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Advanced Principles III > Exam 2 study guide > Flashcards

Exam 2 study guide Flashcards

1
Q

What neurotransmitters are involved in wakefulness

A

acetylcholine, dopamine, norepinephrine, histamine, and 5-hydroxytryptamine (serotonin)

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2
Q

_________ is accomplished by a brainstem neuronal pathway known as the ascending reticular activating system (ARAS)

A

Wakefulness

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3
Q

Sleep is maintained by inhibition of the ARAS via a hypothalamic nucleus known as the ventrolateral preoptic (VLPO) nucleus which involves which neurotransmiters

A

γ-aminobutyric acid (GABA) and galanin

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4
Q

_____ promotes sleep by inhibiting cholinergic ARAS neurons and activating VLPO neurons

A

Adenosine

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5
Q

The hallark of OSA is?

A

sleep-induced hypoxia and arousal-relieved upper airway obstruction

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6
Q

Predisposing factors to OSA include

A 
o	genetic inheritance
o	non-Caucasian race
o	upper airway narrowing
o	obesity
o	male gender
o	menopause
o	use of sedative drugs and alcohol
o	cigarette smoking
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7
Q

Direct physiologic mechanisms involved in the pathogenesis of OSA include?

A

1) anatomic and functional upper airway obstruction
2) a decreased respiratory-related arousal response
3) instability of the ventilatory response to chemical stimuli

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8
Q

In OSA obstruction can be due to

A

bony craniofacial abnormalities, or excess soft tissue, such as thick parapharyngeal fat pads, or enlarged tonsils

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9
Q

Children have many reasons for anatomic upper airway narrowing, including

A

the very common enlargement of tonsils and adenoids, as well as the much less common congenital airway anomalies

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10
Q

For every 1-point increase in the Mallampati score, the odds ratio for OSA is increased by?

A

2.5 times

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11
Q

The respiratory-related arousal response is stimulated by:

A

1) Hypercapnia
2) Hypoxia
3) Upper airway obstruction
4) The work of breathing, which is the most reliable stimulator of arousal

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12
Q

Obesity is a risk factor for OSA in all age groups. __________ increase in body weight is associated with a ______ increase in the odds of having OSA and a ______increase in the apnea-hypopnea index

A

10%
6-fold
32%

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13
Q

A _____ weight loss is associated with a _______ decrease in the apnea-hypopnea index

A

10%

26%

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14
Q

Diagnosis criteria for OSA

A
  1. S/S: daytime sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, observed apnea
  2. Associated medical or psychiatric disorders such as HTN, CAD, afib, CHF stroke, DM, cognitive dysfunction, and mood disorders
  3. Predominantly obstructive respiratory events recorded during sleep center nocturnal PSG or during out-of-center sleep testing
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15
Q

What factors put children at an increased risk for respiratory complications?

A 
o	History of copious secretions
o	Prematurity
o	Parental smoking
o	Nasal congestion
o	Reactive airway disease
o	Endotracheal intubation
o	Airway surgery
o	Clear systemic signs of infection (fever, purulent drainage, productive cough, and rhonchi)
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16
Q

Identify adverse events in pts with URIs:

A 
o	Bronchospasm
o	Laryngospasm
o	airway obstruction
o	postintubation croup
o	desaturation
o	atelectasis
o	hypoxemia
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17
Q

Asthma is REVERSIBLE airflow obstruction characterized by?

A

o Bronchial hyperreactivity
o Bronchoconstriction
o Chronic airway inflammation

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18
Q

Genetic and environmental causes of asthma include?

A

o Family Hx
o Maternal smoking during pregnancy
o Viral infections (esp rhinovirus and infantile RSV)
o Exposure to highly infectious environments (farms, daycares, pets)

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19
Q

What is the pathophysiology of asthma?

A

o Chronic inflammation of lower airways
o Activation of inflammatory cascade → infiltration of airway with eosinophils, neutrophils, mast cells, T & B cells, and leukotrienes
o End result = airway edema (especially in the bronchi)

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20
Q

What are the signs and symptoms of asthma

A

o Characterized by acute exacerbations mixed with periods of no symptoms
o Wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia

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21
Q

What are PFT findings in asthma

A

o FEV1, FEV1/FVC ratio, and FEF25-75% all reduced but improve with bronchodilators.
o Downward scooping of the expiratory limb of the flow-volume loop.
o Bronchodilator responsiveness provides supporting evidence if asthma is suspected based on S/S

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22
Q

Identify short acting bronchodilators used for immediate relief of asthma

A

Albuterol
Lavalbuterol
Metaproterenol
Pirbuterol

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23
Q

Side effects of beta 2 agonists include?

A

Tachycardia
Tremors
Dysrhythmias
Hypokalemia

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24
Q

Identify the factors that could cause increased airway resistance during general anesthesia

A

 Depression of the cough reflex
 Impairment of mucociliary function
 Reduction of the palatopharyngeal muscle tone
 Depression of diaphragmatic function
 Increased fluid in the airway wall
 Airway stimulation by endotracheal intubation
 Parasympathetic nervous system activation
 Release of neurotransmitters of pain (sub p & neurokinin) may play a role

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25
Q

Identify preop risk factors for periop respiratory complications during general anesthesia for a patient with asthma

A

Eosinophilia parallel the degree of airway inflammation

Reduction in FEV1 or forced vital capacity (FVC) to <70% of predicted

FEV1:FVC ratio < 65% of predicted

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26
Q

life threatening bronchospasm that persists despite treatment

A

Status asthmaticus

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27
Q

Describe the treatment of status asthmaticus

A

o Emergency tx = B2 agonists
o Early tx: IV corticosteroids (Hydrocortisone & Methylprednisone)
o Supplemental O2 to maintain sats >90%
o Magnesium and oral leukotriene inhibitors may be used for refractory cases
o Presence of hypercarbia requires tracheal intubation and mechanical ventilation
o Ventilator settings should be adjusted to prolong the expiratory phase to allow for complete exhalation and to prevent auto-PEEP
o In rare, life-threatening circumstances where status asthmaticus is resistant to pharmacologic therapies, GA (Sevo or Iso) may be initiated to produce bronchodilation

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28
Q

What is the normal FVC

A

Male 4.8 L

Female 3.7 L

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29
Q

What is the maximum minute ventilation

A 
Males = 140- 180
Female= 80- 120
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30
Q

What are the S/S of bronchospasm intra-op?

A
  • High peak airway pressure
  • Upsloping of ETCO2 waveform
  • Wheezing
  • Desaturation
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31
Q

Other differential diagnosis of intra-op bronchospasm and wheezing include ?

A 
o	Kinking
o	Secretions
o	overinflation of ETT cuff
o	light anesthesia
o	endobronchial intubation
o	aspiration
o	pulmonary edema
o	PE
o	Pneumo
o	acute asthma attack
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32
Q

Progressive loss of alveolar tissue and progressive airflow obstruction that is NOT reversible

A

COPD

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33
Q

___________ and ___________ develop as progressive pulmonary fibrosis results in the loss of pulmonary vasculature.

A

Pulmonary hypertension and cor pulmonale

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34
Q

In a patient with pulmonary fibrosis, dyspnea is prominent and breathing is?

A

rapid and shallow

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35
Q

Inflammatory disease characterized by growth of benign inflammatory masses

A

Sarcoidosis

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36
Q

___________ are administered to suppress the manifestations of sarcoidosis and to treat hypercalcemia

A

Corticosteroids

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37
Q

___________ may be necessary to provide lymph node tissue for the diagnosis of sarcoidosis

A

Mediastinoscopy

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38
Q

____________ leads to pulmonary fibrosis and no treatment has been shown to be beneficial for this disease.

A

Eosinophilic Granuloma

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39
Q

Condition of unknown etiology that results in deposition of lipid-rich proteinaceous material in the alveoli. Present with dyspnea and arterial hypoxemia. May occur independently or in association with chemotherapy, AIDS, or inhalation of mineral dusts.

A

Alveolar Proteinosis

40
Q

________may be needed to remove the alveolar material and improve macrophage function in a patient with alveolar proteinosis.

A

Whole-lung lavage

41
Q

Double lumen tube is needed for lung lavage to separate lungs during lavage of a patient with alveolar Proteinosis to

A

optimize oxygenation during the procedure

42
Q

Hypodynamic shock

A

o Decreased CI and vasoconstriction
o Decreased CO results in increased oxygen extraction and lactic acidosis
o Organ dysfunction from inadequate blood flow
o Includes hypovolemic shock, cardiogenic shock, and obstructive shock

43
Q

Causes of hypodynamic shock includes?

A

Hypovolemic shock
Cardiogenic shock
Obstructive shock

44
Q

Hyperdynamic shock

A

o High CI and vasodilation
o Normal or decreased oxygen extraction
o Increased or normal filling pressures depending on volume status and myocardial performance
o Organ dysfunction from maldistribution of blood flow, rather than inadequate blood flow
o Causes: sepsis, severe trauma, anaphylaxis, specific drug intoxications, neurogenic shock, adrenal insufficiency, and severe pancreatitis

45
Q

Causes of hyperdynamic shock include?

A
  • Sepsis
  • severe trauma
  • anaphylaxis
  • specific drug intoxications
  • neurogenic shock
  • adrenal insufficiency
  • severe pancreatitis
46
Q

The hallmark sign of hypovolemic shock is?

A

Decreased filling pressures

47
Q

Causes of hypovolemic shock include?

A

Hemorrhage, dehydration, and massive capillary leak

48
Q

The most common cause of cardiogenic shock is?

A

MI involving 40% or more of the left ventricle

49
Q

causes of cardiogenic shock are?

A

o Acute MI involving 40% or more of left ventricle
o Cardiomyopathies
o Valvular lesion
o Increased cardiac filling pressures
o Due to LV failure or mechanical complications

50
Q

Systolic dysfunction in cardiogenic shock results in?

A

Decreased CO and SV

Systemic perfusion is decreased, which results in compensatory vasoconstriction and fluid retention…further leading to myocardial dysfunction

Hypotension decreases coronary perfusion pressure and worsens MI

51
Q

Diastolic dysfunction in cardiogenic shock results in?

A

Increase LVEDP, pulmonary congestion, and hypoxemia

52
Q

The most common cause of obstructive shock is ?

A

Pericardial tamponade
Acute PE
Tension pneumothorax

53
Q

_______ may have similar clinical manifestations to obstructive shock?

A

Cardiogenic shock

54
Q

In obstructive shock, cardiac filling pressures usually increased from?

A

Outflow obstruction
Impaired ventricular filling
Decreased ventricular compliance

55
Q

Initial fluid challenge for sepsis is?

A

30 mL/kg

56
Q

Vasopressors for treatment of sepsis

A

 Norepinephrine the first line vasopressor for septic shock (and cardiogenic)
 If MAP < 65 mm Hg, add epinephine
 If MAP still < 65 mmHg, add vasopressin 0.03-0.04 U/min
 Dobutamine can be added in the presence of myocardial dysfunction or when hypoperfusion persists

57
Q

Target Hgb in septic shock is?

A

7-9 g/dL

58
Q

______ shock is similar to septic shock

A

Traumatic shock

59
Q

Multifactorial, including a distributive immunologically mediated response to injury as well as shock from hemorrhage

A

Traumatic shock

60
Q

The most common cause of preventable hospital death is?

A

PE

61
Q

Features of PE

A

(1) transient dyspnea and tachypnea
(2) pulmonary infarction or congestive atelectasis manifested by pleuritic chest pain, cough, hemoptysis, pleural effusion, or pulmonary infiltrates
(3) right ventricular failure associated with severe dyspnea and tachypnea
(4) cardiovascular collapse with hypotension, syncope, and coma (massive PE)
(5) nonspecific symptoms including: confusion, coma, pyrexia, wheezing, recalcitrant HF, and dysrhythmias

62
Q

Cardiac reflexes of the heart

A

Brainbridge reflex
Oculocardiac reflex
Celiac plexus stimulation

63
Q

Brainbridge reflex

A

Variation in the R-R this reflex which accelerates the HR when intrathoracic pressure is increased during inspiration and slows the HR when the intrathoracic pressure decreases during expiration

64
Q

Occulocardiac reflex:

A

bradycardia due to traction on eye muscles

65
Q

Celiac plexus stimulation

A

bradycardia due to traction on the mesentery

66
Q

In antidromic form of AVNRT (wide QRS tachycardia) what drugs should be avoided and which should be given

A

DO NOT GIVE adenosine, CCB, β-blockers, or amiodarone

DO GIVE procainamide 10 mg/kg then cardiovert if drug therapy unsuccessful

67
Q

In orthodromic AVNRT (narrow QRS tachycardia) what drugs should be avoided and which should be given

A

Perform vagal maneuver, then give adenosine, verapamil, β-blockers, or amiodarone

68
Q

Treatment for mobitz II

A

 Transcutaneous/ transvenous cardiac pacing
 Permanent pacemaker
 Isoproterenol > Atropine

69
Q

Treatment for Mobitz I (wenckebach)

A

 Atropine if the patient is symptomatic

 If atropine is ineffective, pacing is indicated

70
Q

Anesthetic management for a patient with 3rd degree block

A

o Transcutaneous or tranvenous cardiac pacing
o Isoproterenol may be helpful in maintaining an acceptable HR
o Caution with administering antidysrhythmic drugs!
o Preop placement of a transvenous pacemaker or the availability of transcutaneous cardiac pacing is necessary before an anesthetic is administered for insertion of a permanent cardiac pacemaker

71
Q

The most common cause of 3rd degree AV block in adults is?

A

Lenègre disease: fibrotic degeneration of the distal conduction system associated with aging

72
Q

Causes of 3rd degree block

A

Lenègre disease: fibrotic degeneration of the distal conduction system associated with aging

Lev disease: Degenerative and calcific changes in more proximal conduction tissue adjacent to the mitral valve annulus can also interrupt cardiac conduction

73
Q

Onset of 3rd degree block may be signaled by

A

Syncope/vertigo aka “Stokes-Adams attack”

74
Q

Treatment for torsades

A

magnesium 1-2 g over 5 min

75
Q

Features of Tosades

A
  • ‘Delta wave’ - ventricular preexcitation causing a slurred upstroke to the QRS complex
  • PRI < 120ms
  • QRS > 120ms
  • Inherited disorder
  • AVNRT is the most common tachydysrhythmia seen in patients with WPW syndrome
  • Orthodromic AVNRT
  • Antidromic AVNRT
76
Q

Normal mitral valve orifice area is?

A

4-6 cm2

77
Q

Symptoms usually develop with mitral valve area is?

A

less than 1.5 cm2

78
Q

broad notched P waves suggest?

A

atrial enlargement

79
Q

Diagnostic findings of CXR in mitral stenosis

A

left atrial enlargement resembles straightening of the left heart border and elevation of the left mainstem bronchus

80
Q

opening snap that occurs early in diastole and a rumbling diastolic heart murmur

A

Mitral Stenosis

Best heard at the apex or left axilla

81
Q

Intraoperative events that have a significant impact on mitral stenosis

A
  1. Sinus tachycardia
  2. Afib with RVR
  3. Marked increase in blood volume i.e transfusion/trendelenburg
  4. Drug induced decrease in SVR
  5. Hypoxemia and hypercarbia that may exacerbate pulmonary hypertension and evoke right ventricular failure.
82
Q

In MR pt Neuraxial anesthesia is acceptable in the absence of anticoagulation

A

True

83
Q

what are the 2 factors associated with the development of aortic stenosis

A

Age related degeneration and calcification

Presence of a bicuspid aortic valve

84
Q

Most common congenital valvular abnormality that causes aortic stenosis earlier in life

A

Bicuspid aortic valve

85
Q

Aortic aneurysms grow faster in patients with _______________, and there is a higher risk of aortic dissection and rupture..

A

Bicuspid aortic valve

86
Q

Normal aortic valve area is?

A

2.5-3.5 cm2

87
Q

Transvalvular pressure gradients higher than ________ and an aortic valve area of less than_________are characteristic of severe aortic stenosis

A

50 mmHg

0.8 cm2

88
Q

Management of anesthesia in aortic stenosis

A

o Maintain NSR
o Avoid bradycardia or tachycardia
o Avoid hypotension
o Optimize intravascular fluid volume to maintain venous return and left ventricular filling

89
Q

induction in a patient with aortic stenosis

A

General anesthesia in preference to epidural or spinals because risk of hypotension

Use IV induction drug that does not decrease SVR

Etomidate and benzodiazepines

An opioid induction agent may be useful if left ventricular function is compromised

Ketamine may induce tachycardia and should be avoided

90
Q

Diagnosis of a STEMI is made by:

A

o Ischemic symptoms
o Pathological Q waves noted on EKG
o EKG changes indicative of new ischemia such as LBBB or ST changes
o New onset of myocardium or regional wall abnormality evidenced by imaging

91
Q

Sign and symptoms of a STEMI include?

A

Diaphoresis, anxiety, sinus tachycardia, hypotension, notable dysrhythmias, and rales

92
Q

Clinical management of STEMI includes?

A

o Initiation of oxygen therapy
o IV Morphine
o SL Nitroglycerine (decreases catecholamine release and O2 requirements)
o Asprin or P2Y12 inhibitors
o β-blockers when appropriate
 Be cautious in heart block or in low CO
o Thrombolytic therapy, coronary angioplasty, CABG if failed PCI, and adjunct medical therapy

93
Q

Diagnosis of UA/NSTEMI is made by pt exhibiting these 3 principle presentations:

A
  1. Angina at rest longer than 20 mins
  2. Chronic angina that is more frequent and easily provoked
  3. New onset of angina that is prolonged, disabling, and very severe
94
Q

• Unstable angina/Non-ST segment elevation result from a reduction in myocardial oxygen supply. Five pathophysiological process contribute cause which are:

A

o Nonocclusive thrombosis (from coronary plaque)
o Vasoconstriction (from cocaine use, cold, variant angina)
o Atherosclerosis
o Inflammation (ex. vasculitis)
o Increased oxygen demand due to myocardial ischemia

95
Q

Signs and Symptoms of Unstable Angina/NSTEMI include:

A

o Hemodynamic instability
o Symptoms of CHF
o EKG abnormalities (ex. ST segment elevation, ST depression, T wave inversion
o New regional wall motion abnormality on ECHO and elevated cardio biomarkers levels establish the diagnosis of an ACUTE MI

Advanced Principles III (11 decks)

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