Exam 1 Flashcards
process when water is driven by osmotic gradients through a semipermeable membrane separating solutions with different solute concentration
osmosis
TBW in water:
Male % and Liters
Female % and Liters
Infant %
Male 60% and 42L
Female 50% and 39L
Infant 75%
% of total body weight of the following fluid compartments:
TBW
ECF
ICF
RBC in Liters of H2O?
% of ECF that is:
ISF
Plasma
TBW 60%
ECF 20%
ICF 40%
RBC= ~1.5L of H2O
ISF = 75% of ECF Plasma = 25% ECF
Approx total blood volume in an adult male in liters
~5L - Plasma (3.5L) + RBCs (1.5L)
2 fluid types in the ECF (related to movement)
functional and sequestered
osmosis is a passive process driven by differences in particle _______, not size.
numbers
pressure gradient created by solute molecules that displace water
osmotic pressure
molecules move through a semipermeable membrane from an area of higher concentration to an area of lower concentration
diffusion
movement of molecules against their electrochemical gradient in a process that requires energy. [e.g. Na+/K+ATPase]
Active Transport
the force (mmHg) generated by the pressure of fluid within or outside of a capillary on the capillary wall
Hydrostatic Pressure
osmotic pressure (mmHg) exerted by proteins in the blood plasma or interstitial fluid
Colloid Osmotic Pressure (Oncotic Pressure)
number of osmotically active particles per liter of solvent; mOsm/L
Osmolarity
number of osmotically active particles per kilogram of solvent (water); mOsm/kg
Osmolality
Plasma Osmolality formula
2[serum Na+] + [Glucose]/18 + [BUN]/2.8
Normal = 280-290 mOsm/kg
Osmolal Gap: measured osmolality >10 mOsm/kg H2O than calculated
in a fluid compartment, the sum of all positive ions (cations) exactly equals the sum of all negative ions (anions)
Law of Electrical Neutrality
intracellular and intravascular concentration of electrolyte in mEq/L Na+ K+ Ca++ Ma+ Cl-
ion - ICC, IVC Na+ = 10, 134-145 K+ = 156, 3.5-5 Ca++ = 3, 5 Ma++ = 26, 3 Cl- = 2, 103
what ion contributes the greatest to determining osmolality?
Na+
Physiologically, ______ and _____ are the primary determinants of tonicity
sodium, potassium
Isotonic solutions
BSS; Normosol™-R or Plasma-Lyte
Hypertonic solutions
0.9% NaCl is slightly hypertonic; 3% NaCl or 20% mannitol is very hypertonic
Hypotonic solutions
Lactated Ringer’s (LR) slightly hypotonic; 0.45% NaCl and D5W are hypotonic
ICF has high concentrations of which ions?
Potassium (K+): 156 mEq/kg H2O
Magnesium (Mg2+): 26 mEq/kg H2O
Phosphate (P04-): 108 mEq/kg H2O
Proteins 55 mEq/kg H2O
*notice this mEq/kg and relates to osmolality
ICF has low concentrations of which ions?
Sodium (Na+): 10 mEq/kg H2O
Chloride (Cl-): 2 mEq/kg H2O
Calcium (Ca2+): 3 mEq/kg H2O
*notice this mEq/kg and relates to osmolality
ECF has high concentrations of which ions?
Sodium (Na+): 136 - 145 mEq/L
Chloride (Cl-): ~110 mEq/L
Calcium (Ca2+): ~4 mEq/L
*notice this mEq/L and relates to osmolarity
ECF has low concentrations of which ions?
Potassium (K+): 4 mEq/L
*notice this mEq/L and relates to osmolarity
interstitial fluid is separated from intracellular by the _______ _______.
plasma membrane
the interstitial component of the ECF is separated from the vascular component by the _______ ________.
capillary endothelium
blood volume in liters,
2 components and percentages
Blood volume ~ 5 liters
60% of blood is plasma
40% of blood is red blood cells
smallest but most vital of the 3 fluid compartments?
plasma
Interstitial fluid is a complex mixture of what fluids?
Ultrafiltrated plasma (Intravascular water) Transudated Plasma Transcellular Fluids (fluid and electrolytes actively pumped out of cells)
what are the four starling forces that govern the movement of fluid at the capillary level?
hydrostatic pressure in the capillary (Pc)
hydrostatic pressure in the interstitium (Pi)
oncotic pressure in the capillary (pc )
oncotic pressure in the interstitium (pi )
how does fluid that is filtered into the interstitial space make its way back into the vasculature?
via the lymphatic drainage system
water balance is mediated by what three mechanisms?
osmolality sensors in the anterior hypothalamus
baroreceptors in the left atrium, carotid arteries and aortic arch
the juxtaglomerular apparatus (RAAS)
vasopressin is produced in the ____ and released by the ____.
produce in the hypothalamus and released by the posterior pituitary
the most abundant ecf ion….
sodium
primary site of Na+ regulation
kidney via changes in rate of glomerular filtration & tubular resorption
Your patient is hyperglycemic with a blood sugar of 400 and must go to surgery. Due to their hyperosmolar state they have developed a seemingly dilutional hyponatremia. How can you determine an approximate actual sodium level for this patient?
For every 100 mg/dL of glucose above 100, add 1.6 mEq/L to the measure sodium
four general categories of hyponatremia
Pseudohyponatremia
Hypovolemic Hyponatremia
Hypervolemic Hyponatremia
Euvolemic Hyponatremia
examples of pseudohyponatremia
False low PNa+; normal osmolality; presence of other osmolar particles in the serum that don’t contribute to plasma osmolality
Severe hyperlipidemia or hyperproteinemia, blood draw error
examples of hypovolemic hyponatremia
Decreased ECF volume combined with an even greater loss of Na+
Body fluid losses: Sweating, vomiting, diarrhea, GI suction, “third spacing”
Renal causes: Diuretic use, CHF, mineralocorticoid deficiency, renal tubular acidosis, and salt wasting nephropathy or cirrhosis
examples of hypervolemic hyponatremia
Na+ and H2O are retained, but H2O retention exceeds Na+ retention
Heart failure, chronic renal failure, and hepatic failure
Edema; fluid retention is due to renal hypoperfusion and resulting aldosterone secretion
examples of euvolemic hyponatremia
Euvolemic but have increased TBW
Causes: Syndrome of inappropriate antidiuretic hormone secretion (SIADH), psychogenic polydipsia, hypothyroidism, mild CHF with diuretic use, water intoxication, and MDMA use
three most common causes of SIADH
pulmonary lung masses, CNS disorders, and medication
Acute hyponatremia time, treatment and target rise metrics
Acute = less than 48 hours
may be corrected rapidly, but ONLY if neurologically impaired
Treatment = 150 ml of hypertonic (3%) NaCl PIV over 20 min.; furosemide to increase renal excretion of free H2O
Target rise in PNa+ by 4-6 mEq/L within the first 4–6 hours; should not exceed 8 mEq/24°
Chronic hyponatremia time, treatment considerations and target rise metrics
Chronic = > 48 hrs
Slow correction unless seizures or coma
Treatment = 150 ml of hypertonic (3%) NaCl PIV over 20 min.; furosemide to increase renal excretion of free H2O
Correction should not exceed 12 mEq/L over 24 hours
what patients are most at risk for osmotic demyelinating syndrome?
hyponatremic, hypokalemic, malnourished patients such as chronic alcoholics
TURP syndrome cause, risk factors, S&S and treatment
Transurethral Resection of the Prostate (TURP) Syndrome
For benign prostatic hyperplasia; cystoscopic approach
Surgeon uses Isotonic, non-electrolyte fluid with glycine or sorbitol with mannitol to continuously irrigate the bladder.
When this irrigant makes its way into the vascular space via the resected vascular tissue of the prostate it can cause a hypo-osmolar plasma state
Risk factors: prolonged (>1 hour) surgical time, irrigating bag > 40 cm above the operative field, use of hypotonic irrigation fluid, bladder pressure >15 cm H2O
S&S: Cardiopulmonary, neurologic, hematologic, renal, metabolic (Table 21.4)
Treatment: Stop surgery, loop diuretic, support CVS, treat low PNa+ if severe
What is the formula for replacing water deficits in patients with hypovolemic hypernatremia?
Water deficit = (o.6 x total body weight in kg) x (sodium concentration/140 −1)
what is the major intracellular cation?
K+
What 2 factors affect how the kidneys regulate potassium?
renal tubular fluid and aldosterone
potassium balance is primarily governed by what mechanism?
urinary loss
4 Major roles of potassium in the body?
Generation of the resting cell membrane potential and the action potential
Protein synthesis
Acid–base balance
Maintenance of intracellular osmolality
what is aldosterone’s action on sodium and potassium?
aldosterone leads to the retention of sodium and the excretion of potassium.
Hypokalemia most common causes
Serum [K+] < 3.5 mmol/L
Usually iatrogenic; most common electrolyte disorder in patients; most are asymptomatic
Causes: (1) Increased renal loss; (2) Increased G.I. loss; (3) Transcellular shift
2 most common causes hypokalemia due to transcellular potassium shift
respiratory alkalosis and beta agonists
what other electrolyte abnormality is commonly seen in patients with hypokalemia?
hypomagnesemia
hypokalemia is often asymptomatic but when they do arise they will likely be of ______ and _____ in origin.
cardiac, neuromuscular
EKG changes in hypokalemia
T-wave flattening ST depression U waves QT interval prolongation, ventricular dysrhythmias and cardiac arrest
Hypokalemia treatment
Treatment
1 mEq/L serum reduction = 200 mEq total body loss
Potassium chloride 40 to 60 mEq PO q 2 to 4 hours is well tolerated
Intravenous: 10 to 20 mEq/hr; max 0.5 to 0.7 mEq/kg/h
Hyperkalemia common causes and levels
Serum [K+] > 5.5 mmol/L (Mild: 5.5 – 6.0; Moderate: 6.1 – 6.9; Severe: > 7.0)
Common causes :
Pseudohyperkalemia: Hemolysis due to drawing or storing of the laboratory sample or post–blood sampling leak from markedly elevated white blood cells, red blood cells, or platelets
Renal failure: Acute or chronic
Kidneys account for ~90% of K+ excretion; serum K+ begins to rise only when renal function falls to < 25% of normal
Acidosis: Diabetic ketoacidosis (DKA), Addison’s disease (adrenal insufficiency), renal tubular acidosis
Cell death: Rhabdomyolysis, tumor lysis syndrome, massive hemolysis or transfusion, crush injury, burn
Drugs: Beta-blockers, acute digitalis overdose, succinylcholine, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), spironolactone, amiloride, potassium supplementation
Hyperkalemia S&S
Chronic: often asymptomatic
Moderate to severe hyperkalemia: nausea, vomiting, and diarrhea
Severe may present with neuromuscular findings like muscle cramps, generalized weakness, paresthesias, tetany, and focal or global paralysis – not sensitive or specific findings.
MOST IMPORTANT consequence of hyperkalemia
The reduction is myocardial membrane resting potential leading to progressive ECG abnormalities
Tumor lysis syndrome, which can cause increased potassium levels, can be induced by the administration of which common anesthesia medication?
dexamethasone
First and most common change on the ECG in the setting of hyperkalemia
symmetrical peaking of the T wave
3 mainstays of treatment for hyperkalemia in rank order
- stabilization of cardiac membrane
- shifting potassium back into cells
- eventually removing potassium from the body
in hyperkalmia, administration of what other electrolyte will help to stabilize the cardiac membrane?
calcium (chloride or gluconate) IV push, which will restore the electrical gradient at the cardiac
membrane.
calcium chloride is most effective
what is the most reliable agent for shifting potassium into the cells in the setting of hyperkalemia?
insulin, give with glucose to prevent hypoglycemia. stimulates sodium potassium ATPase
Most abundant electrolyte in the human body
calcium
2 primary forms of circulating calcium
Free ionized fraction in ECF (60%); this is the physiologically active form! [1.12 to 1.32 mmol/L]
Protein bound (mostly albumin) (40%); pH dependent alkalosis ↑ binding, acidosis ↓ binding
3 hormones involved in the regulation of calcium
Parathyroid Hormone
Calcitonin
Cholecalciferol (Vitamin D3)
Normal range for ionized calcium
1.12-1.32 mmol/L or 4.5-5.3 mg/dL
Parathyroid hormone MOA
closely regulates free ionized fraction of Ca2+
↑ bone resorption and renal tubular reabsorption of Ca2+
Ionized fraction of Ca2+ regulates PTH secretion by negative feedback mechanism
Hypocalcemia stimulates and hypercalcemia suppresses PTH release.
Calcitonin MOA
inhibits bone resorption of Ca2+
opposes parathyroid hormone
Cholecalciferol (vitamin D3) MOA
↑ intestinal absorption of Ca2+ and phosphate (PO₄³⁻) and increase bone mineralization
Synthesized in sun-exposed skin and provided in the diet – hydroxylated in the liver to 25-OH vitamin D and then in the kidneys to the primary active form of 1,25-(OH)2 vitamin D [1,25-dihydroxycholecalciferol]
What are the cardiac effects associated with increased intracellular Ca2+?
increased contractility, inotropy, and cardiac output
Calcium is important in the activation of which coagulation factors?
thrombin, VII, IX and X
how does the reduction in albumin affect total serum calcium?
1 g/dl ↓ in albumin = 0.8 mg/dl ↓ in Ca2+
True or False, hypoalbuminemia is a common cause of hypocalcemia and leads to an overall reduction in ionized calcium?
False
Hypoalbuminemia is a common cause of hypocalcemia in hospitalized patients, but…
This affects TOTAL serum Ca2+ (1 g/dl ↓ in albumin = 0.8 mg/dl ↓ in Ca2+)
Ionized Ca2+ is unaffected
Most common cause of symptomatic hypocalcemia
Hypoparathyroidism Massive blood transfusions Toxins (i.e. hydrofluoric acid and ethylene glycol) Pancreatitis Tumor lysis syndrome Chronic malnutrition
Hypocalcemia S&S
Neuromuscular
Mild symptoms: myalgias, muscle cramps/stiffness, circumoral paresthesias, minor twitching, anxiety, fatigue, and depression
Severe symptoms: seizures, laryngeal spasm, hallucinations, and psychosis
Chvostek and Trousseau signs (not very reliable)
Cardiovascular
Dysrhythmias, prolonged QT interval, ↓ CO, hypotension
Hypocalcemia major anesthesia implication
laryngospasm 2/2 tetany
Hypocalcemia treatment
Acute symptomatic hypocalcemia = medical emergency
Adults: 100mg of elemental Ca2+ over 5-10 minutes, then 0.5 – 2 mg/kg/hr
Correct metabolic derangement first, if possible
Remember Mg2+
Chronic/asymptomatic hypocalcemia may be treated over time with oral calcium and Vit. D
Hypercalcemia is defined as a total serum calcium level above:
Total serum calcium above 10.4 mg/dL (2.60 mmol/L)
Two most common causes of hypercalcemia
Primary hyperparathyroidism most common in outpatients (~90% due to adenoma)
Malignancy for inpatients (esp. breast & lung); release PTHrPs and calcitriol
Hypercalcemia S&S
S&S: “Bones, stone, groans, and moans” (… and the heart!)
Bone pain; osteopenia and fractures
Renal Calculi; polyuria and polydipsia
Abdominal symptoms: N&V, constipation
Neuropsychiatric problems: weakness, fatigue, stupor
Cardiac:
Shortened QTI, elevated ST, AV block, sinus arrest, A-fib, V-fib
Hypercalcemia Treatment goals
Increase urinary excretion of Ca2+
Correction of hypovolemia with 0.9% saline
“Wide open” until B/P and perfusion corrected, then 200-300 cc/hr (depending on comorbidities)
Monitor other electrolytes, especially K+
Dialysis may be required
Inhibit bone resorption and GI reabsorption of Ca2+
Osteoclast inhibitors
Bisphosphonates: Zoledronic acid (Reclast®)
Calcitonin: more rapid than bisphosphonates
Reduce GI absorption
Glucocorticoids
Second most abundant intracellular cation
Mg++
Total serum concentration of Mg++
Total serum concentration is 1.5 to 2.0 mEq/L (0.75 to 1.0 mmol/L)
Ionized is active form
Magnesium is an essential cofactor in most ______ requiring processes
ATP
Mg2+ regulates what intracellular ions flux by competing for binding sites and influencing its intracellular transport?
Ca++
Hypomagnesemia goes hand in hand with which other electrolyte deficiency?
Hypokalemia
Hypomagnesemia levels and etiology
Serum Mg2+ <1.3 mEq/L; 10% of hospitalized and up to 60% of ICU patients
Etiology:
Decreased intestinal absorption: malnutrition, as is common in chronic alcoholics; prolonged diarrhea and nasogastric aspiration; chronic PPI use
Increased renal excretion: increased tubular flow and/or impaired tubular function
Drugs: aminoglycosides, amphotericin B, cisplatin, pentamidine, and cyclosporine
Hypomagnesemia S&S
Neuromuscular: lethargy, confusion, tremor, fasciculations, ataxia, nystagmus, tetany, & seizures
Cardiac: atrial fibrillation, multifocal atrial tachycardia, premature ventricular complexes, ventricular tachycardia, torsades de pointes, and ventricular fibrillation
Hypomagnesemia Treatment
If severe S&S – MgSO4 (1 - 2 g = 8 - 16 mEq elemental magnesium) bolus, repeat
If stable, load with 1 to 2 g over 10 - 60 minutes, follow with maintenance 0.5 to 1 g/hr until symptoms have resolved
Hypermagnesemia Levels and etiology
Serum Mg2+ >2.5 mEq/L;
fairly uncommon; normal kidney function quickly excretes
Most are iatrogenic – from magnesium ingestion (laxatives, antacids) or intravenous dosing
Hypermagnesemia S&S
CNS/Neuromuscular depressant
usually seen when serum Mg2+ is above 4 mEq/L Decreased deep tendon reflexes 4-5 Hypotension 5-7 Respiratory insufficiency 10 Heart Block 10-15 Cardiac Arrest 10-24
Hypermagnesemia Treatment
IV isotonic fluids to dilute the extracellular magnesium;
Loop diuretics to promote renal excretion
Antagonized quickly with 10% calcium gluconate 10–20 mL IV (1–2 g) over 10 minutes
acids removed from the body by what three systems?
Respiratory (lungs), GI, Renal
What are the 2 types of acids produced in the body?
Volatile acid: carbonic acid (H2CO3)
An equal amount of CO2 is lost in the lungs
Fixed acids: (lactic acid, ketone bodies, phosphoric acid) equate to 40–80 mmol of hydrogen ions
These can’t be blown off
The kidneys normally excrete 40- 80 mmol of [H+]
the negative logarithm (to the base 10) of the concentration of hydrogen ions
pH
a substance that donates a proton
acid
substance that accepts protons in solution
Base
a weak acid and its conjugate base, which resists a change in pH when a stronger acid or base is added, thereby minimizing a change in pH
Buffer
What are the 4 major buffer systems in the body?
Bicarb, Hgb, Protein, and Phosphate
Henderson-Hasselbalch equation
pH = 6.1 + log(serum bicarbonate concentration/0.03 × Paco2)
Normal values for pH, PaCO2, HCO3, Anion Gap
pH: 7.4 (range 7.35 – 7.45)
paCO2: 40 (± 5) mmHg
HCO3-: 24 (± 2) mEq/L
Anion Gap: 8 – 16 mEq/L
What are the 3 chemical mechanism to maintain normal pH?
Chemical buffering: mediated by [HCO3-] in the ECF and by protein and phosphate buffers in the ICF
Alveolar ventilation: alters the paCO2
Renal H+ handling: kidneys adapt to pH by HCO3- reabsorption & excretion of NH4+ and titratable acids such as H2PO4-
What enzyme catalyzes and dissociates carbonic acid in the bicarb/CO2 buffering system?
Carbonic anhydrase
characterized by a decrease in plasma [HCO3-] due to either HCO3- loss or accumulation of acid
Metabolic acidosis
characterized by elevation in plasma [HCO3-] due to either H+ loss or HCO3- gain
Metabolic alkalosis
characterized by elevation in pCO2 resulting from alveolar hypoventilation
Respiratory acidosis
characterized by decrease in pCO2 resulting from hyperventilation
Respiratory alkalosis
Formula to determine anion gap
AG = [Na+ ] − [ (HCO3- + Cl−) ]
Normal is 8 – 16 mEq/L
Almost all significant increases in AG are caused by production of ______ ______.
Unmeasured anions
Usual causes of high AG metabolic acidosis:
Methanol Uremia Diabetic ketoacidosis/ketones Paraldehyde (rarely seen anymore) Isoniazid/iron toxicity Lactic acidosis Ethanol/ethylene glycol Salicylates
Accumulation of these unmeasured organic anions, proportionally reduce the Cl- and HCO3- concentration
What is the primary reason that a normal anion gap is positive 8-16 mEq/L and not zero?
the presence of negative charged plasma proteins such as albumin that are unmeasured in the anion gap formula.
what are the three types of renal tubular acidosis?
Proximal (type 2) RTA: impaired proximal tubular HCO3− reabsorption, so HCO3− is lost
Distal (type 1) RTA: Inability to secrete H+ in distal tubule
Distal hyperkalemic (type 4) RTA: hypoaldosteronism or aldosterone resistance causes hyperkalemia
What are the three key mechanisms that play a role in human carcinogenesis?
- Activation of proto-oncogenes, resulting in hyperactivity of growth-related gene products
- Mutation of genes, resulting in the loss or inactivity of gene products that would normally inhibit growth (examples are p53 gene, BRCA1 & BRCA2 genes)
- Mutation of genes, resulting in an overexpression of products that prevent normal cell death or apoptosis, thus allowing continued growth of tumors
Mutant genes that, in their non mutant state, direct protein synthesis and cellular growth
Oncogens
Genes that encode proteins that, in their normal state, negatively regulate proliferation (Are also referred to as anti-oncogenes)
Tumor suppressor genes
Normal, non mutant genes that code for cell growth
Proto oncogenes
Patients on this type of treatment have increased risks/incidence rates of cancer
Immunosuppressant therapy ( AIDS, organ transplant, etc)
Characteristics of MALIGNANT tumors include
Can kill host if untreated Confirmed by invasive or metastasizing nature Tissue-specific differentiation Greater degree of anaplasia indicates aggressive malignancy Grows rapidly May initiate tumor vessel growth Frequently necrotic Always Dysfunctional
Cancers are named for their location: name the following
- Malignant epithelial tumor:
- Those found in ducts of glands:
- Malignant connective tissue tumor:
- Carcinoma
- Adenocarcinoma
- Sarcoma
Cancers are named for their location: name the following
- Cancer of lymphatic tissue
- Cancer of blood forming cells
- Lymphoma
- Leukemia
Initial diagnosis of cancer is most often done via:
Aspiration cytology
Diagnostic tests that may be utilized to assess size, and spread of tumor include (3)
CT
MRI
PET Scan
Cancer cells utilize this structure to spread elsewhere throughout the body
Lymphatic System (proximity to the lymphatic system effects cancer metastasis)
Name and describe the four stages of cancer and what they include:
Stage 1 is confined to its organ of origin
Stage 2 is locally invasive
Stage 3 has advanced to regional structures
Stage 4 has spread to distant sites
Different types of radiation therapy include (3):
External beam technology
Radioactive seeds
Stereotactic radiosurgery- CyberKnife or Gamma Knife
How is Targeted Chemotherapy different from traditional chemotherapy
Targeted Chemo are a set of chemotherapeutic drugs directed against specific processes in tumor cell proliferation & migration (frequently used WITH traditional methods as cancers may become resistant to targeted therapies)
The most serious side effects of cancer treatment include (3)
Bone marrow suppression (most common), cardiovascular & pulmonary toxicity & central & peripheral nervous system damage
Cardiovascular side effects are most associated with what type of chemotherapy?
Anthracyclines (Ex: doxorubicin, daunorubicin, epirubicin & idarubicin)
Acute vs Chronic Anthracycline Toxicity
Acute: Early in treatment, cardiac dysrthythmias, cardiomyopathy, usually reversed with d/c of therapy
Chronic: May occur within a year of treatment, ir decades after completion, LV dysfunction, and cardiomyopathy
How can cardiotoxicity r/t anthracyclines be decreased, and what should be done at baseline for all those receiving anthracyclines?
Free radical scavengers (dexrazoxane or liposomal preparations) may be used to decrease superoxide radicals
Echocardiogram
What non chemotherapy cancer treatment may also cause an array of cardiovascular effects
Mediastinal Radiation
Chemotherapy associated with pulmonary side effects, and the major anesthetic implication for us
Bleomycin
High concentrations of O2 may exacerbate lung damage r/t the development of free radicals
Tumor Cell Lysis Syndrome is associated with what two electrolyte abnormalities?
- Hyperkalemia- cardiac dysrhythmias
- Hyperphosphatemia- secondary hypocalcemia –> further dysrhythmias & tetany
Treatments associated with Renal adverse effects include (5)
Radiation Ifosfamide Methotrexate Cisplatin Cyclophosphamide
Cancer treatments associated with adverse hepatic effects (5)
Methotrexate Asparaginase Arabinoside Plicamycin Steptozocin
Cancer treatments of of the head and neck may have what side effects that may cause difficulty in intubation and ventilation (3)?
- Limitation of mouth opening
- Decreased neck & tongue mobility
- Tracheal stenosis
Radiation to the neck will increase the incidence rate of what type of cancer
Thyroid
Pathophysiologic disturbances that may manifest before cancer diagnosis & may result in cancer detection
Paraneoplastic Syndrome
Name the preventative cancer vaccines currently available (2):
HPV
HEP-B (prevents hepatocellular carcinoma)
Which types of cancer are most associated with a fever r/t paraneoplastic syndrome
Fever may occur with any CA, but is particular to liver metastasis and rapidly proliferating tumors such as leukemia and lymphomas
Neuro abnormalities r/t paraneoplastic syndrome are most associated with what types of cancer
Rare, but the vast majority manifest before cancer diagnosis (80%) & occur more often with small cell lung cancer (SCLC), lymphoma & myeloma
Which types of endocrine paraneoplastic syndromes are associated with SCLS (2)
SIADH
Cushing’s
What types of cancer(s) are associated with the following findings
- Acanthosis nigricans (on the palms)
- Clubbing/mottling
- Usually GI
- Intrathoracic tumors & lung metastasis
SVC Syndrome (causes, symptoms, etiology)
Obstruction of SVC,often from lung cancer Veins above the heart become enlarged Symptoms: Facial and upper extremity edema Increased ICP Syncope
Most often brain metastasis from what other forms of cancer (2)
Lung and Breast
Metastatic lesions of the spine can often be traced back to what other types of cancer (4)
Lung, breast, prostate, lymphoma
Name and describe the two common forms of cancer pain
- Nociceptive: caused by peripheral stimulation of nociceptors in the somatic or visceral structures
- Neuropathic: involves peripheral or central afferent neural pathways –>burning or lancinating pain –> responds poorly to opioids
What type of analgesia is contraindicated in those with a local or systemic infectious process
Neuraxial Analgesia
The leading cause of cancer deaths among both genders
Lung Cancer (90% are preventable aka r/t smoking)
How long after someone quits smoking is their lung cancer risk that of a non-smokers?
10-15 years
Name the three types of non small cell lung cancer (NSCLC)
- Squamous cell carcinoma
- Adenocarcinoma
- Large cell carcinoma
What tests may be performed to assess surgical candidacy of lung cancer?
At what point will surgical intervention have little to no benefit?
- PFT’s
- In the case of SCLC, or lung metastasis
The most common form of colorectal cancer is:
Adenocarcinoma
Risks factors associated with colorectal cancer include (4)
Smoking (>35 pack years)
Age >50
Family Hx of colorectal ca
Diet high in calories, animal fats and meat protein
Intraoperative blood transfusions given for this type of cancer actually decrease the postoperative survival rate for it
Colorectal Cancer
What are the risk factors (3) and most common form of prostate cancer
- Presence of hereditary gene mutation
- African American
- Vasectomy
- Adenocarcinoma (almost always)
Risk factors for breast cancer include (7)
- Increased age (75% at > 50 years)
- Familial history
- Early menarche, late menopause, late first pregnancy & nulliparity
- BRCA1 & BRCA2 genetic mutations 🡪 autosomal dominant traits
- Diet & body weight (???)
- Radiation exposure (particularly during puberty)
- Benign-breast disease– > lobular carcinoma-in situ
The most common site of breast cancer metastasis is:
Bone
What characteristics of breast cancer are associated with a worse prognosis (3)
- Estrogen - absence
- Progesterone - absence
- HER2 overexpression
Breast cancer chemo is separated into two categories. What are they and what chemo agents fall into each?
- HER2-negative (Doxorubicin & cyclophosphamide)
- HER2-positive (Monoclonal antibodies directed against HER2 added to doxy and cyclo)
Where are a majority of cardiac tumors located, what do they mimc, and what are S/Sx?
75% occur in the left atrium, mimics mitral disease, pulmonary edema
(25% in the right atrium, mimics tricuspid disease, ↓ CO & right heart failure)
All head and neck tumors should be assumed to have this anesthetic concern, regardless of physical examination?
Difficult airway (Distorted airway anatomy unappreciable to physical exam)
Risks associated with thyroidectomy include (2)
RLN injury
Permanent hypoparathyroidism
Gastric cancers are associated with what other conditions (4), and are predominantly what type of cancer?
- Achlorhydria
- Pernicious anemia
- Chronic gastritis
- H. pylori infection
90% are adenocarcinoma
What is the most common type of pancreatic cancer, and where is it usually located
95% are ductal adenocarcinoma with a majority found at the head of the pancreas
The most common presenting factor for bladder cancer is:
Hematuria
What is the major type(1) and subtypes (2) of testicular cancer
95% are germ cell cancers, subtypes:
- Seminoma spreads from regional lymphatics to retroperitoneum & mediastinum
- Non-seminoma spreads hematogenously to viscera (lungs)
What population is most commonly affected by cervical cancers, and what is responsible for the majority of cases
Women 15-34( 50-70 more commonly have endometrial CA)
-HPV type 16 & 18 are responsible for 70% of cases
What is the most deadly GYN malignancy
Ovarian CA
The majority of skin cancer deaths arise from which form of cancer
Melanoma: only 2% of total cases, but most deadly
The two most common types of skin cancer are:
1: Basal Cell Carcinoma (Most grow superficially & rarely metastasize)
What are the anesthetic considerations for someone with bone cancer (2)
- Care when positioning = risk of fractures
- Pathologic fractures of the ribs impair ventilation & predisposes to pneumonia
Type of bone cancer that occurs in children and young adults, usually affecting the pelvis, femur, or tibia
Ewing’s Sarcoma
Hodgkin Lymphoma (etiology, incidence rate, treatment, and survival rate)
- Lymph node based malignancy that rarely involves the bone marrow or CNS (10% of all lymphomas)
- Incidence rates increased in those 15-34 & >80
- Chemo and radiation
- 20 year survival rate is 90%
Non-Hodgkin Lymphoma (subtypes and what the types are based on)
Subtypes based on cell type, immunophenotypic & genetic features
- B-cell
- T-cell
- NK-cell
The four subtypes of Leukemia are:
- Acute lymphoblastic leukemia (ALL)
- Chronic lymphocytic leukemia (CLL)
- Acute myeloid leukemia (AML)
- Chronic myeloid leukemia (CML)
The most common leukemia for children:
Acute lymphoblastic leukemia (ALL)
The most common leukemia in adults:
Chronic lymphocytic leukemia (CLL)
Acute myeloid leukemia (AML) etiology and survival rates:
- Increased myeloid cells in bone marrow arrest cell maturation –> hematopoietic insufficiency
- 5-year survival is 15-70% depending upon progression
ACUTE PROMYELOCYTIC LEUKEMIA (etiology, treatment, prognosis)
Subset of AML that accounts for 5-20%. Confirmed by presence of promyelocytes in bone marrow & blood. Urgent treatment required to prevent DIC
All-trans retinoic acid–> risk during induction of retinoic acid syndrome
Long term remission 70-90%
Chronic myeloid leukemia (CML): etiology and treatment
- Myeloid leukocytosis with splenomegaly
- Allopurinol –> hyperuricemia
- Hydroxyurea, leukapheresis or splenectomy –>cytoreduction
- Chemotherapy
- Hematopoietic stem cell transplant
Where is bone marrow most often aspirated from for diagnosis or transplant?
Posterior iliac crest
Complications of bone marrow transplants include:
- Graft rejection: Immunologically competent cells of the host destroy the donor cells
- Pulmonary complications
- Sinusoidal obstruction syndrome: Manifests within days up to a year after transplantation with mortality incidence 50%
Innate vs Adaptive immunity:
Innate: Rapid and nonspecific, passed on each generation to protect the species, requires no prior exposure
Adaptive: must be developed individually, with more delayed onset of action, but develops a memory and specific antigen responses
