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Principles of Anesthesia > Exam 2: Liver/GI, Muscle, MH, autoimmune, hematological, obesity, cancer, ortho, eras > Flashcards

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

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2
Q

if ast and alt are both high, what does this indicate

A

hepatitis

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3
Q

what should platelet count be before minor surgery

A

20,000-30,000

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4
Q

what should platelet count before major surgery

A

100,000

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5
Q

what platelet count do you have increased chance of bleeding

A

50,000

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6
Q

what are the three PO pain medications listed in the ERAS protocol

A

gabapentin/pregabalin
acetaminophen
celecoxib

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7
Q

t or f- according to eras protocol, block nurse should administer versed/fentanyl for block procedure

A

true

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8
Q

What is the ERAS block associated with colorectal/gyn/urology procedure

A

erector spinae block

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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

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10
Q

in what scenario would you need to reduce amount of lidocaine drip according to ERAS protocol

A

if patient receive preop block

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11
Q

what population should you reduce ketamine dose according to ERAS protocol

A

elderly

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12
Q

when should last dose of ketamine be according to ERAS protocol

A

45 minutes before extubation

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13
Q

what can magnesium bolus cause according to ERAS protocol

A

muscle weakness

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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

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15
Q

according to ERAS protocol, when should you reduce dose of robaxin

A

elderly/renal impairment

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16
Q

according to ERAS protocol what do you need to monitor when giving robaxin

A

vasodilation- hypotension

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17
Q

according to ERAS protocol when can you re dose robaxin

A

6 hrs

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18
Q

t or f- bolus robaxin for max effect

A

f- give over 15 minutes, may cause hypotension

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19
Q

what is a scenario when you would not give robaxin for ERAS, and why

A

seizure disorder- lowers seizure threshold

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20
Q

according to ERAS protocol, what are 4 meds to give for pONV

A

zofran
decadron
benadryl- before incision
scopalamine- pre op

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21
Q

according to ERAS protocol, what i the fluid of choice for volume replacement

A

albumin/colloids
-then LR or different colloid

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22
Q

according to ERAS protocol, when should acetaminophen be re-dosed after pre op dose

A

6 hrs

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23
Q

according to ERAS protocol, what surgeries should you consider deep extubation

A

hernia
fascial closure

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24
Q

according to ERAS protocol, what are the SVV and SV goals

A

SVV <13%
SV> or equal to baseline

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25
Q

according to ERAS protocol, ci/co can be used for fluid monitoring in what type of patient

A

normal LV function

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26
Q

SVV is not accurate in which 3 patients

A

atrial fibrillation
open abdomen case- false decrease
ab insufflation- false increase

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27
Q

in cases where svv is not accurate, what other measurement may be used

A

SV

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28
Q

according to ERAS protocol, when will svv be falsely elevated

A

abdominal insufflation

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29
Q

according to ERAS protocol, when will svv be falsely decreased

A

open abdomen case

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30
Q

when assessing patient with osteoarthritis, what should you have patient perform preoperatively

A

neck range of motion
joint and limb mobility

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31
Q

what is a consideration when placing bovi pad for surgery

A

avoid metal joints
avoid pacemaker
-place magnet on pacemaker

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32
Q

t or f- while in prone position, stretch arms out over head in superman position to avoid pressure injury

A

f- don’t stretch out all the way, may cause brachial plexus injury

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33
Q

when moving patient’s arms into superman position for prone position, which way should you rotate arms

A

always underneath, so move hand towards the floor

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34
Q

what position is patient usually in for ERCP and what population may this cause harm

A

prone with heard turned toward side
-osteoarthritis- fracture

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35
Q

what is a consideration with positioning for ERCP with patient who has osteoarthritis

A

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

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36
Q

what two diseases may cause stiff necks that she mentioned in lecture

A

down syndrome
osteoarthritis

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37
Q

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

A

f- muscle relaxer/nmb may increase range of motion, but you will be causing injury

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38
Q

what can happen if you rotate arm up and over while in prone position

A

shoulder dislocation

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39
Q

should you move patient past point of comfort level after muscle relaxers/nmb increase range of motion in osteoarthritis patient

A

no-stay at comfort level

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40
Q

what do you give for refractory hypotension in rheumatoid arthritis patient

A

steroids

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41
Q

what do you need to make sure to give RA patient perioperatively

A

stress dose steroid

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42
Q

why do orthopedic or msk surgeries have increased risk of bleeding

A

bones bleed- difficult to control, can’t cauterize

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43
Q

what are some things the surgeon might ask for that make you think the patient has uncontrolled bleeding

A

thrombin
bone wax
gel foam

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44
Q

a patient has to return to surgery a day after being in surgery. which type of anesthesia would you avoid or caution

A

regional- probably on blood thinners post operatively, don’t want to cause hematoma

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45
Q

what are s/s of a clot during surgery

A

hypotension, tachycardia, low co2

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46
Q

where should you look for blood loss during surgery

A

drapes
laps
raytecs
floor
suction

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47
Q

during IM nail, where do you need to look for blood loss

A

bag attached to patient
drapes
-ask surgeon how much is in bag

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48
Q

what are things you need to have prepared for patient with bleeding risk

A

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

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49
Q

t or f- while in beach chair position, it is acceptable to put Iv in opposite arm ac

A

f- opposite arm is bent and held across body, ac will be inaccessible

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50
Q

how long may blood take to get ready if patient has antibody

A

1 hr

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51
Q

what patients should you be cautious of giving preop fluid

A

chf
elderly
renal disease

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52
Q

what is a good fluid to give chf, elderly, renal disease

A

albumin

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53
Q

what is the med she mentions to give preoperatively for pain and why

A

tylenol iv
-don’t have to monitor

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54
Q

what lab result may cause the surgeon to cancel a joint replacement surgery

A

increased wbc

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55
Q

what are the three labs to look before surgery that she mentioned

A

wbc
platelets
hct

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56
Q

what are two forms of ppe she mentioned to make sure to have during ortho procedure

A

goggles
shoe covers
-also stand and put drapes high for power irrigator

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57
Q

what are some injury prevention measures for lateral position

A

straps
axillary roll for brachial plexus
pillow under dependent arm
neck in midline position

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58
Q

when patient undergoes neurosurgery with head pins, what are some anesthetic considerations

A

-paralyzed throughout procedure
-deep sedation
-do not touch head pins
-usually prone during the case, but head is off table

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59
Q

how often should positioning be documented

A

q15 minutes

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60
Q

what are the head considerations during prone positioning

A

-maintain cervical alignment
-pillow or folded towel under shoulder
-ensure lips/tongue are clear of teeth

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61
Q

what are the eyes considerations during prone positioning

A

protect forehead, eyes, chin

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62
Q

what are the nose considerations during prone positioning

A

padded headrest to provide airway access
pad for face/foam pillow
space between nose and bed

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63
Q

what are the chest compression/iliac crest considerations during prone positioning

A

chest rolls from clavicle to iliac crest to allow movement and decrease abdominal pressure

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64
Q

what are the breast/male genitalia considerations during prone positioning

A

keep free from torsion

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65
Q

what are the knees considerations during prone positioning

A

padded with pillow to feet

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66
Q

what are the feet considerations during prone positioning

A

padded footboard

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67
Q

what is the AANA standard for positioning

A

8

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68
Q

according to ERAS protocol, how can you prevent ileus

A

avoid narcotics if possible
use regional techniques

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69
Q

what complications can ileus lead to

A

aspiration, ischemic bowel, sepsis

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70
Q

according to ERAS protocol, how long should patient sit on chair for on day of surgery

A

2 hours

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71
Q

according to ERAS protocol how long should patient sit on chair and walk on days after surgery

A

sit: 5 hours in chair
walk: 3 times

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72
Q

what is the amino acid for wound healing found in nutrition shake patient drinks morning of surgery

A

arginine

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73
Q

what is the cutoff for clear liquids and the carbohydrate drink for diabetics

A

3 hours- gastraparesis

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74
Q

what is the cutoff for clear liquids and the carbohydrate drink

A

2 hours

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75
Q

how can you tell magnesium is causing muscle weakness

A

deep tendon reflex are lost

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76
Q

t or f- give robaxin intraoperatively and post operatively

A

true

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77
Q

what is the max amount of albumin that can be administered according to eras protocol

A

1500ml

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78
Q

what are the overall goals of ERAS she mentioned

A

organ preservation
wound healing
recovery

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79
Q

what is the term for decreased oxygen carrying capacity

A

anemia

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80
Q

what can cause hgb levels to be falsely elevated that she mentioned

A

dehydration

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81
Q

what can cause hgb levels to be falsely low that she mentioned

A

pregnancy- expanded blood volume

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82
Q

what condition will there not be enough oxygen to carry out to tissues

A

anemia

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83
Q

what is the term for increase in hct r/t expanded rbc mass leading to increased blood viscosity

A

polycythemia

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84
Q

t or f- one single lab value identifies anemia

A

false

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85
Q

what is the most important adverse effect from anemia

A

decrease in tissue oxygen delivery d/t decrease in cao2 (arterial oxygen concentration)

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86
Q

a hemoglobin decrease from 15 to 10 will cause how much of a decrease in cao2

A

33%

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87
Q

how does body initially compensate for anemia

A

release of oxygen from hgb to tissues

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88
Q

explain how pallor is caused during anemia

A

release of o2 from skin/kidneys to heart/brain and muscles- body shunts oxygen to vital organs

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89
Q

will cardiac output in anemia be low or high

A

high- need to pump more blood because it isn’t carrying as much oxygen

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90
Q

what are sx of anemia

A

pallor
fatigue
decreased exercise tolerance
orthopnea
dyspnea on exertion

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91
Q

what can chronic severe anemia result in

A

cardiomegaly
pulmonary congestion
ascites
edema
high output failure

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92
Q

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

A

anemia

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93
Q

what hgb level serves as periop blood transfusion trigger

A

6 or hct 18

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94
Q

how much blood loss will reflect a hct drop by 1%

A

100 ml

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95
Q

what are factors to consider when deciding to transfuse blood

A

preop hgb level
risks of anemia vs risk of transfusion
co-existing diseases- rf, chf
anticipated blood loss

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96
Q

what disease may trigger giving blood at a hct of 28-30%

A

coronary artery disease

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97
Q

a renal patient who is chronically anemic comes to preop wth a hgb level of 7. should you transfuse

A

No- unless she isn’t compensated, look at the other factors

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98
Q

how should you replace a 15% loss of blood

A

none

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99
Q

how should you replace a 30% loss of blood

A

crystalloid only

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100
Q

how should you replace a 30-40% loss of blood

A

rbc

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101
Q

how should you replace a >50% loss of blood

A

mtp 1:1:1

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102
Q

what should you also give during mtp to promote coagulation

A

calcium

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103
Q

what disease causes decreased carrying capacity of oxygen and clumping of red blood cells

A

sickle cell disease

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104
Q

which hgb is associated with sickle cell trait vs disease

A

hgb c= trait
hgb s= disease

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105
Q

what is the primary trigger for sickle cell crisis

A

deoxygenation

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106
Q

why is a prolonged surgery a concern for sickle cell disease patient

A

more pain
more temp decrease
more blood loss

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107
Q

what are pre op considerations for sickle cell disease

A

-keep them warm
-give iv fluids to prevent rbc clumping
-iv tylenol for pain
-avoid shivering
-leg squeezers
-oxygenate well!!!

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108
Q

what are pre op tests/labs for sick cell disease

A

chest x ray
t & c
order special blood-antibody screen

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109
Q

what is a vaso occlusive crisis in sickle cell patient

A

block capillaries leading to pain, and ischemia leading to end organ damage

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110
Q

what can worsen vaso occlusive crisis

A

dehydration
infection
cold/shivering
hypoxemia
vascular stasis
stress
acidosis

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111
Q

how can you treat chronic pain from sickle cell disease

A

ketamine

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112
Q

what type of intubation technique would you want to use for sickle cell disease and why

A

video laryngoscope- avoid deoxygenation

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113
Q

what is a consideration for imaging in patient with sickle cell crisis

A

NO CONTRAST- induces sickling of cells

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114
Q

what is a potential renal complication in males with sickle cell disease

A

priapism- sickle cells block off penile blood flow

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115
Q

what is hct goal preoperatively for sickle cell disease

A

30%

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116
Q

what type of procedure should you transfuse preoperatively in patient with sickle cell disease and hct below 30%

A

med/high risk procedure

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117
Q

why should you have prbc on hand during surgery for a patient with sickle cell disease

A

special blood match w/antibody
acute sickle cell crisis

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118
Q

what are intraop considerations for sickle cell disease patient

A

avoid hypotension
warm patient- bair hugger
avoid venous stasis
prbc’s ready for acute crisis
pain control
hydrate
normocapnea

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119
Q

how do you adjust vent to increase/decrease co2

A

decrease= increase rate/tidal volume
increase= decrease rate/tidal volume

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120
Q

what are postop considerations for sickle cell disease patient

A

pain control
look for acute chest syndrome
continuous o2 monitor
prevent hypoventilation
prevent shivering
give fluids
monitor temp

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121
Q

what is the disease where low hgb is caused by rbc’s trapped in spleen

A

splenic sequestration crisis

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122
Q

what are s/s of splenic sequestration crisis

A

irritability
sleepy
pale
weak
tachycardia
left abdomen plain
fever=medical emergency

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123
Q

what is the leading cause of death/hospitalization for sickle cell disease

A

acute chest syndrome

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124
Q

what are s/s of acute chest syndrome

A

fever
chills
cough
tachypnea
hypoxemia
sob/chest pain

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125
Q

what should you tell pacu nurses to look for in patient with sickle cell disease

A

acute chest syndrome

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126
Q

how do you treat acute chest syndrome

A

-cpap or vent for resp failure
-nitric oxide/albuterol for bronchodilation
blood transfusion
abx
iv fluids

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127
Q

t or f- assume hyperreactive airway in acute chest syndrome

A

true

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128
Q

when will acute chest syndrome typically manifest during surgery period

A

pacu

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129
Q

what is the leading cause of microcytic anmia

A

thalassemias

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130
Q

what is the leading cause f macrocytic anemia

A

folate/b12 deficiency

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131
Q

what is a frequent source of folate deficiency

A

alcohol

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132
Q

what deficiency can sustained nitrous oxide and poor scavenging system lead to

A

vit b 12

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133
Q

t or f- pulse ox is reliable during methemoglobinemia

A

false
always shows 85%

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134
Q

what meds should be avoided with methemoglobinemia

A

nitric oxide
nitrates
local anesthetics

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135
Q

what should ekg be monitored for during methemoglobinemia

A

ischemia

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136
Q

how do you measure oxygen with methemoglobinemia

A

art line
abg

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137
Q

is tissue getting enough oxygen during methemoglobinemia

A

no

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138
Q

what is sx when methemoglobinemia is between 30-50%

A

hypoxia

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139
Q

what is sx when methemoglobinemia is >50%

A

coma/death

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140
Q

what is the term for increased blood viscosity that slows flow and decreases o2 delivery

A

polycythemia

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141
Q

how does polycythemia usually result

A

sustained hypoxia resulting in compensatory increase in rbc mass

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142
Q

what happens at hct of 55-60%

A

blood flow to organs reduced
clots

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143
Q

what level of hct is life threatening

A

> 60%

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144
Q

a patient comes in with headaches and fatigue and have a high hct. what may be the problem

A

polycythemia causing impaired cerebral circulation

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145
Q

t or f- polycythemic patient is at risk for hyper-coagulation but not hemorrhage

A

f- at risk for both

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146
Q

t or f- do not withhold aspirin for 7 days in polycythemic patient so their blood can be thinned

A

f- still hold for 7 days

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147
Q

how do you treat polycythemia

A

ddavp
cryoprecipitate to increase vWF

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148
Q

how do you treat factor 5 deficiency

A

ffp and platelets

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149
Q

when giving 10-15ml/kg of ffp, how much do you expect missing clotting factor to be raised

A

20-30%

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150
Q

what meds should be avoided in hemophilia a

A

toradol
aspirin

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151
Q

how do diagnose hemophilia a

A

elevated ptt

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152
Q

what are platelets derived from

A

megakaryocytes

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153
Q

where are megakaryocytes found

A

bone marrow

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154
Q

what stimulates bone marrow to make megakaryocytes

A

thrombopoeitin

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155
Q

where is thrombopoeitin made

A

liver

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156
Q

what lab finding do you expect to see if patient who will be undergoing splenectomy

A

low platelets

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157
Q

when should you give platelets for patient undergoing splenectomy and why

A

after spleen has been removed
-spleen is cause of low platelets

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158
Q

the surgeon mentions there is oozing from microvascular bleeding, what blood product should be given

A

FFP

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159
Q

what is the most common hereditary bleeding disorder

A

von willebrand

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160
Q

each unit of apheresis platelets/6 donor platelets will increase platelet count by how much

A

50,000

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161
Q

what medication do give vw disease in preop

A

ddavp

162
Q

what are sx of vw disease

A

epistaxis
menorrhagia
gingival bleeding
easy bruising
hematomas

163
Q

why is vw factor important

A

platelet plug formation
carrier protein for factor 8

164
Q

what blood test will be elevated in vw disease

A

PTT

165
Q

what is a normal platelet count

A

150,000-300,000

166
Q

at what platelet count should surgery be canceled

A

<20,000– or delay for platelet transfusion

167
Q

what inr is too high for surgery and needs to be discussed with surgeon

A

> 2.5

168
Q

when should you not give toradol

A

low platelets
kidney problems
asthma

169
Q

what is the OTC med class we talked about that increases bleeding

A

herbals

170
Q

when a patient is prone and a bleeding risk, what can you use to prevent oral bleeding

A

soft bite block to prevent tongue cuts
clear lips out of the way of teeth

171
Q

t or f- it is ok to give toradol at end of surgery in patient with bleeding risk

A

true

172
Q

what s/s suggest blood loss while in pacu

A

color change
mentation change
tachycardia
hypotension
decreased uop
hypothermia
cvp drop

173
Q

you suspect increased blood loss based on vital signs. What can you check to confirm

A

dressings
drains
labs

174
Q

what meds can you give for cancer nausea

A

zofran
droperidol
metoclopramide

175
Q

why is decadron not given to cancer pt with nausea

A

already immunosuppressed

176
Q

what are infection prevention measure for cancer pt

A

alcohol iv ports
sterile tegaderm- no tape- for iv
swab art line site

177
Q

what is a good reversal med for lung cancer patient

A

suggamadex

178
Q

what part of airway may be stiff in lung cancer patient who has undergone radiation

A

trachea

179
Q

what is an appropriate intubation technique for lung cancer patient

A

videoscope w/rsi- decreases risk of deoxygenation and trauma

180
Q

will lung cancer patient who has undergone radiation need or smaller or larger ett

A

smaller

181
Q

is lma or ett usually better for bronch and why

A

ett- decreases coughing, more secure airway

182
Q

what are 4 considerations for colon cancer

A

dry from bowel prep, give iv fluids
-have blood available
-have art line/hemosphere
-ng tube after intubation

183
Q

how do you manage vent in steep trendelenburg position for robotic prostatectomy

A

pressure control
-tidal volumes will be lower because of increased abdominal pressure so increase rate to reach appropriate minute ventilation

184
Q

which acid base imbalance increases pulmonary hypertension

A

resp acidosis

185
Q

what are positioning consideration for robotic prostatectomy

A

shoulder straps
face protection
safe positioning
goggles

186
Q

should you extubate obese patient deep or awake

A

awake

187
Q

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

A

no- they want to watch nerve stimulus

188
Q

what provides 25% of blood flow to the liver

A

proper hepatic artery

189
Q

what are s/s of tylenol od

A

nvd, coma, abdominal pain, sweating

190
Q

what provides 75% of blood flow to the liver

A

portal vein

191
Q

what do hepatic veins dump into

A

inferior vena cava

192
Q

how does liver return blood to the heart

A

hepatic veins connect to inferior vena cava

193
Q

how does 75% of blood flow to the liver

A

portal vein

194
Q

what are the two major vessels where liver receives blood from

A

portal vein
proper hepatic artery

195
Q

what is a potential complication of hepatitis a or b

A

cirrhosis

196
Q

how much of cardiac output is direct towards the liver

A

30%

197
Q

what is a liver blood flow consideration when giving general or neuraxial anesthesia

A

general/neuraxial decreas map, so it will decrease flow to liver

198
Q

how much of the liver oxygen supply is from port vein vs proper hepatic artery

A

both 50%

199
Q

what types of anesthesia will decrease liver blood flow

A

general, neuraxial

200
Q

what can failure to eliminate ammonia lead to

A

hepatic encephalopathy

201
Q

what is a normal pt value

A

10.9-12.5 seconds

202
Q

how is synthetic function of liver tested

A

albumin
pt/inr

203
Q

what is normal albumin level

A

3.5-5.0 g/dL

204
Q

t or f- many patients with liver disease have normal function until disease is severe

A

true

205
Q

which lab test is very sensitive for acute liver injury

A

PT

206
Q

which lab test is NOT very sensitive for acute liver injury

A

albumin

207
Q

which lab test is NOT very sensitive for acute liver injury

A

albumin

208
Q

what clotting factors is pt sensitive for

A

factor 5 and 7

209
Q

what blood test indicates cholestatic or infiltrative hepatic conditions

A

elevated alkaline phosphate

210
Q

what blood tests indicate cellular integrity injury-of-liver

A

AST and ALT

211
Q

what does a marked elevation of both AST and ALT indicate

A

hepatitis

212
Q

what is normal value for ast

A

10-40 units/L

213
Q

what is normal for of ALT

A

10-55 units/L

214
Q

what is the significance of AST/ALT ratio >2

A

suggests cirrhosis or alcoholic liver disease

215
Q

besides decreased mac, what other complications can acute alcohol ingestion put patient at risk for

A

bleeding
aspiration
decreased brain hypoxia tolerance

216
Q

t or f- you can base overall liver function on AST/ALT alone

A

f- only gives 1/4 of the picture

217
Q

what blood tests should be looked at when evaluating liver function

A

pt
albumin
alkaline phosphate
ast/ALT
direct bilirubin

218
Q

what cell processes old red blood cells and where are they located

A

reticuloendothelial cells
-spleen

219
Q

what is the life of an rbc

A

120 days

220
Q

what does ast do

A

helps metabolize amino acids

221
Q

what does alt do

A

helps convert protein into energy

222
Q

what are the aminotransferases

A

AST and ALT

223
Q

is ast or alt liver specific

A

ALT

224
Q

what are the two main causes of cirrhosis

A

chronic alcohol abuse
chronic viral hepatitis

225
Q

what kind of meds do you want to avoid with liver disease

A

meds metabolized in liver
-prop, vec, roc, neostigmine

226
Q

t or f- increasing cardiac output will increase hepatic blood flow in cirrhosis

A

f- will still be decreased

227
Q

what are some common dysrhythmias from liver failure

A

a fib/a flutter

228
Q

what are the manifestations of cirrhosis

A

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
Q

what liver disease could fatigue and malaise be indicative of

A

cirrhosis

230
Q

what measurement reflects the fibrotic process and vascular resistance associated with cirrhosis

A

portal hypertension

231
Q

how does the body offset resistance from portal hypertension

A

creates vessels to bypass liver- portosystemic shunt

232
Q

what does cirrhosis do to vascular resistance

A

increase it

233
Q

how is resistance from cirrhosis offset by blood vessels

A

collateral vessels are created that bypass the liver

234
Q

what is a portosystemic shunt

A

an abnormal vessel that allows blood to bypass the liver

235
Q

why does cirrhosis cause drugs and toxins to remain in system for longer period

A

portosytemic shunts are created, so drugs/toxins don’t get to liver for metabolism/detoxificaition

236
Q

what does cirrhosis do to albumin, pt, aminotrasnferase, and alkaline phosphatase

A

albumin- decreased
increased: pt, aminotransferase, alkaline phosphatase

237
Q

what should you have available during surgery when patient has cirrhosis/liver failure

A

blood

238
Q

what type of heart failure is associated with liver problems

A

right heart failure

239
Q

what causes caput medusae

A

portal hypertension- blood gets backed up

240
Q

what are the s/s of portal hypertension

A

hypoalbuminemia
caput medusae
ascites

241
Q

what is the term for dilated submucosal veins

A

gastroesophageal varices

242
Q

where do esophageal varices usually bleed from

A

distal esophagus
proximal stomach

243
Q

what does ascites do to volume of distribution

A

increases it

244
Q

what does ascites do to oncotic pressure

A

decreases it

245
Q

what is oncotic pressure

A

The pressure created by the osmotic effects of the solutes

246
Q

what does ascites do to protein binding and volume of distribution

A

decreases protein binding
increases vd

247
Q

what are complications of cirrhosis

A

portal htn
varices
splenomegaly
ascites
restrictive defects
resp alkalosis
hepatopulmonary syndrome
portopulmonary syndrome

248
Q

you are doing a procedure on a patient with varices, what is the most appropriate way to secure airway

A

intubate- rsi

249
Q

what accounts for 1/3 death of cirrhosis

A

variceal bleed

250
Q

what does recurrent bleeding from varices indicate need for

A

portosystemic shunt-tips

251
Q

what does drainage of ascites lead to

A

hypotension

252
Q

how is pulmonary compliance affected with cirrhosis

A

if they have ascites, decreases pulmonary compliance

253
Q

what kind of drugs should you avoid with cirrhosis

A

hepatotoxic
inhibit cyp450

254
Q

what are some examples of drugs to avoid with cirrhosis

A

acetaminophen
halothane
amiodarone
abx: pcn, tetracycline, suflas
cimetidine

255
Q

what are some abx that should be avoided with liver failure/cirrhosis

A

pcn, tetracycline, suflonamides

256
Q

t or f- give a smaller dose of tylenol in patient with liver failure

A

false
give none

257
Q

what is a tips procedure

A

transjugular intrahepatic portosystemic shunt

258
Q

what does tips procedure treat

A

reduce esophageal varices bleeding
refractory ascites

259
Q

what is big risk of tips procedure

A

hemorrhage

260
Q

what do you do to prepare for hemorrhage from tips

A

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
Q

what cardiac problems is tips procedure contraindicated

A

HF
pulm htn
severe tricuspid regurg

262
Q

t or f- make sure to put og tube in patient with esophageal varice

A

f- nothing down the esophagus!!

263
Q

what volatile best preserves hepatic blood flow

A

isoflurane

264
Q

what volatile should not be used with liver failure

A

halothane

265
Q

what volatile is best for liver patients

A

isoflurane

266
Q

why do you want to avoid peep in liver patient

A

decreased hepatic blood flow
increases resistance to drainage

267
Q

your patient that has liver failure wants to have regional anesthesia instead of geta. What should you check before proceeding

A

PT/INR

268
Q

t or f- make sure to keep liver patients dry to decrease bleeding risk

A

f- liberal use of iv fluids

269
Q

how can you maintain hepatic blood flow during anesthesia

A

isoflurane
avoid peep
normocapnia
liberal use of iv fluids
regional anesthesia after inr

270
Q

what does chronic alcohol do to mac

A

increases mac

271
Q

a patient with chronic alcoholic ingestion comes in for a procedure, what would you put sevo at to achieve 1 mac

A

3%

272
Q

besides decreased mac, what else do you need to remember about acute alcohol ingestion patient

A

prone to aspiration
-alcohol delays gastric emptying

273
Q

what are four considerations for intoxicated patient

A

decreased mac
aspiration risk
bleeding risk
less tolerant to hypoxia

274
Q

t or f- chronic alcohol ingestion may decrease responsiveness to catecholamines

A

true

275
Q

when does alcohol withdrawal syndrome begin

A

6-8 hours after blood alcohol concentration returns to near normal

276
Q

when is the peak of alcohol withdrawal syndrome

A

24-36 hrs

277
Q

when does delirium tremens occur

A

2-4 days without alcohol

278
Q

what are the early s/s of alcohol withdrawal syndrome

A

tremors, hallucinations, nightmares

279
Q

what are the late s/s of alcohol withdrawal syndrome

A

sns: tachycardia, htn, dysrhythmia
N, V, confusion, agitation, insomnia

280
Q

what are s/s of delirium tremens

A

grand mal seizure
tachycardia
hyper/hypotension
combative

281
Q

how do you treat delirium tremens

A

diazepam (benzo)
beta blockers

282
Q

t or f- any factor that decreases cardiac output will decrease hepatic blood flow

A

true

283
Q

which type of surgery will place the patient at greater risk for decreased hepatic blood flow: upper abdominal or extremity surgery

A

upper abdominal

284
Q

what are three factors that can decrease hepatic blood flow

A

sympathetic stimulation
hypo/hypercarbia
positive pressure ventilation

285
Q

what would you potentially want to avoid on ventilator with liver patient

A

positive pressure ventilation- may decrease hepatic blood flow

286
Q

t or f- succinylcholine is contraindicated in patient with severe liver disease because liver-disease may decrease plasma cholinesterase activity

A

f- contraindicated because of hyperkalemia

287
Q

when would succinylcholine be contraindicated for liver patient

A

hyperkalemia

288
Q

what is a patient with ascites at increased risk for that is concerning for intubation

A

reflux
aspiration

289
Q

a patient with ascites starts desaturating during standard intubation, what may be the problem

A

aspiration

290
Q

why should you give blood slowly in patient with cirrhosis/liver failure

A

decreased clearance of citrate

291
Q

t or f- In patient with ascites and varices, make sure to put og tube down into stomach to prevent aspiration

A

f- no esophageal instrumentation with varices!

292
Q

t or f- give blood as fast as possible in cirrhosis liver patient to increase hepatic blood flow

A

f- give slow because citrate clearance is decreased by cirrhosis liver

293
Q

what will hypoalbuminemia cause with any drug effect that is protein bound

A

prolonged effects

294
Q

what med classes can contribute to hepatic encephalopathy

A

opioids
benzos

295
Q

what is a nmb that isn’t metabolized in liver

A

nimbex

296
Q

does opioid dose need to be adjusted in liver patient

A

yes-decrease dose

297
Q

t or f- propofol is unacceptable in liver failure patient

A

f- acceptable, metabolism isn’t significantly altered

298
Q

t or f- since volatiles vasodilate, they will increase hepatic flow

A

f- decrease hepatic blood flow

299
Q

which volatile is hepatotoxic

A

halothane

300
Q

when would elective surgeries be contraindicated in liver disease

A

fulminant hepatic failure
late stage cirrhosis
acute hepatitis
end stage liver disease

301
Q

what is the most common cause of acute liver failure

A

tylenol od

302
Q

what are four causes of acute liver failure

A

hepatitis
toxins (tylenol od)
hepatic vein clot
wilson’s disease

303
Q

t or f- nsaids are avoided in liver patient

A

t- hepatic metabolism

304
Q

what is tylenol limit in 24 hours

A

4000mg

305
Q

what lab test would you not give tylenol if it was elevated

A

LFT

306
Q

what is the dose for tylenol

A

12-15 ml/kg q 5-6 h
not to exceed 4000mg in 24 hrs

307
Q

what is the dose for tylenol > 50kg

A

1000 mg/iv q6
650 mg/iv q4

308
Q

how do you correct coagulation abnormalities in liver patient

A

FFP

309
Q

is the liver patient more prone to infections

A

yes

310
Q

why should hypotension be avoided in liver patient

A

because it decreases hepatic blood flow

311
Q

how should volatiles be dosed in liver patient

A

low dose

312
Q

severe pulmonary htn is a contraindication to what type of transplant

A

liver

313
Q

which gender is more likely to have gallstones

A

women
fat-female-forty

314
Q

what does insufflation with co2 cause to abdomen

A

increased intra abdominal pressure

315
Q

what does insufflation with co2 do to vital signs

A

increases map and svr
decreases co, venous return, frc

316
Q

what position may improve ventilation during insufflation with co2 during cholycystectomy

A

reverse trendelenburg

317
Q

what are the goals of mechanical ventilation with insufflation of co2 during cholecystectomy

A

prevent atelectasis
adequate ventilation
offset co2 absorption

318
Q

why do surgeons insufflate

A

need to get abdominal wall off where they are working

319
Q

what is essential med to keep surgeon happy during abdominal insufflation

A

adequate nmb

320
Q

your tidal volume goes down after abdominal insufflation. how can you adjust ventilator during insufflation of abdomen to maintain minute ventilation

A

decrease tidal volume
increase rate

321
Q

during cholecystectomy, how do you protect patient during reverse trendelenburg

A

strapped onto bed
foot board
hover mat will be slippery- take off
arms secure

322
Q

why is atelectasis more common in cholecystectomy

A

insufflation causes increased pressure in chest decreases lung expansion

323
Q

t or f- abdominal insufflation surgeries has increased risk of reflux and aspiration

A

true

324
Q

what can you do to help surgeon and prevent aspiration in abdominal insufflation surgery

A

og tube to decompress

325
Q

the patient’s heart rate all of the sudden drops during abdominal insufflation, what is your first action

A

ask surgeon to let off pneumoperitoneum
-then give robinul

326
Q

what kind of embolus is associated with abdominal insufflation

A

co2 embolus
look at capnography

327
Q

_________________ can cause spasm of the sphincter of oddi

A

opioids

328
Q

t or f- give opioids during cholangiogram to help with pain

A

f- opioids can cause false positives, try to avoid or reduce
ok to give after test

329
Q

how can you reduce sphincter of oddi spasm

A

glucagon
nitroglycerin
atropine

330
Q

t or f- use narcan to reverse opioid during cholangiogram

A

f- will reverse all opioid effects, use another drug

331
Q

what is ercp

A

Endoscopic retrograde cholangiopancreatography

332
Q

what do you give with ercp when spasm occurs

A

glucagon

333
Q

t or f- paralyze with a pneumoperitneum

A

true

334
Q

when should you dose opioids for cholangiogram

A

after procedure

335
Q

what are some questions you can assess for reflux

A

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
Q

what meds can you give preop to prevent reflux and when should you give them

A

bicitra, pepcid, zantac, alka seltza gold
within 20 mins of surgery

337
Q

what are the intra op reflux prevention methods

A

-rsi: succ/roc
-cricoid pressure until tube placement confirmed
-suction ready, cuff promptly inflated
-reglan optional

338
Q

how should patient be extubated with GERD

A

fully reverse and awake and following commands before extubation

339
Q

what should you do preop for a patient with an ileus

A

ng tube

340
Q

a patient has increased abdominal pain, abdominal distention and vomiting during preop. What is a likely cause

A

ileus

341
Q

t or f- give reglan to patient with ileus to help their bowels wake up

A

f- may cause perforation

342
Q

how do you induce and extubate a patient with ileus

A

intubate: rsi w/suction in preop and intraop
extubate: fully awake and reverse nmb

343
Q

what medication should you avoid with peptic ulcer disease or GI bleeding

A

toradol

344
Q

t or f- put in an ng/ogt with peptic ulcer disease to suction out acidic bile

A

f- suction may cause bleeding and erosion

345
Q

what are the most common signs of carcinoid syndrome

A

flushing
diarrhea

346
Q

what are some other s/s of carcinoid syndrome

A

hypo/hypertension
bronchoconstriction
tachycardia
pain

347
Q

how does carcinoid tumor cause carcinoid syndrome

A

large amounts of serotonin and vasoactive substances reach systemic circulation- originate in gi tract

348
Q

what meds can you give to help treat carcinoid syndrome

A

pepcid
octreotide
albuterol
ipratropium
zofran

349
Q

how long should you give octreotide before surgery for carcinoid tumor

A

1-2 days before surgery, continue intraop

350
Q

what meds should you avoid with carcinoid tumor and why

A

roc/vanc- histamine release

351
Q

what is the first line treatment for myasthenia gravis

A

pyridostigmine

352
Q

t or f- myasthenia gravis causes increased aspiration risk

A

t- patients have muscle weakness in mouth/throat so have harder time swallowing secretions

353
Q

t or f- give succ without non depolarizing nmb in myasthenia gravis patient

A

true

354
Q

which nmb have an increased and decreased effect in myasthenia gravis

A

increased: nondepolarizing
decreased: depolarizing

355
Q

which disease would you want to increase gas/propofol because you aren’t using non-depolarizing nmb

A

myasthenia gravis

356
Q

how can you help increase relaxation in patient with myasthenia gravis- not a paralytic

A

volatile anesthetics

357
Q

t or f- you can skip paralytic in myasthenia gravis intubation

A

t- sevo 3% instead of 2% though

358
Q

what is a potential complication for intubation with scleroderma

A

decreased mandibular motion- tight skin- mouth may not open well- video scope or mcgrath

359
Q

what may be another complication with scleroderma

A

difficult iv/art access d/t dermal thickening

360
Q

what meds are contraindicated in duchenne’s muscular dystrophy and why

A

do not give SUCC
AVOID VOLATILES- do tiva or nitrous
have dantrolene available!

361
Q

why do patient’s with duchenne’s muscular dystrophy have predisposition to pneumonia

A

chronically weak resp muscles/decreased ability to cough results in lost pulm reserve and accumulation of secretions.

362
Q

how should you manage ventilation/extubation-for duchenne’s muscular dystrophy

A

peep, good breaths at end of case, lavage, full reversal (suggamadex), robinul for secretions, wide awake extubation

363
Q

what is a good intubation approach to use for rheumatoid arthritis patient

A

video laryngoscope- w/RSI

364
Q

t or f- rheumatoid arthritis patient may need steroid stress dose

A

true

365
Q

which disease should you make sure to put ointment in eyes

A

rheumatoid arthritis

366
Q

what are three operations with increased MH occurrence

A

orthopedic- joint dislocation repair
ophthalmic- ptosis, strabismus
head and neck- dental, cleft palate

367
Q

MH causes an increased consumption of what

A

atp
o2

368
Q

MH causes an increased production of what:

A

lactic acid
co2
heat

369
Q

if masseter muscle tension is too high, what can happen

A

may be impossible to open mouth for intubation

370
Q

if masseter muscle tension is too tight, how can you manage airway

A

mask
nasal intubate
fiberoptic bronch
bougie

371
Q

what do you do if patient has exaggerated jaw muscle tone for more than a few minutes

A

cancel surgery

372
Q

what is trismus-masseter spasm

A

jaw muscle rigidity w/limb muscle flaccidity after succ administration

373
Q

your patient undergoes trismus, what do you check next

A

-etco2
-urine color- coca cola color
-arterial/venous blood for CKMB elevation
-acidosis
-electrolytes (potassium)

374
Q

your patient gets jaws of steel after you have established airway. It is ok to proceed with surgery

A

f- cancel surgery

375
Q

patient’s jaw is slightly resistant to opening, can you continue surgery

A

yes- but be careful

376
Q

patient’s jaw is modestly tight, what are your 2 options

A

cancel
proceed with non triggering agents

377
Q

what is the early lab finding of MH

A

hypercarbia

378
Q

what are the two types of classic clinical manifestations of MH

A

-rigidity after induction w/succ, successful intubation, follow rapidly by sx
-normal response to induction, uneventful course until onset of sx

379
Q

what are some signs of MH after a normal induction of anesthesia has occurred

A

-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
Q

what are the steps for mh treatment

A

turn off triggering agent
hyperventilate w/o2
call for help- phone number
dantrolene 2.5mg/kg
correct acidosis/electrolyte abnormalities

381
Q

incidence of mh is higher in patients with what disease

A

duchenne muscular dystrophy

382
Q

what kind of patient do you want to treat like they have mh

A

duchenne muscular dystrophy

383
Q

how do you prep anesthesia machine for MH

A

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
Q

how do you manage intraop in patient with esophageal varices

A

-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
Q

How can you prepare patient for TIPS procedure

A

2 big IV’s- 16 g or central line
ART line for bp and labs
Blood in OR
Cardiac clearance
NOTHING IN ESOPHAGUS

386
Q

your patient diagnosed with acute hepatitis comes in for an elective surgery. What is your anesthesia plan

A

cancel surgery

387
Q

What is the TLIF procedure

A

transforaminal lumbar inter body fusion

388
Q

what is positioning and blood loss expected in TLIF

A

long surgery
prone
bloody

389
Q

chronic alcoholic will have an increased or decreased metabolism of drugs

A

increased

390
Q

how will chronic alcoholic respond to catecholamines

A

decreased response

391
Q

what is a consideration when patient has cardiomyopathy from chronic alcohol use

A

more sensitive to cardiodepressant effects of alcohol

392
Q

t or f- chronic alcoholic has less protein binding of drug, so drugs that are protein bound will have less active drug in blood

A

f- more active drug in blood

393
Q

how do you treat acute alcohol withdrawal

A

alcohol
beta blocker
alpha 2 agonist

394
Q

what diseases should you avoid succinylcholine

A

myotonic dystrophy
MH
duchenne’s muscular dystrophy
multiple sclerosis

395
Q

what disease should you avoid roc

A

myasthenia gravis

396
Q

why is succinylcholine contraindicated in patient with severe liver disease

A

if they are hyperkalemic
-although severe liver disease does decrease plasma cholinesterase activity

397
Q

what does direct bilirubin measure in the liver

A

excretory level- too high= obstruction

398
Q

nitrous oxide alone may be suitable for acute liver failure patient

A

yes

399
Q

how should you intubate liver patient

A

rsi-w/ascites

400
Q

what is hepatorenal syndrome characterized by

A

decreased gfr
renal vasoconstriction

401
Q

what is creatinine level in hepatorenal syndrome

A

> 1.5 mg/dL

402
Q
A

Principles of Anesthesia (4 decks)

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