which of the following factors most often dictates selection of outpatient surgery?

Allergies
ASA status
co-morbidities
patient choice
pharmacologic considerations
reimbursement considerations
surgeon preference

A

reimbursement considerations

75
Q

What drug will NOT reverse spasm of the sphincter of oddi?

A

Neostigmine

76
Q

How much buffer is available in sodium bicarbonate 8.4%?

A

1 meq/ml of buffer for 84 mg of sodium bicarb

77
Q

What is a compound fracture?

A

bone penetrates the skin

78
Q

Why does a compound fracture represent an emergent surgical procedure?

A

risk of infection

79
Q

What is the best method of restoring blood pressure for a trauma patient who has suffered significant hemmorhage?

A

give blood

80
Q

What is the best plan for emergence for adult who has undergone total laryngectomy?

A

spontaneous ventilation (during anastomosis) + trach collar to normal pacu

81
Q

If:

FiO2 = 0.21
SaHbO2 = 86%
SaHbCO = 0.4%
SaHbMET = 0.2%
PaO2 = 72 mmHg
PaCO2 = 38 mmHg
pH = 7.36
Hb = 17.6

What is the acid-base state?
What is the acid base condition?

A

Normal

Normal

82
Q

For the toxicity of which LA is intralipid administered?

A

bupivicaine

83
Q

What is the YAG laser’s advanage over the CO2 laser for airway surgery?

A

attracted to dark pigment (Hb) and helps with controlling bleeding

84
Q

What total score meets fast-track criteria for bypassing the recovery room?

A

12 or greater

85
Q

What score obviates fast tracking?

A

score of zero in any category

86
Q

What are the guidelines for neuraxial anesthesia in pts taking daily aspirin 81 mg?

A

continue with neuraxial

87
Q

What should the inital current setting be for a nerve stimulator being used for a peripheral nerve block?

A

0.2 - 0.5 mA

88
Q

Which regional anesthetic technique will most likely produce ipsilateral diaphragmatic paresis or paralysis?

A

Interscalene block b/c can hit phrenic nerve

89
Q

How do you manage cuff pain occurring 40 min. after adminstration of a Bier block?

A

inflate distal cuff and deflate proximal cuff

90
Q

What narcotics are prohibited for administration in PACU to outpatients?

A

None

91
Q

What led to the propofol shortage that occured in the fall 2009?

A

contamination of product

92
Q

Wha is the drug of choice to pharmacologically support the pt with acute cardiac tamponade? How is it administered?

A

Isoproterenol

Infusion

93
Q

Which VQ type of lung unit produces hypoxemia associated with post-op atelectasis?

A

low V/Q

94
Q

What are the ASA guidelines for adults for NPO status for clear liquids?

A

2 hours

95
Q

How should the chest tube placed in a pt following pneumonectomy be managed in PACU?

A

leave clamped

96
Q

Which way will the following reaction be driven as blood becomes more acidemic?

R-NH3 <– –> R-NH2 + H+

A

to the left

97
Q

A pt sustained blunt neck trauma. There is a high index of suspicion for laryngeal fracture. General is planned for neck exploration.

The pt is awake and alert with stable VS. Oxygenation and ventilation are satisfactory. What is the most appropriate airway management for this pt?

A

Trach

98
Q

The pt becomes dyspneic and stridorous and sat begins to decrease. What is the most appropriate airway management for this pt?

A

HPOV

99
Q

Where is the mastoid bone located?

A

behind the ear

COMP EXAM 15 (3 decks)

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