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Assessment > E3 > Flashcards

E3 Flashcards

1
Q

Advantage, disadvantage and osmolality of sorbitol (3.3%)

A

Advantages
Less chance for TURP syndrome

Disadvantages:
Hyperglycemia
?Lactic acidosis
Osmotic diuresis

Osmo:
165 mOsm/ml

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2
Q

Cause of carcinoid syndrome

A

Serotonin overproduction

Histamine release

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3
Q

Differentiate between T1DM and T2DM causes and complications

A 
T1DM= insulin deficiency
complications = DKA
T2DM= insulin resistance
Complications = HHNK
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4
Q

How does hypoglycemia manifest intraoperatively? Best determination?

A

DEC HR
DEC BP
Resp failure

Finger stick glucose

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5
Q

Anesthetic considerations for antiHTN status in renal pts

A

Hold ACE-i day of surgery to DEC intraop hypotension

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6
Q

Clinical presentation of CRF

A

Anemic (d/t DEC erythropoeitin)
INC bleeding time d/t plt dysfxn (NOT thrombocytopenia)
INC K+
INC Mg

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7
Q

Anesthetic considerations for blood volume status in renal pts

A

Estimate by comparing preHD weight to post HD weight

Monitor vitsl for orthostatic hypotension and INC HR

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8
Q

What type of medications and actions should be avoided in pts w/ pheo?

A

Anything that causes sympathetic sitmulation

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9
Q

Which inhaled anesthetic is best in pts with carcinoid tumors and liver mets?

A

Desflurane

B/c of its low rate of metabolism

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10
Q

Ideal irrigation fluid

A 
Great visibility 
Clear
Isotonic
Free of toxicity
Electrically inert
Inexpensive
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11
Q

Occurrence of metabolic syndrome

A

25% of people

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12
Q

S/Sx of HHNK

A 
Polyuria
polydipsia
hypovolemia
Hypotension
INC HR
Organ hypoperfusion
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13
Q

Which drug can exacerbate HTN when given prior to alpha blockade in pts w/ pheo?

A

beta-blockers

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14
Q 
Clinical presentation based on carcinoid location
Small intestine
Rectum
Bronchus
Thymus
Ovary/Testicle
Mets
A

Small intestine:
Abd pain, intestinal obstruction, tumor, GIB

Rectum:
Bleeding, constipation, diarrhea

Bronchus:
Asymptomatic

Thymus:
Anterior mediastinal mass

Ovary/Testicle:
Mass on physical exam

Mets:
Liver=hepatomegally

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15
Q

Carcinoid syndrome is caused by an excess amount of

A

Serotonin, histamine or bradykinin

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16
Q

Cause of T2DM, occurrence, treatment and complication

A

Cause:
Relative beta-cell insufficiency
Insulin resistance in peripheral tissues

Occurrence
INC w/ age, obesity and inactivity

Treatment
Oral antidiabetics
Usually don’t require exogenous insulin

Complications
HHNK

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17
Q

Complication in treating wheezing or bronchospasms r/t carcinoid tumors

A

Not responsive to
Beta2-adrenergic agonists
Theophylline
Epi

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18
Q

Most likely cause of intraop oliguria

A

Inadequate circulating fluid volume
administration of diuretics (can compromise renal fxn)
Abdominal insuflation compression

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19
Q

Which lab tests are important to evaluate renal function?

A

GFR
BUN
Crt

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20
Q

Neurologic effects of hyperglycemia

A

confusion, coma, fatigue, blurred vision

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21
Q

Which serum electrolytes determine if renal fxn impairment is suspected?
Why are these important?

A

Na, K, Cl, HCO3

They are normal until frank renal failure is present

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22
Q

Preop management of pheo

A

Block toxic effects of catecholamines to prevent/reverse end organ damage

alpha blockade

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23
Q

What is the best pharmacological treatment for refractory HTN and coronary vasospasm in a pt w/ pheo?

A

CCBs

Diltiazem

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24
Q

Potency of ADH and Ang II

A

ADH much more potent than Ang II

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25
Q

Amount of CO to kidney

A

25%

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26
Q

Where is the common peroneal nerve and significance during TURP.

A

Location:
Lateral calf

Significance:
Most common nerve injury d/t compression

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27
Q

Occurrence, cause and s/sx of carcinoid syndrome

A

Occurrence:
In ~20% ppl w/ carcinoid tumor

Cause:
Large amounts of serotonin and vasoactive substances in systemic circulatoin

S/Sx:
Wheezing, diarrhea, cutaneous flushing (head, neck, trunk, BUE)

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28
Q

Preop consideration w/ pt comorbidities and urolithiasis

A

obesity, HTN, hyperparathyroidism
Pts w/ renal failure or CKD
Plt dysfxn, anemia, electrolyte abnormalities

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29
Q

What is the response associated w/ glucagon administration

A

Sympathetic response

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30
Q

How doe vasopressors affect the kidneys during surgery

A

DEC GFR d/t INC renal vascular resistance

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31
Q

Causes of postrenal

A

Obstruction of urinary outflow

At any point from the tubules to urethra

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32
Q

Cause of intrarenal injury

A

Nephron involvement d/t ATN
Renal tubule injury
Result in ischemia d/t DEC BF

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33
Q

Blood loss consideration w/ TURP

A

Approx 2.5% of pts require transfusion

Avg EBL is 2-4 mL/min

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34
Q

3 Defects in DM

A

1) INC rate of hepatic glucose release (b/c glucose can’t be utilized in cell)
2) impaired basal and stimulated insulin secretion
3) inefficient use of gluc by peripheral tissues

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35
Q

Where can irrigation fld be absorbed and what is the significance?

A

Absorbed via venous sinuses of prostate

Can lead to circulatory overload and toxicity

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36
Q

Advantage, disadvantage and osmolality of distilled water

A

Advantage:
improve visibility

Disadvantage:
Hemolysis
Hemoglobinemia
Hemoglobinuria
Hyponatremia

Osmo = 0 mOsm/L

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37
Q

S/Sx typical of both norepi and epi secreting pheo

A

INC SVR/afterload
Normal CO
DEC plasma vol (d/t alpha blockade)
Hyperglycemia (d/t SNS stimulation)

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38
Q

How do long periods of low BP affect kidneys and what can cause that

A

DEC RBF d/t cross-clamping (AAA sx), hemorrhage, or sepsis

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39
Q

What are dermatomes

A

Skin area innervated by a given spinal nerve

And the corresponding cord segment

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40
Q

How is a thoracic epidural useful in pheo surgery? How is it not useful?

A

Useful:
Postop pain mgmt for improved analgesia after laparotomy

Non useful:
Sympathetic blockade
Doesn't completely control HTN
d/t circulating catecholamines
May INC chance of postop hypotension
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41
Q

Medication treatment of idiopathic hypercalciuria

A

Thiazide diuretics

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42
Q

RAAS organ involvement

A

Liver= Angiotensinogen secretion

Kidney= Stimulus for renin secretion
b/c DEC BP, Na or sympathetic tone

Lungs= ACE secretion
to convert Ang I to Ang II

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43
Q

Preop lab test prior to carcinoid surgery

A

CBC, Chem panel, LFTs, Serum gluc, ECG, Urainry 5-HIAA assay

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44
Q

Problem with INC ketoacidosis in DKA and 3 types of ketones

A

Anion gap creation
MEtabolic acidosis

3 ketones:
beta-hydroxybutyrate
Acetoacetate
Acetone

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45
Q

How does release of catecholamines affect kidneys

A

INC RVR

DEC RBF and GFR

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46
Q

Postop pain management for renal failure

A

Give opioid carefully
Can lead to hypoventilation even with small doses
d/t activemetabolites
Give naloxone for severe depression

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47
Q

What electrolytes affect the anion gap

A 
Anions = Cl- and HCO3
Cations= Na+ and K+
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48
Q

BNP has what effect on the kidneys

A

ANP and BNO cause DILATION of AFFERENT arterioles and CONSTRICT EFFERENT arterioles
There is an overal DEC in renal vascular resistance and INC in GFR

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49
Q

Describe the areas of the kidney.

A 
Cortex=outer region
•	Located just under the kidney capsule
	Medulla = central region
•	Located just under the kidney capsule
	Papilla = inner most tip of inner medulla
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50
Q

What are the corresponding dermatome levels?
= peri-anal surgery, “saddle block”
= foot and ankle surgery
= Vaginal delivery and uterine procedure
= lower abdominal procedures
= upper abdominal surgery

A

 S2-S5 = peri-anal surgery, “saddle block”
 L2 = foot and ankle surgery
 T10 = Vaginal delivery and uterine procedure
 T6 = lower abdominal procedures
 T4 = upper abdominal surgery

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51
Q

Anesthesia effects on kidneys

A

DEC RBF and GFR

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52
Q 
corresponding organ innervation
T8-T12
Lumbosacral and thoracic input
T11-T12, S2-S4
T11-T12
S2-S4
A 
T8-T12 = kidney and ureter
Lumbosacral and thoracic input = pelvic organs 
T11-T12, S2-S4 = bladder and prostate
T11-T12 = Dome of bladder
S2-S4 = neck of pladder and prostate
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53
Q

Difference in glyconeogenesis and glycgenolysis

A

Glyconeogenesis = creation of glucose

Glycogenolysis = breakdown of glucose

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54
Q

Purpose of storing nutrients

A
  • Available during periods of fasting
  • To maintain gluc delivery to brain, muscle and organs
  • INC transport of gluc into cells
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55
Q

GFR level in CRF

A

<25 ml/min

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56
Q

For adequate regional anesthesia technique, which dermatomal level should you achiene for an upper abdominal surgery and what is the landmark

A 
level = T4
landmark = nipple level
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57
Q

Problem of DEC gluc utilizatoina nd INC lipolysis in DKA

A

Leads to formation of FA that are oxidized by the liver into ketone bodies

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58
Q

Describe spinal levels in relation to sensory block

A

Spinal block is above the level of spinal sensory innervation

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59
Q

What is the glomerulus anatomy and function

A

Anatomy:
Highly convoluted series of capillary loops
emerges from afferent arteriole and leads into efferent arteriole
Surrounded by bowman’s capsule

Function:
Filtration

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60
Q

How does a neuraxial block affect kidneys during surgery

A

Can DEC BP and CO

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61
Q

What occurs late in the postprandial period with glucose and why?

A
  • 2-4 hrs after eating
  • When glucose utilization exceeds production transition from EXogenous gluc delivery to ENdogenous production
  • to maintain normal plasma gluc level
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62
Q

Medication treatment of tachycardia from phenoxybenzamine. Cautions and complications.

A

HR>120
Give beta-blocker
Propranolol, esmolo, atenolol, metoprolol, labetolol

Cautions:

  • DO NOT give until adequate a-blockade
  • NEVER administer before a-blockade

Complications

  • Blockade of vasodilatory B2-receptors results in Unopposed a-agonism
  • Leads to vasoconstriction and HTN crisis
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63
Q

What is the purpose and normal range for urine protein and glucose?

A

Protein:
Normal excretion = 150 mg per day
increase amount after exercise or standing several hours
Indication of infection
Very high level indicate severe glomerular damage
Massive proteinuria = >750 mg/day

Glucose:
Filtered at the glomerulus
100% reabsorbed at PCT
Glycosuria = high glucose levels exceed ability of PCT to reabsorb the glucose
indicative of DM
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64
Q

What happens when plasma gluc decreases?

A

Inhibits insulin release

INC gluc

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65
Q

Administration of depolarizing afents is avoided for patients w/ chroni renal dx b/c of risk of

A

Hyperkalemia

Raises K by 0.5 meq/L

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66
Q

Fluid management and UO during anesthesia

A

Use w/ caution
LR contain 4 meq K+
Avoid K-containing fluids
Maintain UO >0.5 ml/kg/hr

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67
Q

3 types of urolithiasis procedures

A

Percutaneous nephrolithotomy
Shock wave lithotripsy
Ureteroscopy

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68
Q

Dermatomes of the hand

A 
C8 = 4th and 5th finger
C7 = 1st and 2nd finger
C6 = thumb
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69
Q

What does the adrenal medulla release

A

Catecholamines

Norepi and epi

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70
Q

What is gestational diabetes and implications for anesthesia

A

Glucose intolerance recognized during pregnancy
Identify to DEC perinatal morbidity and mortality
Likely undergo c-s delivery d/t INC birth weight baby

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71
Q

What/where are the adrenal glands, function and component parts

A

what:
Small triangular endocrine glands

Where:
On top of the kidneys

Function:
Synthesize and store essential hormones
Release stress hormone

Component parts:
Adrenal cortex and medulla

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72
Q

What is pheochromocytoma and where does it occur

A

Tumor of neuroendocrine tissue
Arises from chromaffin cells of adrenal medulla

Neoplastic proliferation of cells:
Leads to release of 1 or more substance
Norepi or Epi

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73
Q

What monitoring can guide fluid replacement

A

CVP

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74
Q

Action of each renal mediators and effects on RBF and GFR

A

SNS catecholamines:
Afferent/efferect SNS innervation
Produce vasoconstriction by activating a-1 receptors
More a1 receptors on afferent arterioles
DEC RBF and GFR

ANG II:
Vasoconstrictor of afferent and efferent arterioles
DEC RBF

ANP:
dilation = afferent arterioles
constriction = efferent arterioles
INC RBF

PGs
Locally produced E2 and I2
Vasodilate efferent and afferent
INC RBF and GFR

Dopamine:
Precursor to NE w/ selective action on arterioles
Low levels = dilation of cerebral, cardiac, splanchnic and renal arterioles
INC RBF and GFR

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75
Q

What alpha blockers can be used for treatment of pheo? What are their differences/similarities? Which is best and why?

A

alpha blockers and difference in MOA:
prazosin, doxazosin, terazosin
-Selective, competitive, a1-adrenoceptor antagonist

Difference:
a1 selective blockers
LESS tachycardia than nonselective a-blocker

Similarity:
Both can cause postural hypotension

phenoxybenzamine

  • Nonselective, noncompetitive, a-adrenoceptor antagonist
  • BEST b/c noncompetetive and nonselective
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76
Q

What are the 5 criteria of metabolic syndrome and how is it diagnosed

A

Need to meet 3 of 5 criteria

  1. HTN >130/85
  2. FPG >110 mg/dl
  3. Abdominal obesity (waist >40 in men, 35 in women)
  4. INC serum triglycerids >150 mg/dl
  5. LOW serum HDL levels (<40 men, <50 women)
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77
Q

What is the most effective phramacological treatment for beta-blocker OD and why

A

Glucagon

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78
Q

What is TURBT, TURP, ESWL

A

Transurethral resection of bladder tumors
Transurethral resection of the prostate
Extracorporeal shock wave lithotripsy

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79
Q

2 major complications of DM

A 
T1 = DKA
T2 = HHNK
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80
Q

Indicators of good renal function

A

Blood pressure

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81
Q

Anesthesia plan for pt undergoing ureteroscopy

A

GA
Pt CANNOT move
Us NMBD?

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82
Q

What is chronic renal failure

A

progressive irreversible deterioration of renal fxn

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83
Q

HHNK in type 2 DM manifests as

A 
absence of ketones
Requiring larges doses of insulin
Serum gluc >600 mg/dl
Osmo >340
pH >7.3
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84
Q

Purpose of random glucose level and elevated value

A

Used in symptomatic hyperglycemia

High =/>200 mg/dl

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85
Q

Octreotide mimics the action of

A

somatostatin

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86
Q

What is DM

A

Defects in insulin secretion or insulin resistance

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87
Q

Drugs that decrease serum gluc

A

Volatile anesthetics

beta antagonists

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88
Q

Most common presentation of carcinoid tumor

A

Abd pain

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89
Q

CV complications in pts with carcinoid tumors

A

30-50% have carcinoid heart disease
Manifests as right-sided HF
May need CV work-up

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90
Q

Serotonin released by carcinoid tumors cause

A

Hyperglycemia

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91
Q

Cause of paraplegic dysreflexia

A

Bladder distension

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92
Q

Which receptor/NT mediates afferent and efferent arteriole constriction and which autonomic system releases it

A

a1 receptor
epinephrine
SNS (aka adrenergic) system

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93
Q

Anesthetic considerations for gastric aspiration prophylaxis in renal pts

A

Especially in DM
to prevent vomiting during induction
Give renal dose of H2-receptor blockers

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94
Q

Kidney is what type of organ

A

Excretory

Endocrine

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95
Q

Important preop diagnostics for pheo

A

Echo (For EF and LV wall fxn d/t cardiomyopathy)

ECG

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96
Q

Cause of prerenal injury

A

Direct result of renal hypoperfusion
Irreversible cell damage
Complete lack of BF for 30-60 min

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97
Q

Administration of octreotide

A

SQ, IV or continuous IV
24-48 hts prior to surgery
Continue throughout procedure

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98
Q

Use of phenoxybenzamine
MOA
Goal
Cautions

A

Use:
Pheochromocytoma 1st-line treatment
Start at least 2 weeks prior to surgery

MOA:
NONcompetitive, NONselective, alpha-adrenoreceptor antagonist

Goals:
Normotension
Eliminate ST-segment or T-wave changes
Eliminate arrhythmias

Cautions:
Overtreatment can cause severe orthostatic hypotension

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99
Q

Advantage, disadvantage and osmolality of mannitol (5%)

A

Advantages:
Isosmolar solution
Not metabolize

Disadvantages
Osmotic diuresis
?acute intravascular vol expansion

Osmo:
275 mosm/ml

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100
Q

Metformin administration surrounding surgery

A

Held morning of surgery

Resumed when renal fx and circulatory status are stabilized post-op

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101
Q

What occurs as T2DM progresses

A

Pancreatic cell fxn DEC
insulin levels are unable to compensate
hyperglycemia occurs

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102
Q

What is metabolic syndrome associated with

A

Premature atherosclerosis

Subsequent CV disease

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103
Q

Drugs that INC serum gluc

A

Beta agonist

steroids???

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104
Q

Why do pts w/ CRF have longer bleeding times

A

d/t plt dysfxn
Poor quality of plt NOT number
NOT thrombocytopenia

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105
Q

Describe the types of nephrons

A

Superficial cortical nephrons:
• glomeruli in the outer cortex
• relatively short loops of Henle
 descend only into the outer medulla

Juxtamedullary nephrons:
• glomeruli near the corticomedullary border
• Glomeruli are larger than those of the superficial cortical nephrons
 have higher GFR
• long loops of Henle
 deep into the inner medulla and papilla

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106
Q

Which activates the release of aldosterone in the blood vessels and where is does the converting enzyme arise?

A

Ang II

Converted by ACE which is released from the lungs

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107
Q

9 Preop considerations for urolithiasis

A 
Comorbidities 
Bladder stones in seen w/ poor voiding
Paraplegic pts
Pts w/ idopathichypercalciuria
Opioid treatment
Transfusion
Monitoring
Abx prophylaxis
Eye protection
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108
Q

When may a pheo first manifest

A

Anesthesia/Surgery
Mimics=Thyrotoxicosis, MH

Pregnancy as preeclampsia

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109
Q

Causes and physiology of DKA

A

Absolute lack of insulin
-leads to hyperglycemia and ketoacidosis

DEC gluc utilizatoin and INC lipolysis
-leads to formation of FA that are oxidized in the liver to ketone bodies

INC mobilization of free FAs
-from adipose tissue to liver
initiated by insulin deficiency on fat cells

Switch of hepatic lipid metabolism to ketogenesis

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110
Q

4 Guidelines/cautions of for TURP

A
  1. Resection time <1 hr
  2. Height of irrigation soln @30 cm above OR table
  3. Fld dropped to 15 cm at the end of the case
  4. Open venous sinuses INC intravascular reabsorption
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111
Q

Identify and describe the 3 zones of the adrenal cortex

A

Zona reticularis:
inner most zone

Zona fasciculata:
Middle/widest zone
Synthesizes and secretes glucocorticoids and adrenal androgens

Zona glomerulosa:
Outermost zone
Secretes mineralcorticoids

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112
Q

ESWL process

A
  • Correlate pulse w/ EKG and shock w/ R wave
  • May inc HR to aid in shock?
  • Diuretic to increase fluid in ureter and shock resonates in fluid to help pulverize stone
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113
Q

Postop monitoring of EKG, O2 and labs

A

EKG:
monitoring INC K+

O2 levels:
significant in anemia

Labs:
Check BUN, crt, Hct

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114
Q

What/where is the adrenal cortex, function and component parts

A

What/Where
80% of adrenal tissue w/ 3 distinct layers
Outer zone of endocrine glad

Function:
Secretes adrenocortical steroid hormones

Component parts:
3 zones
Zona reticularis
Zona fasiculata
Zona glomerulosa
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115
Q

Advantages and disadvantages of H2O irrigation fld

A

Advantages = clear, no electrolytes

Disadvantage:
hyponatremia
Hemolysis
electrolyte imbalance
hypervolemia
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116
Q

Shock waves, during a lithotripsy, are synchronized how with the EKG?

A

R wave

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117
Q

What is the most common type of stone

A

Calcium

Radio-paque

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118
Q

Function of endocrine system

A

secretes hormone into circulation

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119
Q

Occurences of urolithiasis

A

Prevalence
Men = 10%
Women = 5%

50% of pts w/ initial stone will have recurrence w/in 5yrs

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120
Q

Where does the obturator nerve cause contraction when stimulated by electrocautery

A

Ipsilateral thigh muscle

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121
Q

Primary disease states or causes that can lead to AKI of each type (10,9,7)

A 
Prerenal:
DEC PO intake
Vomiting/Diarrhea
Diuresis
Diaphoresis
Burns
GI bleed/blood loss
CHF
Cirrhosis
Hepatorenal syndrome
Sepsis/shock
Intrarenal:
Contrast nephropathy
Thromboembolic dx
Atheroembolic dx
interstitial nephritis
Pigment nephropathy
Acute glomerulonephritis
ATN
Vasculities
TTP
Postrenal:
Nephrolithiasis
Paoillary necrosis
Neurogenic bladder
enlarged prostate
Pelvic malignancy
Ratroperitoneal fibrosis
Renal vein thrombosis
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122
Q

Clinical characteristics of metabolic syndrome

A

HTN
dyslipidemia
obesity

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123
Q

S/Sx when epi predominates pheo. Due to what action

A

S/Sx:
SBP HTN
DBP LOW
Tachycardia

Due to:
Effects d/t beta-adrenoreceptor

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124
Q

DKA manifests w/ what levels of serum gluc and anion gap?

A 
Serum gluc >300 mg/dl
Anion gap = elevated
Osmo >300
INC lactate and ketones
LOW HCO3
pH <7.3
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125
Q

Which statement is true regarding management of pheo?

1) pheoxybenzamine should be used for 2 weeks postoperatively
2) treatment with dilatiazem should be started to rapidly control bp
3) beta-blockade is used to treat tachycardia after adequate alpha-blockade has been attained
4) salt and fluid intake should be restricted to prevent further exacerbation of the patients HTN

A

3)beta-blockade is used to treat tachycardia after adequate alpha-blockade has been attained

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126
Q

Which drugs used during the preoperative period have contributed to a significant decrease in mortality from pheochromocytoma?

A

alpha-adrenergic blockers

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127
Q

S/sx r/t hyponatremia

A

Mental confusion
Nausea
Vtach?

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128
Q

Which nephron extends into the outer medulla and describe the loop of henles

A

Superficial cortical nephron

Short loop of henle

129
Q

What is 1st line treatment for T1 & T2 DM

A

T1 = insulin

T2 = metoformin

130
Q

4 different types of irrigation solutions

A

Distilled water
glycine (1.5%)
Sorbitol (3.3%)
Mannitol (5%)

131
Q

Why is the pH low in DKA/HHNK

A 
Means there is an excess of free H+ and deficient HCO3
b/c of H+ complete dissociation from 
•	β-hydroxybutyrate
•	Acetoacetate
•	Acetone

Excess H+ binds to HCO3- thus lowering the HCO3- concentration

132
Q

Treatment of pheochromocytoma

A

Surgical:
Resection is definitive treatment
Mostly done laparoscopic

133
Q

What happens when plasma glucose increases?

A

stimulates insulin release

DEC glucose

134
Q

Preop considerations before carcinoid resection

A 
Thorough history
Physical examination
Labs
Urine 5-HIAA assay
CV workup?
Bronchospasm treatment
135
Q

If sympathetic stimulation occurs in OR what is 1 thing that can happen?

A

Bleeding (d/t HTN)

136
Q

3 Kidney endocrine mediators released

A

Renin
Erythropoetin
1,25-dihydroxycholecalciferol

137
Q

Oral antidiabetic agents, drug examples and MOA

A

Secretagogues:
RX-sulfonylureas, melitinides
MOA-INC insulin acailability

Biguinides:
RX-metformin
MOA-suppresses excesive hepatic gluc release

Thiazolidinediones or glitazones
RX-rosiglitazone, pioglitazone
MOA-improve insulin sensitvity

a-glucosidase inhibitors
RX-acarbose, miglitol
MOA-delay GI glucose absorption

138
Q

Complete preop renal function evaluation

A 
H and P
Disease duration
Urinalysis
Assessment of GFR
Lab tests
139
Q

Treatment of hypoglycemia

A

BG goal > 100 mg/dl

D50W = initial dose of 0.5 g/kg

140
Q

What triggers hyperosmolar condition in T2DM

A

Hyperglycemia

141
Q

Difference between DKA and HHNK

A

Fluid deficit
T1 = 5 L
T2 = 9L

Acidosis and ketones
T1=yes and yes
T2=no and no

142
Q

How does absolute lack of insulin affect DKA

A

leads to hyperglycemia and ketoacidosis

143
Q

6 Irrigation solution considerations

A
  • Absorbed via open venous sinuses of prostate
  • Portion absorbed systemically
  • Can lead to circulatory overload
  • Toxicity from fld solutes
  • Absorbed vol is 10-30 ml/min of resection time
  • Longer resection = MORE complications
144
Q

What are the hemodynamic s/sx r/t in pheo

A

Due to catecholamine excess

Vary depending on which catecholamine dominates

145
Q

What are the triggers of HHNK

A 
Infection
Sepsis
PNA
Stroke
MI
146
Q

What does a a widened agap indicate in metabolic acidosis

A

Caused my unmeasured anions

-lactate, ketones or INC organic acids

147
Q

Autonomic system effects on glucose

A 
PSNS stim after eating
SNS stim (INC insulin to get gluc in cell)
148
Q

Induction considerations for renal pts

A

Most IV drugs can be used
ESRD respond as hypovolemic
May RSI w/ SCh when K<5.5

149
Q

6 Catecholamine release triggers? How to prevent/blunt response?

A 
Anesthesia induction
Depolarizing NMBD
Tracheal intubation
Pt positioning
Skin incision
Pneumoperitoneum

Prevent/blunt:
give beta-blocker, opioids, INC MAC

150
Q

What 6 factors increase BUN

A 
Protein intake
tPN
Steroids
Fever
Dehydration 
GI bleeding
151
Q

CV and pul status preop considerations

A
  • Intravascular volume changes
  • Pts on anticoagulant meds may not be candidate fro spinals
  • Consider risk vs benefit of stopping anticoags preop to perform spinal
152
Q

How does the pancreas function as an exocrine organ

A

Excrete hormones into duodenum for digestion

Hormone produced in acini tissue

153
Q

Disadvantages and CI of 0.9% NS and LR

A

Disadvantage = ionized; not electrically inert
CI= unipolar cautery use
Ok for bipolar cautery

154
Q

What happens to glucose released by liver at what percent?

A

70-80% is metabolized by brain, GI tract and RBC

155
Q

CNS signs of hypoglycemia

A
  • Sluggishness
  • Headache
  • Confusion
  • Irritability
  • Seizures
  • Coma
156
Q

What are the dermatome levels to provide adequate anesthesia and corresponding procedures?

A

 S2-S5 = peri-anal surgery, “saddle block”
 L2 = foot and ankle surgery
 T10 = Vaginal delivery and uterine procedure
 T6 = lower abdominal procedures
 T4 = upper abdominal surgery

157
Q

Clinical diagnosis of pheo

A

24 hr urine
Plasma-free metanephrines
Glucagon stimulation test
CT/MRI

158
Q

Most common nerve injury in any surgery?

A

Ulnar nerve injury is common nerve injury for all procedures

159
Q

Advantage/Disadvantage of spinal block vs GETA

A

SAB = allows for neuro assessment

GETA = no neuro assessment

160
Q

Normal glucose physiology balance

A

Balance between

glucose utilization, endogenous production and dietary delivery

161
Q

A diagnostic criterion for DKA

A 
Increased anion gap
pH<7.3
Metabolic acidosis
Serum gluc >
hyperglycemia d/t insulin deficiency
162
Q

CV work up in carcinoid tumor pt would include and why

A

Right sided HF=
edema

ECHO

163
Q

4 ways neuraxial anesthesia affect SNS

A

Sympathetic blockade (sympathectomy)
Theoretically imporve renal perfusion
Attenuates catecholamine-induced vasoconstriction
Suppresses surgical stress response

164
Q

What does Hgb A1C measure and normal level

A 
	Average BG for 2-3 months
	Glucose enters RBC 
•	links up (or glycates) w/ hgb 
	The INC glucose in blood
•	INC hgb gets glycated
NORMAL: HbA1c =/< 6.5%
165
Q

What is the fluid deficit difference between DKA and HHNK

A 
DKA = 5 L 
HHNK = 9 L
166
Q

What does the liver do during DKA

A

INC glycogenolysis
INC gluconeogenesis (from non-CHO metabolism like lipids)
INC ketogenesis

167
Q

Neuraxial Anesthesia considerations during TURP

A

T9-T10 prevents the obturator reflex

168
Q

4 Anestthesia considerations

A

Release of catecholamines
Long periods of hypotension
Vasopressors
Effects of neuraxial blocks

169
Q

Significance of extension of block to C6

A

It can go caudally to C5 which supplies the phrenic nerve

170
Q

What is the provocative test for pheo

A

Glucagon stimulation test

171
Q

What is MENS

A

Multiple endocrine neoplasia

172
Q

Symptoms of neuraxial block extending upward?

A

Difficulty breathing

173
Q

Importance of physical exam in carcinoid pt preop

A

Determine the presence/severity of S/Sx of carcinoid syndrome
Assess for flushing, diarrhea, wheezing and murmur

174
Q 
During a physical examination, the patient with a markly elevated 5-HIAA excretion, develops severe flushing, wheezing, nausea and lightheadedness. WS are notable for BP 70/30 mmHgg and a HR of 135 bpm. Which of the following is the appropriate therapy and why
octreotide
albuterol
atropine
epinephrine
A

Octreotide

Somatostatin derivative that

175
Q

Insulin presence during HHNK

A

Insulin is sufficient to prevent lipolysis and ketone production
But is overwhelmed by hyperglycemia

176
Q

Lab abnormalities w/ DKA and corresponding levels

A 
DEC Na (d/t INC gluc)
INC glus >300
DEC bicarb <18
DEC pH <7.3
Ketones
INC lactate
INC osmo >300
177
Q

Purpose of renal mediators

A

Vasoconstricotrs and vasodilators

178
Q

Why is Na+ low in DKA/HHNK

A

From the effects of hyperglycemia

179
Q

9 Clinical manifestations of DKA

A
  1. INC sreum gluc
  2. Hypovolemic shock
  3. INC production of ketoacids
  4. Anion gap creation
  5. Metabolic acidosis
  6. Kussmaul resp
  7. N/v abd pain
  8. Confusion/coma
  9. Fatigue, blurred vision
180
Q

HHNK treatment

A

Fld resuscitation
Insulin
Correct lyte imbalance

181
Q

What renal indicator is not a good indicator is not a good indicator of renal function intraoperatively?

A

Urine output

182
Q

Is the pancreas an exocrine or endocrine organ

A

Both

183
Q

what is the functional unit of the kidney, it’s parts and it’s purpose?

A

Nephron

Parts:
glomerulus, renal tubules
consists of glomerulus and tubules

184
Q

Triggers for DKA. Which is most common.

A

Infection (most common)
Omission/inadequate use of insulin
New-onset DM
Surgery

185
Q

A gap formula

A

(Na + K) - (Cl +HCO3) =A gap
Cations - anions = a gap

Negative and pos charges aren’t balanced
Means that There are more free H+ since there are less anions

186
Q

What effects do serotonin, bradykinin and histamine have during carcinoid syndrome? Treatments?

A

Serotonin:
Responsible for diarrhea d/t INC gut motility and intestinal secretions
Bronchoconstriction
Treatment:
5-HT3 antagonist (serotonin receptor antagonist)

Histamine:
Causes red, patchy pruiritic flushing 
Bronchoconstriction
Treatment:
H-1 or H-2 receptor blocker

Bradykinin:
Responsible for hypotension d/t profound vasomotor relaxation
Causes bronchospasm, esp in asthmatics and pts w/ CV dx

187
Q

What induction medications can be used?

A

Opioids
NMBD
Inhaled anesthetics

188
Q

Abnormal labs in HHNK and values

A

INC BG >600 mg/dl mg/dl
DEC pH >7.3
DEC HCO2 >15
INC osmo >340 mOsm/L

189
Q

Advantage, disadvantage and osmolality of glycine (1.5%)

A

advantage:
Less likelihood of TURP syndrome

Disadvantages:
Transient postop visual syndrom
Hyperammonemia
Hyperoxaluria

Osmo:
200 mOsm/ml

190
Q

Production of insulin, and purpose

A

Production
Released from pancreas (BETA cells)
In response to INC BG

Receptors on cell membranes

Purpose
Responsible for storing excess nutrients
as glycogen in liver, fat in adipose tissue and protein in muscle

191
Q

General and occasional presentation of pheo

A

Generally solitary, benign and sporadic

Occasionally multifocal, malignant or part of a syndrome

Usually on RIGHT adrenal gland

192
Q

Where should UO be maintained

A

UO >0.5 mg/kg/hr

193
Q

Presentation of pts w/ urolithiasis

A

Severe colicky pain to ipsilateral flank
Painless urinary infection
Hematuria

194
Q

What does oral glucose test measure, how and diagnostic level.

A

Serum gluc 2 hours after drink high gluc drink

Diagnostic level =/>200 mg/dL

195
Q

Catecholamine differentiation in S/Sx of pheo

A 
Norepi: 
MOST common
Sustained
Effect d/t alpha-adrenergic stimulation
SBP AND DBP HTN
Reflex bradycardia
Epi:
Less common
Paroxysmal
Effects d/t beta-adrenoreceptor stimulation
SBP HTN   DBP LOW
Tachycardia
196
Q

CV signs of hypoglycemia

A
  • Initial stimulation of the SNS
  • INC HR
  • HTN
  • diaphoresis
  • Lacrimation
  • Very similar to signs of light anesthesia
197
Q

When doing a c-section which level should be blocked and why

A

T4

D/T pressure to push on upper abdomen to deliver baby

198
Q

Which nephron extends deep into the medulla and describe the loop of henle

A

Juxtamedullary nephron

Longer loop of henle

199
Q

Where is glucagon secreted and how does insulin affect it’s action?

A

Secreted = alpha cells of pancreas

Insulin effects = antagonizes glucagon

200
Q

What/where is the adrenal medulla and function

A

Inner-most layer of adrenal gland

Produces catecholamines that fxn as hormones throughout the body
Epi and norepi

201
Q

How are carcinoid tumors clinically diagnosed?

A

Urine and plasma assays of serotonin and it’s metabolite

CT/MRI/US
Identification of primary tumor

Bronchoscopy
Localization of tumor in bronchiole tree

Xrays (chest/abd)
Incidental findings

202
Q

Diagnostic criteria

A

Any listed criteria establishes diagnosis of DM
In absence of hyperglycemia symptoms, tests are repeated
In acute setting hyperglycemia symptoms include polyuria, polydipsia, weight loss and blurred vision

203
Q

Treatment of T2DM

A

Diet exercise and drugs

204
Q

As an endocrine organ, the kidneys

A

secrete renin
synthesize erythropoetin
1,25-dihydroxycholecalciferol

205
Q

Treatment of bronchospasm in pts w/ carcinoid tumors. DOC and adjuvants

A

DOC = octreotide

Adjuvants=
Corticosteroids, ipratropium bromide (anticholinergic), antihistamines

206
Q

Leading cause of DM in the us

A

ESRD

Followed by HTN

207
Q

Paraplegia at what level increases risk of autonomic hyperreflexia? What would be the reason to perform regional anesthesia and at what level?

A

T6

To blunt sympathetic autonomic reflex response at T5

208
Q

What is glucagon, how is it produced and what is it’s function.

A

Catabolic hormone that promotes energy release from adipose tissue and liver

Secreted by a-cells

insulin antagonist
INC myocardial contractility, HR and AV conduction

209
Q

3 types of AKI and characteristics

A

Prerenal:
Caused by DEC in effective circulating volume and renal perfusion, or bilat arterial occlusion

Intrarenal
Caused by glomerular or renal tubular injuries, or intrarenal vascular disruptions

Postrenal
Cause by obstruction of the urinary tract or bilat renal veins

210
Q

What is a positive glucagon stimulation test and what does it indicate?

A

Indicates diagnosis of Pheochromocytoma

Positive response:
INC plasma catecholamines 
3x > baseline
w/in 1-3 min of glucagon administration
Perform when DBP<100 mmHg
211
Q

Incidence in US

A

Approx 1000 cases/year

212
Q

Pharmacologic agents associated w/ carcinoid crisis. Which drugs provoke and don’t provoke release of mediators.

A

Drugs that provoke release:
Succs, mivacarium, atracarium, Epi, norepi, dopa, isoproterenol, thiopental

Drugs NOT known to release mediators:
Propofol, etomidate, Vec, cisatracurium, rocuronium, sufenta, alfenta, fenta, remi
ALL inhalation agents

213
Q

How does succinylcholine affect pheo? How can this be countered?

A

Induces muscle fasiculation in abdomen
Can cause tumor compressoin and catechol release
Defasciculate w/ ND-NMBD

214
Q

S/Sx of pheo

A

HTN
HA, Sweating, pallor, palpitations
Orthostatic hypotension (from hypovolemia d/t alpha blockade)

215
Q

Anesthetic considerations for HD status in renal pts

A

HD w/in 24 hrs of elective Sx to prevent volume overload

216
Q

What can cause hyperglycemia in pts carcinoid tumors.

A

Excess serotonin

217
Q

What are the 5 adrenal cortex hormones and their function

A

Mineralcorticoids (aldosterone):
responsible for volume regulation via Na/K exchange

Aldosterone:
INC K+ secretion and excretion
INC NA reabsorption/retention

RAAS

Glucocorticoids (cortisol):
gluconeogenesis, INC gluc
promotes glycogen storage
Protein/lipid/CHO metabolism
Anti-inflammatory actions
BP maintenance

Androgens

218
Q

Lithotripsy shock EKG coordination and why

A

Coordinate with R wave to prevent R on T phenomenon

219
Q

MOA and use of Octreotide

A 
MOA:
Somatostatin cyclic peptide
Inhibits
-GI motility
-Gastric acid production
-Pancreatic enzyme secretion
-Bile and colonic fld secretion

Use:
Bronchospasms not responsive to beta-agonists, theophylline, or epi

220
Q

In general, the most important goal in the treatment of the diabetic pt undergoing anesthesia is

A

to prevent hypoglycemia

221
Q

Lab abnormalities w/ HHNK and corresponding levels

A 
DEC Na (d/t INC gluc)
INC glus >300
DEC bicarb <18
DEC pH <7.3
Ketones
INC lactate
INC osmo >300
222
Q

Which nephron has the highest GFR

A

Juxtamedullary

223
Q

Common and ideal (why) beta-blocker used in treatment of pheo related tachycardia

A

Common: propranolol (primary)

Ideal: Esmolol

  • B1-selective antagonist
  • Rapid onset
  • Short elimination half-life
  • Only given IV immediately before surgery
224
Q

Best anesthetic approach w/ TURP or TURBT

A

Central neuraxial

225
Q

Why are ketones present in DKA?

A

Because there is no insulin to allow gluc into the cell

Therefore cells perform metabolism of protein and fats that produce ketones and lactic acid

226
Q

What is the purpose and normal range for

GFR and BUN

A

GFR:
Best measure of glomerular filtratoin
Normal = 125 ml/min

BUN (blood urea nitrogen):
Less specific indicator of kidney fxn
reflects ingested protein and muscle catabolism

227
Q

When using glycine what is an important postop assessment

A

Transient blindness

228
Q

Effects and treatment of neuraxial anesthesia on BP

A

DEC BP

Maintain IVF vol

229
Q

Hormones that DEC sreum gluc

A

Insulin

Somatostatin

230
Q

Most important dermatome landmarks to remember?

A 
T10 = umbilicus
T4= nipple 
C8 = 5th finger

Then:
S1=lateral aspect of foot
L1=inguinal ligament

231
Q 
Innervation for 
Kidney and ureter
Pelvic organs
Bladder
Prostate
A

Kidney and ureter = T8- L2
Pelvic organs= lumbosacral and low thoracic input
Bladder = T11-12 (dome), S2-S4 (neck)
Prostate = T11-12 and S2-S4

232
Q

3 types of urolithiasis

A

Nephrolithiosis (kidney)
Ureterolithiasis (ureter)
Cystolithiasis (bladder)

233
Q

Complications of pheo

A

Cardiomyopathy
Coronary vasoconstriction
DEC coronary BF (leading to ischemia)

234
Q

What/Where are cardio-accelerator nerves and importance

A

T1-T4

can affect renal blood flow and dec VR

235
Q

Temperature considerations with TURP

A
  • Temp DEC approx 1C/hr of surgery

- Shivering in 16% of pts receiving room-temp irrigation flds

236
Q

What happens to glucose and insulin following meals

A

Plasma glucose levels increase

Stimulation an INC in plasma insulin secretion which promotes glucose utilization

237
Q

What occurs to hepatic metabolism during DKA and what is a result

A

Switches to ketogenesis and hepatic lipid metabolism
In response to insulin deficiency

Rise in levels of stress hormones
(glucagon, corticosteroids, catecholamines, growth hormone)

238
Q

What is the liver’s role in glucose, explain.

A

Primary source of endogenous glucose

Produced via:
glycogenolysis
Gluconeogenesis

239
Q

How does the pancreas function as an endocrine organ

A

Releases hormones into circulation for metabolism

Hormones produced in islet of langerhands

240
Q

What are renal tubules

A

Lined epithelial cells which perform reabsorption and secretion

241
Q

What is carcinoid crisis and how does it manifest

A

Life-threatening complication of carcinoid syndrome

Manifests as:
Intense flushing
diarrhea
abd pain
CV signs (Tachy, HTN, hypotension)
242
Q

Anesthesia considerations for pts on HD

A

Blood transfusion
To INC O2 carrying capacity
For excessive blood loss

243
Q

What is the main cause of bronchoconstriction in pts w/ carcinoid tumors

A

Bradykinin

244
Q

DKA serum gluc level, relevance to hypovolemic shock and fluid alterations

A

=/> 300

Shock:
from hyperglycemic osmotic diuresis
AVG fld deficit = 5 L

245
Q

Use of alpha1-antagonists in pheo

A

Used d/t shorter elimination time
Helps avoid postop hypotension
Can cause postural hypotension

246
Q

TURP positioning, complications and prevention

A

Lithotomy position
Common peroneal nerve compression is most common LE nerve injury
Prevent:
pad pressure points and avoid nerve compression

247
Q

Renin’s purpose for aldosterone

A

It is necessary for aldosterone to be activated

248
Q

Symptomatic hyperglycemia

A

Polyuria
Polydipsia
Unexplained weight loss

249
Q

GA effects on hypoglycemia

A

obscured by GA

250
Q

What is the major perioperative goal for carcinoid tumors

A

Prevent release of bioactive mediators

Avoid triggers to prevent crisis

251
Q

5 Pheo preop considerations and why

A 
Large bore IV
-administer fluids; preop fluid optimization
A-line
-Monitor hemodynamic status
CVP 
-Monitor fld status 
PA cath
-Only in severe CV compromise
Thoracic epidural cath
-Post-op pain mgmt
252
Q 
Where are the corresponding locations
S1
L1
T10
T6
T4
T1-T2
C8
A 
	S1 - lateral aspect of foot
	L1 - inguinal ligament area
	T10 - umbilicus
	T6 - xiphoid process
	T4 - nipple
	T1-T2 - inner aspect of the arm and the forearm
	C8- Fifth finger
253
Q

Bronchospasm due to carcinoid tumor is treated with

A

Octreotide
Antihistamine
Anticholinergic (itrapromium bromde)
Steroid

254
Q

The cardioaccelerator nerves originate from which spinal level

A

T2-T5

255
Q

5 Renal mediators

A 
Catecholamines
Ang II
ANP
PGs
Dopamine
256
Q

Anesthetic considerations for K+ status in renal pts

A

=/< 5.5 mEq/L day of Sx

257
Q

How does surgical manipulation affect catecholamines? What is the CRNAs response?

A

Can trigger relase
Results in acute HTN and dysrhythmias

Medications immediately available to treat HTN episodes

Short-acting agents preferable b/c short-acting nature of surges

For SVT/Vent dysrhythmias use
B-blocker or lidocaine

258
Q

Common and uncommon locations of pheo

A

Common:
Abdomen

Uncommon:

  • Extra-adrenal locations
  • Paraganglial cells of the ANS (paraganglioma)
  • In the heart or pericardium
259
Q

what is the functional unit of the kidney and it’s purpose?

A

Nephron

consists of glomerulus and tubules

260
Q

Why is alpha blockade important prior to pheo surgery? (6)

A 
DEC BP
INC intravascular vol
Prevention of HTN
DEC myocardial dysfunction
Protect myocardium 
Protect tissue oxygenation
261
Q

What is the metabolite of serotonin?

A

5-hydroxy-indole-acetic-acid (5-HIAA)

262
Q

When does INC K+ occur in renal pts.

A

Doesn’t occur until pts are uremic

263
Q

Landmarks from dermatome levels

A 
S1 = lateral aspect of foot
L1= inguinal ligament area
T10 = umbilicus
T6 = xiphoid process
T4 = nipple
T1-T2 = inner aspect of the arm and forearm
C8 =FIFTH finger
264
Q

Use of fenoldapam on renal fxn during surgery

A

Dopamine-1 agonist

May provide renal protection

265
Q

When are CCBs used in pheo

A

Pts w/ refractory HTN and coronary vasospasm

266
Q

Electrolyte lab manifestations of CKD inclue

A

Hypermagnesemia

Hyperkalemia

267
Q

Treatment of DKA

A

Hydration
Insulin
Electrolyte replacement

268
Q

Where is glucose filtered and reabsorbed

A

filtere = glomerulus

reabsorption=PCT

269
Q

What are 3 secreted hormones and their purpose from the endocrine system.

A

Peptide
Steroids
Amines

Purpose
Go to target cells to produce physiologic response

270
Q

What to do if neuraxial block is extending past C6

A

raise HOB = fowler position
Start giving _______ ?
Give O2
Give versed

271
Q

Chronic renal failure has what effect on the kidney

A

Causes irreversible renal failure that is d/t DM and/or HTN

272
Q

What does fasting plasma gluc measure and normal value

A

Serum glucose following no caloric intake for =/> 8 hrs

Normal =/< 126 mg/dL
Diagnostic =/<126

273
Q

What is the purpose and normal range for Crt and urine specific gravity.

A

Crt:
Product of muscle metabolism
most specific indicator of renal fxn
Normal= 0.5 to 1.5 mg/dl

Urine specific gravity:
Concentration of solutes in urine
Reflects kidney's ability to concentrate urine
Infections?
Range = 1.005 to 1.030
274
Q

Which statement/s is/are true regarding management of pheo?

1) pheoxybenzamine should be started 2 weeks prior to surgery
2) treatment with dilatiazem should be given to pateints with refractory BP problems and vasospasms to control BP
3) beta-blockade is used to treat tachycardia even if adequate alpha-blockade has not been attained
4) fluid intake should be optimized to prevent s/sx related to hypovolemia

A

1, 2, and 4 are true

275
Q

Effects of INC mobilization of free FAs on DKA

A

Free FAs from adipose tissue to liver initiated by absolute insulin deficiency on fat cells

276
Q

Hypoglycemia occurrence in surgical pts

A

More likely to occur in DM surgical pts

277
Q

8 treatments of urolithiasis

A
  1. Conservative nonsurgical pain management
  2. NSAIDs
  3. Aggressive fld administration to INC UO
  4. Medical expulsive therapy (MET)
  5. Promote ureter relaxation
  6. CCBs (Nifedipine)
  7. a-blockers (tamsulosin)
  8. Corticosteroids
278
Q

Clinical manifestations of HHNK

A

CNS changes-confusion

Dehydration - avg deficit 9L

279
Q

Describe kussmaul respirations and effects on O2 and CO2

A

Rapid deep respirations to compensate for metabolic acidosis

INC O2
DEC CO2

280
Q

Renal colic is associated with

A

Nausea and vomiting

Preop aspiration prophylaxis should be considered

281
Q

What are the vasoconstricor and vasodilator mediators

A

Constrictors:
SNS catecholamines
ANG III
Endothelin

Dilators:
PGE2/PGI2
NO
Bradykinin
Dopamine
ANP
282
Q

Describe purpose of each clinical diagnostic tests. Which is most sensitive?

A

24 hr urine = screening:
-Checks presence of metanephrines and catecholamines in urine

Plasma-free metanephrines:

  • MOST SENSITIVE
  • Metabolized to free metanephrines in tumor cell constinuously release metabolites into circulation

Glucagon stimulation test:

  • Provocative/Induction of SNS response
  • Glucagon acts directly on the tumor
  • Induces catechol release

CT/MRI:
Tumor localization

ECHO:
-Before Sx to detect cardiomyopathy

283
Q

What medications should be avoided in the operative period for pheo?

A

Any meds that release histamine or stimulate autonomic effects
Atracurium, pancuronium, morphine, meperidine, ephedrine, metoclopramide

284
Q

Cause of T1DM, occurrence, treatment and complication

A

Cause:
Deficient secretion of insulin
D/t autoimmune destruction of pancreatic beta cells

Occurrence
Primarily noted in Childhood and adolescence

Treatment
Exogenous insuling

Complication
DKA

285
Q

Bradykinins, released by carcinoid tumors cause

A

Hypotension

Bronchospasm

286
Q

Indications of TURP, how performed and anesthesia plan.

A

Indications:
Prostate removal of BPH

Perform:
Resectoscope inserted into urethra to access protate

Anesthesia:
Subarachnoid block at T10
GETA

287
Q

What can glucagon be used for?

A

B-blocker OD
CHF
Low CO after bypass or MI
to INC MAP during anaphylaxis

288
Q

Preop and anesthetic paraplegic considerations prior to urolithiasis procedure

A

-Pts w/ sensory deficits below T6 at risk for autonomic hyperreflexia
-Require anesthetic block of afferent stimulation to prevent reaction to bladder distention
-Anesthesia:
deep GETA or regional anesthesia

289
Q

A complaint of numbness was noted in the pts right pointing and middle fingers. This corresponds to a sensory block at which dermatome level

A

level = C7

290
Q

Hypoglycemia labs and r/t EEG

A

Hypoglycemia <50 mg/dl

EEG depression
50-55 in nonDM pt
70-85 in DM pt

291
Q

The diaphragm is innervated by the phrenic nerve which arises from which spinal level

A

C5

292
Q

Opioid use in nephrolithiasis

A

Recurrent nephrolithiasis pts may be on chronic opioid therapy

293
Q

What is a carcinoid tumor and common location?

A

Slow-growing neoplasm of neuroendocrine tissue
Secretes bioactive substances

Location:
Bronchus
jejunoilum
colo-rectum

294
Q

Elevated osmo indicates what?

A

Dehydration d/t INC solute concentration

295
Q

Urolithiasis procedure indications

A

Stone unlikely to pass w/o surgery

d/t size, location, presence of strictures or abnormalities

296
Q

Fetal development and purpose of the adrenal cortex. What happens after birth?

A

Development:
Mesodermal origin
Differentiates by gestational week 8 (2 months)

Purpose:
Responsible for production of intrauterine fetal adrenal steroids

After birth:
Adrenal cortex begins to involute and disappears
Replaced by 3 layer adrenal cortex

297
Q

Hormones that INC serum glucose

A

Glucagon
Catecholamines
Cortisol
Growth hormone

298
Q

S/Sx of excessive volume expansion

A 
Resp distress
CHF
Pulm edema
HTN/DEC BP
Bradycardia
299
Q

S/Sx when norepi predominates pheo. Due to what action.

A

S/Sx
SBP and DBP HTN
Reflexive brady cardia

Due to:
Effect d/t alpha-adrenergic stimulation

300
Q

Which major organ secretes angiotensinogen

A

Liver

301
Q

3 major diagnostic tests for DM

A

Hgb A1C
Fastin gplasma glucose (FPG)
Oral glucose tolerance test (OGTT)

302
Q

Who is at risk for metabolic syndrome

A

Pts w/ T2DM

303
Q

Intraoperative complications during pheo surgery

A

Hemodynamic instability

Blood loss

304
Q

When are beta-blockers used in treating pheo.

A

Tachycardia d/t pheo
AFTER adequate alpha-blockade

Predominan epi-secreting tumors
CAD

305
Q

What hormone and metabolite is responsible for carcinoid tumor symptoms

A

Serotonin

5-hydroxy-indole-acetic-acid (5-HIAA)

306
Q

TURP complications, causes and prevention.

A
  • Bladder perf
  • d/t rigid cystoscope used during resection from unexpected pt movement
  • Movement from OBTURATOR NERVE violent contraction d/t electrocautery
  • Give MRs during GETA
307
Q

What is a life-threatening SE of metformin

A

lactic acidosis

308
Q

DKA is the result o f

A

abnormal CHO and fat metabolism

309
Q

Type 1 DM treatment require

A

exogenous insulin to survive

310
Q

What does glucosuria lead to in DKA/HHNK

A

Osmotic diuresis

311
Q

Post-op pain management for TURP

A

Usually minimal

Responds well to nonopiate and nonopiate meds

312
Q

Physical clinical features

A

Kussmaul resp
n/v and abd pain
confusion/coma
fatigue, blurred vision

313
Q

Signs and symptoms of TURP syndrom

A

Cluster of systems r/t hypervolemic H2O intoxication

  • Excess vol expansion
  • Hyponatremia
  • Problems r/t specific irrigating solutions
314
Q

12 Preop anesthesia considerations includes

A 
Comorbid conditions
Recognize pts at high risk of developing periop renal failure
Evaluate serum Crt tren
Blood volume status
Glucose mgmt
Control BP
Continue antiHTN (x ACE-i)
K+ concentration
Gastric aspiration prophylaxis
H2-receptor blockers
Pts on HD
315
Q

Purpose of neuraxial anesthesia in CKD

A

Good for pts w/ CKD

Sympathetic blockade of T2 to T10 levels

316
Q

Neuraxial considerations in HD pts

A

Consider plt dysfxn and residual heparin effects

Minimize DEC BP by maintaining adequate IVF vol

317
Q

Complication of T2DM, causes and physiology

A

Hyperosmolar condition triggered by hyperglycemia in the absence of ketones

Enough endogenous insulin secretion but hyperglycemic episode overwhelms the pancreas

Amount of insulin secreted
-usually sufficient to prevent lipolysis and ketone production

Glucose load exceeds PCT max reabsorption
-Leads to massive solute diuresis and water depletion

318
Q

8 TURP syndrome treatment

A
  1. Oxygenation and CV support
  2. Notify surgeon and terminate Sx
  3. Insert invasive monitor for CV monitoring
  4. Send blood to lab for lytes, crt, gluc, ABG
  5. 12-ld ekg
  6. Treat mild symptoms w/ fld restriction and loop diuretics
  7. Treat severe symptoms w/ 3% NaCl IV <100 ml/hr
  8. D/C 3% NaCl when serum Na>120 mEq/L
319
Q

Use of irrigation fluids in TURP

A

Irrigation fld for bladder and prostate

Improves visualization

Assessment (3 decks)

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