Exam 2: Liver/GI, Muscle, MH, autoimmune, hematological, obesity, cancer, ortho, eras Flashcards
1
Q
how long before surgery can patient have the carbohydrate drink
A
up until 2 hours before surgery
2
Q
if ast and alt are both high, what does this indicate
A
hepatitis
3
Q
what should platelet count be before minor surgery
A
20,000-30,000
4
Q
what should platelet count before major surgery
A
100,000
5
Q
what platelet count do you have increased chance of bleeding
A
50,000
6
Q
what are the three PO pain medications listed in the ERAS protocol
A
gabapentin/pregabalin
acetaminophen
celecoxib
7
Q
t or f- according to eras protocol, block nurse should administer versed/fentanyl for block procedure
A
true
8
Q
What is the ERAS block associated with colorectal/gyn/urology procedure
A
erector spinae block
9
Q
what equipment is listed by ERAS for colorectal/gyn/urology procedures
A
flotrac or clearsight
og tube/ng tube
fluid warmer
bair hugger
iv access
10
Q
in what scenario would you need to reduce amount of lidocaine drip according to ERAS protocol
A
if patient receive preop block
11
Q
what population should you reduce ketamine dose according to ERAS protocol
A
elderly
12
Q
when should last dose of ketamine be according to ERAS protocol
A
45 minutes before extubation
13
Q
what can magnesium bolus cause according to ERAS protocol
A
muscle weakness
14
Q
t or f- according to ERAS protocol, give a ketamine bolus before incision followed by a continuous infusion or bolus every hour
A
true
15
Q
according to ERAS protocol, when should you reduce dose of robaxin
A
elderly/renal impairment
16
Q
according to ERAS protocol what do you need to monitor when giving robaxin
A
vasodilation- hypotension
17
Q
according to ERAS protocol when can you re dose robaxin
A
6 hrs
18
Q
t or f- bolus robaxin for max effect
A
f- give over 15 minutes, may cause hypotension
19
Q
what is a scenario when you would not give robaxin for ERAS, and why
A
seizure disorder- lowers seizure threshold
20
Q
according to ERAS protocol, what are 4 meds to give for pONV
A
zofran
decadron
benadryl- before incision
scopalamine- pre op
21
Q
according to ERAS protocol, what i the fluid of choice for volume replacement
A
albumin/colloids
-then LR or different colloid
22
Q
according to ERAS protocol, when should acetaminophen be re-dosed after pre op dose
A
6 hrs
23
Q
according to ERAS protocol, what surgeries should you consider deep extubation
A
hernia
fascial closure
24
Q
according to ERAS protocol, what are the SVV and SV goals
A
SVV <13%
SV> or equal to baseline
25
according to ERAS protocol, ci/co can be used for fluid monitoring in what type of patient
normal LV function
26
SVV is not accurate in which 3 patients
atrial fibrillation
open abdomen case- false decrease
ab insufflation- false increase
27
in cases where svv is not accurate, what other measurement may be used
SV
28
according to ERAS protocol, when will svv be falsely elevated
abdominal insufflation
29
according to ERAS protocol, when will svv be falsely decreased
open abdomen case
30
when assessing patient with osteoarthritis, what should you have patient perform preoperatively
neck range of motion
joint and limb mobility
31
what is a consideration when placing bovi pad for surgery
avoid metal joints
avoid pacemaker
-place magnet on pacemaker
32
t or f- while in prone position, stretch arms out over head in superman position to avoid pressure injury
f- don't stretch out all the way, may cause brachial plexus injury
33
when moving patient's arms into superman position for prone position, which way should you rotate arms
always underneath, so move hand towards the floor
34
what position is patient usually in for ERCP and what population may this cause harm
prone with heard turned toward side
-osteoarthritis- fracture
35
what is a consideration with positioning for ERCP with patient who has osteoarthritis
put in semi-lateral position
-prone with rolls under one side of chest to tilt head up
-don't rotate head too much, may cause fracture
36
what two diseases may cause stiff necks that she mentioned in lecture
down syndrome
osteoarthritis
37
t or f-when intubating a patient with osteoarthritis, wait until after giving muscle relaxer or nmb so you can manipulate neck beyond range of motion
f- muscle relaxer/nmb may increase range of motion, but you will be causing injury
38
what can happen if you rotate arm up and over while in prone position
shoulder dislocation
39
should you move patient past point of comfort level after muscle relaxers/nmb increase range of motion in osteoarthritis patient
no-stay at comfort level
40
what do you give for refractory hypotension in rheumatoid arthritis patient
steroids
41
what do you need to make sure to give RA patient perioperatively
stress dose steroid
42
why do orthopedic or msk surgeries have increased risk of bleeding
bones bleed- difficult to control, can't cauterize
43
what are some things the surgeon might ask for that make you think the patient has uncontrolled bleeding
thrombin
bone wax
gel foam
44
a patient has to return to surgery a day after being in surgery. which type of anesthesia would you avoid or caution
regional- probably on blood thinners post operatively, don't want to cause hematoma
45
what are s/s of a clot during surgery
hypotension, tachycardia, low co2
46
where should you look for blood loss during surgery
drapes
laps
raytecs
floor
suction
47
during IM nail, where do you need to look for blood loss
bag attached to patient
drapes
-ask surgeon how much is in bag
48
what are things you need to have prepared for patient with bleeding risk
2 piv 18g or larger
t &C w/ blood in OR
crystalloid/albumin/rbc for preop optimization
know positioning for surgery so you can access iv
49
t or f- while in beach chair position, it is acceptable to put Iv in opposite arm ac
f- opposite arm is bent and held across body, ac will be inaccessible
50
how long may blood take to get ready if patient has antibody
1 hr
51
what patients should you be cautious of giving preop fluid
chf
elderly
renal disease
52
what is a good fluid to give chf, elderly, renal disease
albumin
53
what is the med she mentions to give preoperatively for pain and why
tylenol iv
-don't have to monitor
54
what lab result may cause the surgeon to cancel a joint replacement surgery
increased wbc
55
what are the three labs to look before surgery that she mentioned
wbc
platelets
hct
56
what are two forms of ppe she mentioned to make sure to have during ortho procedure
goggles
shoe covers
-also stand and put drapes high for power irrigator
57
what are some injury prevention measures for lateral position
straps
axillary roll for brachial plexus
pillow under dependent arm
neck in midline position
58
when patient undergoes neurosurgery with head pins, what are some anesthetic considerations
-paralyzed throughout procedure
-deep sedation
-do not touch head pins
-usually prone during the case, but head is off table
59
how often should positioning be documented
q15 minutes
60
what are the head considerations during prone positioning
-maintain cervical alignment
-pillow or folded towel under shoulder
-ensure lips/tongue are clear of teeth
61
what are the eyes considerations during prone positioning
protect forehead, eyes, chin
62
what are the nose considerations during prone positioning
padded headrest to provide airway access
pad for face/foam pillow
space between nose and bed
63
what are the chest compression/iliac crest considerations during prone positioning
chest rolls from clavicle to iliac crest to allow movement and decrease abdominal pressure
64
what are the breast/male genitalia considerations during prone positioning
keep free from torsion
65
what are the knees considerations during prone positioning
padded with pillow to feet
66
what are the feet considerations during prone positioning
padded footboard
67
what is the AANA standard for positioning
8
68
according to ERAS protocol, how can you prevent ileus
avoid narcotics if possible
use regional techniques
69
what complications can ileus lead to
aspiration, ischemic bowel, sepsis
70
according to ERAS protocol, how long should patient sit on chair for on day of surgery
2 hours
71
according to ERAS protocol how long should patient sit on chair and walk on days after surgery
sit: 5 hours in chair
walk: 3 times
72
what is the amino acid for wound healing found in nutrition shake patient drinks morning of surgery
arginine
73
what is the cutoff for clear liquids and the carbohydrate drink for diabetics
3 hours- gastraparesis
74
what is the cutoff for clear liquids and the carbohydrate drink
2 hours
75
how can you tell magnesium is causing muscle weakness
deep tendon reflex are lost
76
t or f- give robaxin intraoperatively and post operatively
true
77
what is the max amount of albumin that can be administered according to eras protocol
1500ml
78
what are the overall goals of ERAS she mentioned
organ preservation
wound healing
recovery
79
what is the term for decreased oxygen carrying capacity
anemia
80
what can cause hgb levels to be falsely elevated that she mentioned
dehydration
81
what can cause hgb levels to be falsely low that she mentioned
pregnancy- expanded blood volume
82
what condition will there not be enough oxygen to carry out to tissues
anemia
83
what is the term for increase in hct r/t expanded rbc mass leading to increased blood viscosity
polycythemia
84
t or f- one single lab value identifies anemia
false
85
what is the most important adverse effect from anemia
decrease in tissue oxygen delivery d/t decrease in cao2 (arterial oxygen concentration)
86
a hemoglobin decrease from 15 to 10 will cause how much of a decrease in cao2
33%
87
how does body initially compensate for anemia
release of oxygen from hgb to tissues
88
explain how pallor is caused during anemia
release of o2 from skin/kidneys to heart/brain and muscles- body shunts oxygen to vital organs
89
will cardiac output in anemia be low or high
high- need to pump more blood because it isn't carrying as much oxygen
90
what are sx of anemia
pallor
fatigue
decreased exercise tolerance
orthopnea
dyspnea on exertion
91
what can chronic severe anemia result in
cardiomegaly
pulmonary congestion
ascites
edema
high output failure
92
what may be a problem if a patient tells you preoperatively they can't exercise as much as they used to, or they have orthopnea/dyspnea on exertion now
anemia
93
what hgb level serves as periop blood transfusion trigger
6 or hct 18
94
how much blood loss will reflect a hct drop by 1%
100 ml
95
what are factors to consider when deciding to transfuse blood
preop hgb level
risks of anemia vs risk of transfusion
co-existing diseases- rf, chf
anticipated blood loss
96
what disease may trigger giving blood at a hct of 28-30%
coronary artery disease
97
a renal patient who is chronically anemic comes to preop wth a hgb level of 7. should you transfuse
No- unless she isn't compensated, look at the other factors
98
how should you replace a 15% loss of blood
none
99
how should you replace a 30% loss of blood
crystalloid only
100
how should you replace a 30-40% loss of blood
rbc
101
how should you replace a >50% loss of blood
mtp 1:1:1
102
what should you also give during mtp to promote coagulation
calcium
103
what disease causes decreased carrying capacity of oxygen and clumping of red blood cells
sickle cell disease
104
which hgb is associated with sickle cell trait vs disease
hgb c= trait
hgb s= disease
105
what is the primary trigger for sickle cell crisis
deoxygenation
106
why is a prolonged surgery a concern for sickle cell disease patient
more pain
more temp decrease
more blood loss
107
what are pre op considerations for sickle cell disease
-keep them warm
-give iv fluids to prevent rbc clumping
-iv tylenol for pain
-avoid shivering
-leg squeezers
-oxygenate well!!!
108
what are pre op tests/labs for sick cell disease
chest x ray
t & c
order special blood-antibody screen
109
what is a vaso occlusive crisis in sickle cell patient
block capillaries leading to pain, and ischemia leading to end organ damage
110
what can worsen vaso occlusive crisis
dehydration
infection
cold/shivering
hypoxemia
vascular stasis
stress
acidosis
111
how can you treat chronic pain from sickle cell disease
ketamine
112
what type of intubation technique would you want to use for sickle cell disease and why
video laryngoscope- avoid deoxygenation
113
what is a consideration for imaging in patient with sickle cell crisis
NO CONTRAST- induces sickling of cells
114
what is a potential renal complication in males with sickle cell disease
priapism- sickle cells block off penile blood flow
115
what is hct goal preoperatively for sickle cell disease
30%
116
what type of procedure should you transfuse preoperatively in patient with sickle cell disease and hct below 30%
med/high risk procedure
117
why should you have prbc on hand during surgery for a patient with sickle cell disease
special blood match w/antibody
acute sickle cell crisis
118
what are intraop considerations for sickle cell disease patient
avoid hypotension
warm patient- bair hugger
avoid venous stasis
prbc's ready for acute crisis
pain control
hydrate
normocapnea
119
how do you adjust vent to increase/decrease co2
decrease= increase rate/tidal volume
increase= decrease rate/tidal volume
120
what are postop considerations for sickle cell disease patient
pain control
look for acute chest syndrome
continuous o2 monitor
prevent hypoventilation
prevent shivering
give fluids
monitor temp
121
what is the disease where low hgb is caused by rbc's trapped in spleen
splenic sequestration crisis
122
what are s/s of splenic sequestration crisis
irritability
sleepy
pale
weak
tachycardia
left abdomen plain
fever=medical emergency
123
what is the leading cause of death/hospitalization for sickle cell disease
acute chest syndrome
124
what are s/s of acute chest syndrome
fever
chills
cough
tachypnea
hypoxemia
sob/chest pain
125
what should you tell pacu nurses to look for in patient with sickle cell disease
acute chest syndrome
126
how do you treat acute chest syndrome
-cpap or vent for resp failure
-nitric oxide/albuterol for bronchodilation
blood transfusion
abx
iv fluids
127
t or f- assume hyperreactive airway in acute chest syndrome
true
128
when will acute chest syndrome typically manifest during surgery period
pacu
129
what is the leading cause of microcytic anmia
thalassemias
130
what is the leading cause f macrocytic anemia
folate/b12 deficiency
131
what is a frequent source of folate deficiency
alcohol
132
what deficiency can sustained nitrous oxide and poor scavenging system lead to
vit b 12
133
t or f- pulse ox is reliable during methemoglobinemia
false
always shows 85%
134
what meds should be avoided with methemoglobinemia
nitric oxide
nitrates
local anesthetics
135
what should ekg be monitored for during methemoglobinemia
ischemia
136
how do you measure oxygen with methemoglobinemia
art line
abg
137
is tissue getting enough oxygen during methemoglobinemia
no
138
what is sx when methemoglobinemia is between 30-50%
hypoxia
139
what is sx when methemoglobinemia is >50%
coma/death
140
what is the term for increased blood viscosity that slows flow and decreases o2 delivery
polycythemia
141
how does polycythemia usually result
sustained hypoxia resulting in compensatory increase in rbc mass
142
what happens at hct of 55-60%
blood flow to organs reduced
clots
143
what level of hct is life threatening
>60%
144
a patient comes in with headaches and fatigue and have a high hct. what may be the problem
polycythemia causing impaired cerebral circulation
145
t or f- polycythemic patient is at risk for hyper-coagulation but not hemorrhage
f- at risk for both
146
t or f- do not withhold aspirin for 7 days in polycythemic patient so their blood can be thinned
f- still hold for 7 days
147
how do you treat polycythemia
ddavp
cryoprecipitate to increase vWF
148
how do you treat factor 5 deficiency
ffp and platelets
149
when giving 10-15ml/kg of ffp, how much do you expect missing clotting factor to be raised
20-30%
150
what meds should be avoided in hemophilia a
toradol
aspirin
151
how do diagnose hemophilia a
elevated ptt
152
what are platelets derived from
megakaryocytes
153
where are megakaryocytes found
bone marrow
154
what stimulates bone marrow to make megakaryocytes
thrombopoeitin
155
where is thrombopoeitin made
liver
156
what lab finding do you expect to see if patient who will be undergoing splenectomy
low platelets
157
when should you give platelets for patient undergoing splenectomy and why
after spleen has been removed
-spleen is cause of low platelets
158
the surgeon mentions there is oozing from microvascular bleeding, what blood product should be given
FFP
159
what is the most common hereditary bleeding disorder
von willebrand
160
each unit of apheresis platelets/6 donor platelets will increase platelet count by how much
50,000
161
what medication do give vw disease in preop
ddavp
162
what are sx of vw disease
epistaxis
menorrhagia
gingival bleeding
easy bruising
hematomas
163
why is vw factor important
platelet plug formation
carrier protein for factor 8
164
what blood test will be elevated in vw disease
PTT
165
what is a normal platelet count
150,000-300,000
166
at what platelet count should surgery be canceled
<20,000-- or delay for platelet transfusion
167
what inr is too high for surgery and needs to be discussed with surgeon
>2.5
168
when should you not give toradol
low platelets
kidney problems
asthma
169
what is the OTC med class we talked about that increases bleeding
herbals
170
when a patient is prone and a bleeding risk, what can you use to prevent oral bleeding
soft bite block to prevent tongue cuts
clear lips out of the way of teeth
171
t or f- it is ok to give toradol at end of surgery in patient with bleeding risk
true
172
what s/s suggest blood loss while in pacu
color change
mentation change
tachycardia
hypotension
decreased uop
hypothermia
cvp drop
173
you suspect increased blood loss based on vital signs. What can you check to confirm
dressings
drains
labs
174
what meds can you give for cancer nausea
zofran
droperidol
metoclopramide
175
why is decadron not given to cancer pt with nausea
already immunosuppressed
176
what are infection prevention measure for cancer pt
alcohol iv ports
sterile tegaderm- no tape- for iv
swab art line site
177
what is a good reversal med for lung cancer patient
suggamadex
178
what part of airway may be stiff in lung cancer patient who has undergone radiation
trachea
179
what is an appropriate intubation technique for lung cancer patient
videoscope w/rsi- decreases risk of deoxygenation and trauma
180
will lung cancer patient who has undergone radiation need or smaller or larger ett
smaller
181
is lma or ett usually better for bronch and why
ett- decreases coughing, more secure airway
182
what are 4 considerations for colon cancer
dry from bowel prep, give iv fluids
-have blood available
-have art line/hemosphere
-ng tube after intubation
183
how do you manage vent in steep trendelenburg position for robotic prostatectomy
pressure control
-tidal volumes will be lower because of increased abdominal pressure so increase rate to reach appropriate minute ventilation
184
which acid base imbalance increases pulmonary hypertension
resp acidosis
185
what are positioning consideration for robotic prostatectomy
shoulder straps
face protection
safe positioning
goggles
186
should you extubate obese patient deep or awake
awake
187
you succ and a defasiculating dose of roc to intubate your patient undergoing a mastectomy. You hear the surgeon mention sentinal nodes. Do you give another dose of roc for the rest of the surgery
no- they want to watch nerve stimulus
188
what provides 25% of blood flow to the liver
proper hepatic artery
189
what are s/s of tylenol od
nvd, coma, abdominal pain, sweating
190
what provides 75% of blood flow to the liver
portal vein
191
what do hepatic veins dump into
inferior vena cava
192
how does liver return blood to the heart
hepatic veins connect to inferior vena cava
193
how does 75% of blood flow to the liver
portal vein
194
what are the two major vessels where liver receives blood from
portal vein
proper hepatic artery
195
what is a potential complication of hepatitis a or b
cirrhosis
196
how much of cardiac output is direct towards the liver
30%
197
what is a liver blood flow consideration when giving general or neuraxial anesthesia
general/neuraxial decreas map, so it will decrease flow to liver
198
how much of the liver oxygen supply is from port vein vs proper hepatic artery
both 50%
199
what types of anesthesia will decrease liver blood flow
general, neuraxial
200
what can failure to eliminate ammonia lead to
hepatic encephalopathy
201
what is a normal pt value
10.9-12.5 seconds
202
how is synthetic function of liver tested
albumin
pt/inr
203
what is normal albumin level
3.5-5.0 g/dL
204
t or f- many patients with liver disease have normal function until disease is severe
true
205
which lab test is very sensitive for acute liver injury
PT
206
which lab test is NOT very sensitive for acute liver injury
albumin
207
which lab test is NOT very sensitive for acute liver injury
albumin
208
what clotting factors is pt sensitive for
factor 5 and 7
209
what blood test indicates cholestatic or infiltrative hepatic conditions
elevated alkaline phosphate
210
what blood tests indicate cellular integrity injury-of-liver
AST and ALT
211
what does a marked elevation of both AST and ALT indicate
hepatitis
212
what is normal value for ast
10-40 units/L
213
what is normal for of ALT
10-55 units/L
214
what is the significance of AST/ALT ratio >2
suggests cirrhosis or alcoholic liver disease
215
besides decreased mac, what other complications can acute alcohol ingestion put patient at risk for
bleeding
aspiration
decreased brain hypoxia tolerance
216
t or f- you can base overall liver function on AST/ALT alone
f- only gives 1/4 of the picture
217
what blood tests should be looked at when evaluating liver function
pt
albumin
alkaline phosphate
ast/ALT
direct bilirubin
218
what cell processes old red blood cells and where are they located
reticuloendothelial cells
-spleen
219
what is the life of an rbc
120 days
220
what does ast do
helps metabolize amino acids
221
what does alt do
helps convert protein into energy
222
what are the aminotransferases
AST and ALT
223
is ast or alt liver specific
ALT
224
what are the two main causes of cirrhosis
chronic alcohol abuse
chronic viral hepatitis
225
what kind of meds do you want to avoid with liver disease
meds metabolized in liver
-prop, vec, roc, neostigmine
226
t or f- increasing cardiac output will increase hepatic blood flow in cirrhosis
f- will still be decreased
227
what are some common dysrhythmias from liver failure
a fib/a flutter
228
what are the manifestations of cirrhosis
fatigue/malaise
palmar erythema
spider telangiectasis
gynecomastia
caput medusae
ascites- most specific of liver dysfunction
portal htn
prolong pt
decreased albumin
increased alt/ast
229
what liver disease could fatigue and malaise be indicative of
cirrhosis
230
what measurement reflects the fibrotic process and vascular resistance associated with cirrhosis
portal hypertension
231
how does the body offset resistance from portal hypertension
creates vessels to bypass liver- portosystemic shunt
232
what does cirrhosis do to vascular resistance
increase it
233
how is resistance from cirrhosis offset by blood vessels
collateral vessels are created that bypass the liver
234
what is a portosystemic shunt
an abnormal vessel that allows blood to bypass the liver
235
why does cirrhosis cause drugs and toxins to remain in system for longer period
portosytemic shunts are created, so drugs/toxins don't get to liver for metabolism/detoxificaition
236
what does cirrhosis do to albumin, pt, aminotrasnferase, and alkaline phosphatase
albumin- decreased
increased: pt, aminotransferase, alkaline phosphatase
237
what should you have available during surgery when patient has cirrhosis/liver failure
blood
238
what type of heart failure is associated with liver problems
right heart failure
239
what causes caput medusae
portal hypertension- blood gets backed up
240
what are the s/s of portal hypertension
hypoalbuminemia
caput medusae
ascites
241
what is the term for dilated submucosal veins
gastroesophageal varices
242
where do esophageal varices usually bleed from
distal esophagus
proximal stomach
243
what does ascites do to volume of distribution
increases it
244
what does ascites do to oncotic pressure
decreases it
245
what is oncotic pressure
The pressure created by the osmotic effects of the solutes
246
what does ascites do to protein binding and volume of distribution
decreases protein binding
increases vd
247
what are complications of cirrhosis
portal htn
varices
splenomegaly
ascites
restrictive defects
resp alkalosis
hepatopulmonary syndrome
portopulmonary syndrome
248
you are doing a procedure on a patient with varices, what is the most appropriate way to secure airway
intubate- rsi
249
what accounts for 1/3 death of cirrhosis
variceal bleed
250
what does recurrent bleeding from varices indicate need for
portosystemic shunt-tips
251
what does drainage of ascites lead to
hypotension
252
how is pulmonary compliance affected with cirrhosis
if they have ascites, decreases pulmonary compliance
253
what kind of drugs should you avoid with cirrhosis
hepatotoxic
inhibit cyp450
254
what are some examples of drugs to avoid with cirrhosis
acetaminophen
halothane
amiodarone
abx: pcn, tetracycline, suflas
cimetidine
255
what are some abx that should be avoided with liver failure/cirrhosis
pcn, tetracycline, suflonamides
256
t or f- give a smaller dose of tylenol in patient with liver failure
false
give none
257
what is a tips procedure
transjugular intrahepatic portosystemic shunt
258
what does tips procedure treat
reduce esophageal varices bleeding
refractory ascites
259
what is big risk of tips procedure
hemorrhage
260
what do you do to prepare for hemorrhage from tips
2 big iv's minimum (16 g or central line)
art line- bp and labs
blood in the room-check w/rn before surgery
et tube
cardiac clearance
avoid anything in esophagus
261
what cardiac problems is tips procedure contraindicated
HF
pulm htn
severe tricuspid regurg
262
t or f- make sure to put og tube in patient with esophageal varice
f- nothing down the esophagus!!
263
what volatile best preserves hepatic blood flow
isoflurane
264
what volatile should not be used with liver failure
halothane
265
what volatile is best for liver patients
isoflurane
266
why do you want to avoid peep in liver patient
decreased hepatic blood flow
increases resistance to drainage
267
your patient that has liver failure wants to have regional anesthesia instead of geta. What should you check before proceeding
PT/INR
268
t or f- make sure to keep liver patients dry to decrease bleeding risk
f- liberal use of iv fluids
269
how can you maintain hepatic blood flow during anesthesia
isoflurane
avoid peep
normocapnia
liberal use of iv fluids
regional anesthesia after inr
270
what does chronic alcohol do to mac
increases mac
271
a patient with chronic alcoholic ingestion comes in for a procedure, what would you put sevo at to achieve 1 mac
3%
272
besides decreased mac, what else do you need to remember about acute alcohol ingestion patient
prone to aspiration
-alcohol delays gastric emptying
273
what are four considerations for intoxicated patient
decreased mac
aspiration risk
bleeding risk
less tolerant to hypoxia
274
t or f- chronic alcohol ingestion may decrease responsiveness to catecholamines
true
275
when does alcohol withdrawal syndrome begin
6-8 hours after blood alcohol concentration returns to near normal
276
when is the peak of alcohol withdrawal syndrome
24-36 hrs
277
when does delirium tremens occur
2-4 days without alcohol
278
what are the early s/s of alcohol withdrawal syndrome
tremors, hallucinations, nightmares
279
what are the late s/s of alcohol withdrawal syndrome
sns: tachycardia, htn, dysrhythmia
N, V, confusion, agitation, insomnia
280
what are s/s of delirium tremens
grand mal seizure
tachycardia
hyper/hypotension
combative
281
how do you treat delirium tremens
diazepam (benzo)
beta blockers
282
t or f- any factor that decreases cardiac output will decrease hepatic blood flow
true
283
which type of surgery will place the patient at greater risk for decreased hepatic blood flow: upper abdominal or extremity surgery
upper abdominal
284
what are three factors that can decrease hepatic blood flow
sympathetic stimulation
hypo/hypercarbia
positive pressure ventilation
285
what would you potentially want to avoid on ventilator with liver patient
positive pressure ventilation- may decrease hepatic blood flow
286
t or f- succinylcholine is contraindicated in patient with severe liver disease because liver-disease may decrease plasma cholinesterase activity
f- contraindicated because of hyperkalemia
287
when would succinylcholine be contraindicated for liver patient
hyperkalemia
288
what is a patient with ascites at increased risk for that is concerning for intubation
reflux
aspiration
289
a patient with ascites starts desaturating during standard intubation, what may be the problem
aspiration
290
why should you give blood slowly in patient with cirrhosis/liver failure
decreased clearance of citrate
291
t or f- In patient with ascites and varices, make sure to put og tube down into stomach to prevent aspiration
f- no esophageal instrumentation with varices!
292
t or f- give blood as fast as possible in cirrhosis liver patient to increase hepatic blood flow
f- give slow because citrate clearance is decreased by cirrhosis liver
293
what will hypoalbuminemia cause with any drug effect that is protein bound
prolonged effects
294
what med classes can contribute to hepatic encephalopathy
opioids
benzos
295
what is a nmb that isn't metabolized in liver
nimbex
296
does opioid dose need to be adjusted in liver patient
yes-decrease dose
297
t or f- propofol is unacceptable in liver failure patient
f- acceptable, metabolism isn't significantly altered
298
t or f- since volatiles vasodilate, they will increase hepatic flow
f- decrease hepatic blood flow
299
which volatile is hepatotoxic
halothane
300
when would elective surgeries be contraindicated in liver disease
fulminant hepatic failure
late stage cirrhosis
acute hepatitis
end stage liver disease
301
what is the most common cause of acute liver failure
tylenol od
302
what are four causes of acute liver failure
hepatitis
toxins (tylenol od)
hepatic vein clot
wilson's disease
303
t or f- nsaids are avoided in liver patient
t- hepatic metabolism
304
what is tylenol limit in 24 hours
4000mg
305
what lab test would you not give tylenol if it was elevated
LFT
306
what is the dose for tylenol
12-15 ml/kg q 5-6 h
not to exceed 4000mg in 24 hrs
307
what is the dose for tylenol > 50kg
1000 mg/iv q6
650 mg/iv q4
308
how do you correct coagulation abnormalities in liver patient
FFP
309
is the liver patient more prone to infections
yes
310
why should hypotension be avoided in liver patient
because it decreases hepatic blood flow
311
how should volatiles be dosed in liver patient
low dose
312
severe pulmonary htn is a contraindication to what type of transplant
liver
313
which gender is more likely to have gallstones
women
fat-female-forty
314
what does insufflation with co2 cause to abdomen
increased intra abdominal pressure
315
what does insufflation with co2 do to vital signs
increases map and svr
decreases co, venous return, frc
316
what position may improve ventilation during insufflation with co2 during cholycystectomy
reverse trendelenburg
317
what are the goals of mechanical ventilation with insufflation of co2 during cholecystectomy
prevent atelectasis
adequate ventilation
offset co2 absorption
318
why do surgeons insufflate
need to get abdominal wall off where they are working
319
what is essential med to keep surgeon happy during abdominal insufflation
adequate nmb
320
your tidal volume goes down after abdominal insufflation. how can you adjust ventilator during insufflation of abdomen to maintain minute ventilation
decrease tidal volume
increase rate
321
during cholecystectomy, how do you protect patient during reverse trendelenburg
strapped onto bed
foot board
hover mat will be slippery- take off
arms secure
322
why is atelectasis more common in cholecystectomy
insufflation causes increased pressure in chest decreases lung expansion
323
t or f- abdominal insufflation surgeries has increased risk of reflux and aspiration
true
324
what can you do to help surgeon and prevent aspiration in abdominal insufflation surgery
og tube to decompress
325
the patient's heart rate all of the sudden drops during abdominal insufflation, what is your first action
ask surgeon to let off pneumoperitoneum
-then give robinul
326
what kind of embolus is associated with abdominal insufflation
co2 embolus
look at capnography
327
_________________ can cause spasm of the sphincter of oddi
opioids
328
t or f- give opioids during cholangiogram to help with pain
f- opioids can cause false positives, try to avoid or reduce
ok to give after test
329
how can you reduce sphincter of oddi spasm
glucagon
nitroglycerin
atropine
330
t or f- use narcan to reverse opioid during cholangiogram
f- will reverse all opioid effects, use another drug
331
what is ercp
Endoscopic retrograde cholangiopancreatography
332
what do you give with ercp when spasm occurs
glucagon
333
t or f- paralyze with a pneumoperitneum
true
334
when should you dose opioids for cholangiogram
after procedure
335
what are some questions you can assess for reflux
does your reflux wake you up at night
do you have food contents come up when you lay down
do you take your medicine
did you have trouble last night
336
what meds can you give preop to prevent reflux and when should you give them
bicitra, pepcid, zantac, alka seltza gold
within 20 mins of surgery
337
what are the intra op reflux prevention methods
-rsi: succ/roc
-cricoid pressure until tube placement confirmed
-suction ready, cuff promptly inflated
-reglan optional
338
how should patient be extubated with GERD
fully reverse and awake and following commands before extubation
339
what should you do preop for a patient with an ileus
ng tube
340
a patient has increased abdominal pain, abdominal distention and vomiting during preop. What is a likely cause
ileus
341
t or f- give reglan to patient with ileus to help their bowels wake up
f- may cause perforation
342
how do you induce and extubate a patient with ileus
intubate: rsi w/suction in preop and intraop
extubate: fully awake and reverse nmb
343
what medication should you avoid with peptic ulcer disease or GI bleeding
toradol
344
t or f- put in an ng/ogt with peptic ulcer disease to suction out acidic bile
f- suction may cause bleeding and erosion
345
what are the most common signs of carcinoid syndrome
flushing
diarrhea
346
what are some other s/s of carcinoid syndrome
hypo/hypertension
bronchoconstriction
tachycardia
pain
347
how does carcinoid tumor cause carcinoid syndrome
large amounts of serotonin and vasoactive substances reach systemic circulation- originate in gi tract
348
what meds can you give to help treat carcinoid syndrome
pepcid
octreotide
albuterol
ipratropium
zofran
349
how long should you give octreotide before surgery for carcinoid tumor
1-2 days before surgery, continue intraop
350
what meds should you avoid with carcinoid tumor and why
roc/vanc- histamine release
351
what is the first line treatment for myasthenia gravis
pyridostigmine
352
t or f- myasthenia gravis causes increased aspiration risk
t- patients have muscle weakness in mouth/throat so have harder time swallowing secretions
353
t or f- give succ without non depolarizing nmb in myasthenia gravis patient
true
354
which nmb have an increased and decreased effect in myasthenia gravis
increased: nondepolarizing
decreased: depolarizing
355
which disease would you want to increase gas/propofol because you aren't using non-depolarizing nmb
myasthenia gravis
356
how can you help increase relaxation in patient with myasthenia gravis- not a paralytic
volatile anesthetics
357
t or f- you can skip paralytic in myasthenia gravis intubation
t- sevo 3% instead of 2% though
358
what is a potential complication for intubation with scleroderma
decreased mandibular motion- tight skin- mouth may not open well- video scope or mcgrath
359
what may be another complication with scleroderma
difficult iv/art access d/t dermal thickening
360
what meds are contraindicated in duchenne's muscular dystrophy and why
do not give SUCC
AVOID VOLATILES- do tiva or nitrous
have dantrolene available!
361
why do patient's with duchenne's muscular dystrophy have predisposition to pneumonia
chronically weak resp muscles/decreased ability to cough results in lost pulm reserve and accumulation of secretions.
362
how should you manage ventilation/extubation-for duchenne's muscular dystrophy
peep, good breaths at end of case, lavage, full reversal (suggamadex), robinul for secretions, wide awake extubation
363
what is a good intubation approach to use for rheumatoid arthritis patient
video laryngoscope- w/RSI
364
t or f- rheumatoid arthritis patient may need steroid stress dose
true
365
which disease should you make sure to put ointment in eyes
rheumatoid arthritis
366
what are three operations with increased MH occurrence
orthopedic- joint dislocation repair
ophthalmic- ptosis, strabismus
head and neck- dental, cleft palate
367
MH causes an increased consumption of what
atp
o2
368
MH causes an increased production of what:
lactic acid
co2
heat
369
if masseter muscle tension is too high, what can happen
may be impossible to open mouth for intubation
370
if masseter muscle tension is too tight, how can you manage airway
mask
nasal intubate
fiberoptic bronch
bougie
371
what do you do if patient has exaggerated jaw muscle tone for more than a few minutes
cancel surgery
372
what is trismus-masseter spasm
jaw muscle rigidity w/limb muscle flaccidity after succ administration
373
your patient undergoes trismus, what do you check next
-etco2
-urine color- coca cola color
-arterial/venous blood for CKMB elevation
-acidosis
-electrolytes (potassium)
374
your patient gets jaws of steel after you have established airway. It is ok to proceed with surgery
f- cancel surgery
375
patient's jaw is slightly resistant to opening, can you continue surgery
yes- but be careful
376
patient's jaw is modestly tight, what are your 2 options
cancel
proceed with non triggering agents
377
what is the early lab finding of MH
hypercarbia
378
what are the two types of classic clinical manifestations of MH
-rigidity after induction w/succ, successful intubation, follow rapidly by sx
-normal response to induction, uneventful course until onset of sx
379
what are some signs of MH after a normal induction of anesthesia has occurred
-unexplained sinus tach/arrhythmia
-tachypnea during spont mode
-unexplained decrease in o2
-increased pco2 w/good ventilation
-unexpected resp/met acidosis
-central venous desat
-increase in body temp >38.8 w/ no cause
380
what are the steps for mh treatment
turn off triggering agent
hyperventilate w/o2
call for help- phone number
dantrolene 2.5mg/kg
correct acidosis/electrolyte abnormalities
381
incidence of mh is higher in patients with what disease
duchenne muscular dystrophy
382
what kind of patient do you want to treat like they have mh
duchenne muscular dystrophy
383
how do you prep anesthesia machine for MH
new disposable circuit and fresh gas outlet hose
take off vaporizers/tape off
flush/purge machine- 10l/min for 5-20 mins
new co2 absorber
384
how do you manage intraop in patient with esophageal varices
-rsi and intubate
-type and cross- have blood in OR
-avoid peep- decreases hepatic blood flow
-use isoflurane
-Normocapnea
-check inr if doing regional
-liberal use of IV fluids
385
How can you prepare patient for TIPS procedure
2 big IV's- 16 g or central line
ART line for bp and labs
Blood in OR
Cardiac clearance
NOTHING IN ESOPHAGUS
386
your patient diagnosed with acute hepatitis comes in for an elective surgery. What is your anesthesia plan
cancel surgery
387
What is the TLIF procedure
transforaminal lumbar inter body fusion
388
what is positioning and blood loss expected in TLIF
long surgery
prone
bloody
389
chronic alcoholic will have an increased or decreased metabolism of drugs
increased
390
how will chronic alcoholic respond to catecholamines
decreased response
391
what is a consideration when patient has cardiomyopathy from chronic alcohol use
more sensitive to cardiodepressant effects of alcohol
392
t or f- chronic alcoholic has less protein binding of drug, so drugs that are protein bound will have less active drug in blood
f- more active drug in blood
393
how do you treat acute alcohol withdrawal
alcohol
beta blocker
alpha 2 agonist
394
what diseases should you avoid succinylcholine
myotonic dystrophy
MH
duchenne's muscular dystrophy
multiple sclerosis
395
what disease should you avoid roc
myasthenia gravis
396
why is succinylcholine contraindicated in patient with severe liver disease
if they are hyperkalemic
-although severe liver disease does decrease plasma cholinesterase activity
397
what does direct bilirubin measure in the liver
excretory level- too high= obstruction
398
nitrous oxide alone may be suitable for acute liver failure patient
yes
399
how should you intubate liver patient
rsi-w/ascites
400
what is hepatorenal syndrome characterized by
decreased gfr
renal vasoconstriction
401
what is creatinine level in hepatorenal syndrome
>1.5 mg/dL
402
