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Principles of Anesthesia > Exam 3: endo pulm disorders/disease > Flashcards

Exam 3: endo pulm disorders/disease Flashcards

1
Q

body homeostasis is controlled by what two systems

A

nervous
endocrine

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2
Q

what does the endocrine system work through

A

mediator hormones

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3
Q

what is the master endocrine gland

A

pituitary gland

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4
Q

what are 4 body functions the pituitary gland modifies

A

homeostatic
developmental
metabolic
reproductive

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5
Q

what structure is the pituitary gland located in

A

sella turcica

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6
Q

what region of the brain is the pitutiary gland connected to

A

hypothalamus

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7
Q

how does the pituitary gland connect to the hypothalamus

A

hypophyseal stalk

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8
Q

what controls the secretion of pituitary hormones

A

hypothalamus

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9
Q

what are the lobes of the pituitary gland

A

anterior: adenohypophysis
posterior: neurohypophysis

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10
Q

what does AAA mean in pituitary gland

A

Anterior Adenohypophysis- acromegaly

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11
Q

which hormones come out of anterior lobe of pituitary gland- 6

A

growth hormone
adrenocorticotropic hormone
thyroid stimulating hormone
follicle stimulating hormone
luteinizing hormone
prolactin

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12
Q

which lobe is 80% of the pituitary gland by weight

A

anterior lobe-adenohypophysis

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13
Q

after removal of tumor causing hypopituitarism, you worry about your patient developing polyuria. What problem are you worried about and what medication should be available to fix it

A

diabetes insipidus
vasopressin

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14
Q

what is the approach to the surgery for anterior pituitary tumor

A

transphenoidal- through the nose to reach gland

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15
Q

what two meds may the patient with hypopituitarism require peri-op during removal of tumor of anterior pituitary gland

A

steroids
thyroid hormone replacement

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16
Q

t or f- you can nasally intubate patient who will be have a transphenoidal surgical approach

A

false

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17
Q

what position is patient in for transphenoidal surgical approach

A

sitting

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18
Q

what two monitors are key during surgery and why for removal of tumor on anterior pituitary using transphenoidal surgical approach in sitting position

A

precordial doppler
etco2
-detect venous air embolism

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19
Q

what are other important monitors during transphenoidal appraoch for removal of anterior pituitary tumor

A

BP
HR

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20
Q

what monitor gives the earliest evidence of air embolism during sitting position

A

precordial doppler
-mill wheel bubble in heart

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21
Q

what gas should not be used during anterior pituitary tumor removal via transphenoidal surgical approach- and why

A

nitrous oxide- expands spaces, draws in air into cranial spaces= increased ICP

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22
Q

what do you do when surgeon asks for a valsalva maneuver

A

put vent on manual mode
increase apl pressure to 70
pulse o2 flush to fill bag
squeeze bag- pip will jump up

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23
Q

why would neurosurgeon ask for a valsalva maneuver

A

surgeon is looking for increased pressure in ICP and leaks in dura. If there are no leaks, he can finish the surgery

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24
Q

why should patient be paralyzed during valsalva maneuver when the high pressure is provided

A

avoid coughing

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25
Q

the neurosurgeon is about ready to finish his case and asks for a vasalva maneuver. should your patient be paralyzed at this point

A

paralyzed to avoid coughing

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26
Q

t or f- patient may cough during valsalva maneuver even when deeply sedated

A

true

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27
Q

what is a drip that could help prevent cough during valsalva maneuver

A

lidocaine

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28
Q

what is a precaution to take with patient that has head pins or instruments in a sensitive location who will be getting valsalva

A

paralyze to avoid damage from cough

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29
Q

what volatile gas is neurosafe

A

isoflurane

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30
Q

what is the preference for patient condition during valsalva maneuver during transphenoidal surgical approach for anterior pituitary tumor removal

A
  1. paralyzed
  2. deep sedation
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31
Q

how many twitches should be present before doing valsalva during transphenoidal surgical approach for anterior pituitary tumor removal

A

1 or less

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32
Q

during surgery for anterior pituitary tumor removal, what is a consideration with emergence

A

quick emergence to allow for neuro check

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33
Q

during surgery for anterior pituitary tumor removal, how should emergence be planned for neuro check

A

-narcotic controlled: not too much so they can wake up
-bp controlled: to make up for htn/tachycardia from pain

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34
Q

t or f-during surgery for anterior pituitary tumor removal, patient should be heavily narcotized at the end of surgery for pain

A

f-light or no narcotics so patient can perform neuro check on emergence

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35
Q

what is key preop education for patient undergoing surgery for anterior pituitary tumor removal

A

will wake up with nasal packing
breath through mouth when waking up from surgery/getting extubated

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36
Q

what equipment should be avoided while undergoing surgery for anterior pituitary tumor removal w/ transphenoidal approach

A

nasal airways- npa or ntt
nasal temp probes
ng tubes

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37
Q

what happens to etco2 during co2 air embolism

A

drops out

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38
Q

t or f- panhypopituitarism is more common than single decrease in 1 anterior pituitary hormone

A

true

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39
Q

why does anterior pituitary tumor more commonly cause- hypersecretion or hyposecretion

A

hypersecretion

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40
Q

anterior pituitary: growth hormone is regulated by ______________________ feedback, where hypothalamus or pituitary hormone synthesis/discharge is stopped

A

negative

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41
Q

what are the airway considerations for acromegaly

A

Difficult mask
Difficult DL
Smaller ETT
nothing in nose- large turbinates

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42
Q

why would a DL be more difficult for acromegaly patient

A

tissue overgrowth
macroglossia

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43
Q

why is a smaller ETT needed for acromegaly patient

A

vocal cord enlargement
subglottic narrowing

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44
Q

what intubation method should be used for acromegaly patient

A

rsi with glidescope
-LMA 5 ready as backup

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45
Q

how should acromegaly patient be extubated

A

awake

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46
Q

what lab should be test pre op for acromegaly patient

A

glucose

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47
Q

how should patient that is difficult to mask and has sleep apnea be extubated

A

awake

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48
Q

what hormones does the posterior pituitary secrete

A

adh/vasopressin
oxytocin

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49
Q

a decrease in plasma volume or blood pressure by what % stimulates adh release

A

5-10%

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50
Q

what are the two hallmark signs of diabetes inspidius

A

polyuria
polydipsia

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51
Q

with diabetes insipidus, what med should be given for long term treatment

A

desmopressin- ddavp
(short term= vasopressin)

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52
Q

is preop vasopressin needed for patient with partial diabetes insipidus and why

A

no- surgery increases adh release

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53
Q

what meds may be used intraoperatively to treat patient with complete di

A

desmopressin
vasopressin

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54
Q

when inducing patient with DI, what will likely happen when giving sedative meds and why

A

hypotension- they will be dry

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55
Q

which disease causes high adh levels causing increased water reabsorption in renal tubules even with hypoosmolarity

A

SIADH

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56
Q

which portion of pituitary is involved with siadh

A

posterior

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57
Q

is urine output low or high in siadh

A

low

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58
Q

_________ can result in water intoxication and hyponatremia leading to brain edema

A

SIADH

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59
Q

Is sodium high or low in siadh

A

low- diluted

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60
Q

when should fluid be restricted vs given for siadh

A

restrict: asymptomatic w/ hyponatremia
hypertonic saline: symptomatic w/ neuro s/s

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61
Q

your diabetic patient has a sudden onset of hypotension. what may be happening

A

silent MI

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62
Q

what is the goal hbg a1c for dm

A

<6.5

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63
Q

why is hgb a1c for dm so important

A

<6.5 prevents long term complications of microvascular diseases

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64
Q

what should be evaluated preoperatively for dm patient

A

cardiovascular resistance
volume status
ecg

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65
Q

t or f- make sure to positive pressure mask DM patient before rsi

A

f- no positive pressure masking during RSI

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66
Q

what med should be given preop to dm patients to prevent aspiration

A

h2 blockers, antacids, gastroprokinetic agents

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67
Q

which patient may have an impaired respiratory response to hypoxia

A

DM

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68
Q

how do you prevent aspiration in dm patient during preop, intubation, and intraop

A

preop meds: pepcid, bicitra po
intubate: rsi- roc, succ, intubate
intraop: reglan

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69
Q

what medication helps to speed up gut in dm patient

A

reglan- helps to speed the gut up and get out of gastraparesis

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70
Q

what is very important to document preoperatively for dm patient

A

-peripheral neuropathy: sensation, numbness, tingling, parasthesia
-retinopathy

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71
Q

what is a rare occurrence in dm where heart rate does not respond to demand- may not tolerate exercise

A

autonomic neuropathy

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72
Q

what are s/s of dm patient with gastraparesis

A

nausea
vomiting
get full quickly-early satiety
bloating
epigastric pain

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73
Q

your patient with dm has stiff joint sydnrome, how do you intubate

A

videoscope w/rsi

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74
Q

what lab tests should you always check pre op for dm patient- 3

A

glucose- 80-180 mg/dL= ideal
kidney function- ua, bun, creatinine
electrolytes

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75
Q

a patient with chronic hyperglycemia will likely undergo ________________ _________________ leaving them _______

A

osmotic diuresis
dry

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76
Q

when should you give insulin pre op for patient with dm- and what kind of insulin

A

> 180 mg/DL
regular insulin

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77
Q

how do you assess stiff joint syndrome in dm patient

A

prayers sign

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78
Q

which dm med should be stopped 24-48 hours before surgery

A

metformin

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79
Q

what are the three times you should test blood glucose for dm patient

A

preop
intraop
post op

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80
Q

how should dm patient be intubated

A

videoscope with rsi-
likely have stiff neck

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81
Q

why would ns be used over LR for dm patient

A

lactate converts to glucose= hyperglycemia

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82
Q

what is the formula for calculating goal blood sugar

A

starting blood sugar- (0.1 unit/kg x 30)

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83
Q

what would your bolus dose of insulin be for a patient that weighs 187 pounds and has a starting blood glucose of 380 mg/dL and your goal blood sugar is 125 mg/dL

A

85kg x 0.1= 8.5 units of insulin IV

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84
Q

your patient weighs 176 pounds. Their goal blood sugar is 170 mg/dL and their current bs is 410 mg/DL. How much insulin should be given for a bolus to reach the goal blood sugar

A

176/2.2= 80kg
80kg x 0.1 units of insulin=
8 UNITS OF REGULAR INSULIN given IV

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85
Q

after giving 8 units of regular insulin as a bolus, how much would you expect blood glucose to decrease

A

8 units x 30mg/dL= 240 mg/dL

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86
Q

how much will blood glucose decrease if given 1 unit of insulin

A

30 mg/dL

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87
Q

how do you calculate the regular insulin bolus

A

weight (kg) x 0.1 unit of regular insulin

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88
Q

for the insulin calculations we do for dm, what is the route of regular insulin

A

IV

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89
Q

what is the risk for giving metformin on the day of surgery

A

hypotension
renal hypoperfusion

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90
Q

what lab tests may be elevated in patient taking metformin and therefore should be check preop

A

kidney function

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91
Q

when should surgery be scheduled for dm patient

A

morning, as early as possible

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92
Q

how often should blood glucose be checked during intraop

A

q1 hour

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93
Q

what is the goal of blood glucose control during anesthesia

A

mildly hyperglycemic

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94
Q

when are post op infection rates higher in patient with dm

A

prolonged hyperglycemia

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95
Q

what is normal and high normal blood glucose for surgery

A

normal < 100
high normal 101-125

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96
Q

when should type 2 diabetics stop their oral hypoglycemics

A

night before surgery- except METFORMIN- STOP 1-2 DAYS BEFORE

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97
Q

what is the biggest risk/cause of hypoglycemia for diabetic patient having surgery

A

insulin during npo time

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98
Q

how can you treat hypoglycemia for conscious and unconscious patient

A

1/2 amp of d50= conscious
unconscious= full amp
d50
-check bg q20 mins thereafter
-continuous d5 infusion

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99
Q

at what blood glucose does seizures and loss of conciousness appear

A

<50 mg/dL

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100
Q

what are some s/s of hypoglycemia

A

confusion, dizzy, ha, weak, tachycardia, diaphoresis, pupillary dilation, vasoconstriction

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101
Q

t or f- general anesthesia does not prevent the neurologic signs of hypoglycemia

A

f-it does, that is why you have to check blood glucose frequently

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102
Q

what may happen if hypoglycemia goes untreated

A

irreversible brain damage

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103
Q

ketoacidosis is more common in which diabetes

A

type 1

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104
Q

hyperglycemic hyperosmolarity is more common in which diabetes

A

type 2

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105
Q

which has higher glucose and osmolarity- hhms or dka

A

HHS

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106
Q

what is the anesthetic plan for conn’s syndrome aka hyperaldosteronism

A

correct fluid/electrolytes preop
htn= spironolactone
muscle relaxer may be affected by hypokalemia
ekg monitor for hypokalemia
hyperventilation= worsens hypokalemia

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107
Q

in patient with cushing’s, how should you dose muscle relaxants

A

conservative

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108
Q

what is the anesthetic plan for cushings (high glucocorticoid)

A

correct fluid/electrolytes preop
thin skin= prone to injury
increased risk of infection
thromboemboli are more common

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109
Q

pheochromocytoma orginates in what gland

A

adrenal gland

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110
Q

what does pheochromocytoma secrete

A

norepi alone or w/epi

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111
Q

what symptoms mentioned in preop would alert you to pheochromocytoma- 4

A

ha
diaphoresis
htn (paroxysmal)
palpitations

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112
Q

what are the non selective alpha antagonists

A

Phenoxybenzamine
Phentolamine

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113
Q

what are the selective alpha antagonists

A

prazosin

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114
Q

which should be given first for pheochromocytoma- labetalol or prazosin

A

prazosin

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115
Q

what lines/monitors are needed for pheochromocytoma

A

a line
2 large bore iv’s
urinary cath
cvc/pac

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116
Q

when is htn most likely to occur in anesthesia for pheochromocytoma patient- 4

A

induction
intubation
surgical incision
manipulation
-pre treat!!! w/ prazosin

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117
Q

when is hotn most likely to occur in anesthesia for pheochromocytoma patient

A

removal of the tumor

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118
Q

what drugs should avoid with pheochromocytoma

A

droperidol/metoclopramide
histamine releasing drugs
antimuscarinics
desflurane
naloxone
glucagon
phenergan/compazine

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119
Q

what are some histamine releasing drugs to avoid with pheochromocytoma

A

atracurium
mivacurium
succ
meperidine
MORPHINE
codeine

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120
Q

what are some anti-muscarinics to avoid with pheochromocytoma

A

atropine, glyco, pancuronium

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121
Q

what nmb can be used for pheochromocytoma that she mentioned

A

vec

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122
Q

what do you need to be prepared for when pheochromocytoma tumor is removed

A

hypotension
hypoglycemia

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123
Q

once pheochromocytoma tumor is removed, what bp meds can be used

A

phenylephrine
epi

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124
Q

what should you ask patient with goiter before surgery

A

can you lie flat
how do you sleep at night
do you have trouble breathing while supine

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125
Q

what are tsh, t3, t4 in hyperthyroidism

A

tsh: low
t3/t4: high

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126
Q

what are tsh, t3, t4 in hypothyroidism

A

tsh: high
t3/t4: low

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127
Q

for patient with hyperthyroidism, what meds should be avoided for sns stimulation- 6

A

epi
ephedrine
atropine
ketamine
norepi
dopamine

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128
Q

for patient with hyperthyroidism, what med should be given for hypotension

A

phenylephrine

129
Q

what nerves are the thyroid gland close to-2

A

-recurrent laryngeal nerve
-external motor branch of the superior laryngeal nerve

130
Q

what is the external motor branch of the superior laryngeal nerve responsible for

A

cricothyroid muscle tension
adducts vocal cords

131
Q

what happens if the external motor branch of the superior laryngeal nerve is damaged

A

voice change

132
Q

what happens if recurrent laryngeal nerve is damaged unilaterally vs bilaterally

A

unilateral: partial airway obstruction, abduction paralysis- one cord stays closed- HOARSENESS

bilateral: stridor, closed cords, resp distress

133
Q

t or f- patient needs to be paralyzed for thyroid surgery

A

f- paralyze for intubation, but not thereafter, use short acting paralytic

134
Q

what kind of ett is used for thyroid surgery

A

nims tube
-electrodes in it for assessment of nerves throughout the surgery

135
Q

how should patient be intubated for thyroid surgery

A

nims tube- videoscope

136
Q

which side of vocal cord should red side of nims ett be on

A

right- make sure it is at certain level of vocal cord, careful placement- wait to tape until after monitor tech has verified electrodes

137
Q

what are good meds for thyroid surgery removal after paralytic has worn off, to blunt airway response

A

LTA
iv lidocaine
narcotics
deep volatiles
-can’t redose paralytic

138
Q

during thyroid surgery, what should you make sure of before extubating

A

no cord damage

139
Q

after extubating, what should you assess for patient w/thyroid surgery

A

-immediately put on mask and look for humidity
-look at tidal volumes
-spontaneous breathing rate

140
Q

if you think there is damage to vocal cords post thyroid surgery, what is your intervention

A

immediately intubate

141
Q

what is important to assess preop for thyroid surgery

A

airway assessment
-tracheal deviation
-enlarged thyroid
-hoarse voice: new onset?
-hard to breath when flat?

142
Q

what is the safest intubation approach for thyroid gland surgery with fear of airway compromise during induction

A

awake fiberoptic intubation with topical anesthesia- nebulized lidocaine, transtrahceal block
-put them to sleep after securing airway w/propofol

143
Q

t or f- hyperthyroid patients should only have emergent surgeries completed

A

true

144
Q

what sedative should be avoided with thyrotoxicosis/grave’s disease

A

ketamine

145
Q

what should be given to thyrotoxicosis/grave’s disease preop

A

versed- anxiolysis

146
Q

when intubating thyrotoxicosis/grave’s disease patient, what level of anesthesia is needed

A

deep level

147
Q

what med should be given for intraop hypotension for thyrotoxicosis/grave’s disease patient

A

phenylephrine

148
Q

which nurse is most important for preventing/treating thyroid storm

A

pacu
thyroid storm is most often seen in PACU

149
Q

when is thyroid storm most often seen- pre, intra, or post op

A

post op 6-18 hours

150
Q

how should hypothyroid patient be intubated

A

rsi with videoscope

151
Q

what bp meds should be used for hypothyroid patient

A

indirect acting vasopressors
-ephedrine
-epi
-dopamine
**avoid phenylephrine

152
Q

should direct or indirect acting bp meds be used for hypothyroidism

A

indirect

153
Q

should direct or indirect acting bp meds be used for hyperthyroidism

A

direct

154
Q

what two things is a post op parathyroidectomy at risk for

A

hypocalcemia
laryngospasm

155
Q

what is immediate action with bilateral recurrent laryngeal nerve injury after parathyroid surgery

A

intubation

156
Q

what line is important to have during hyperparathyroid surgery

A

art line- to draw labs

157
Q

t or f- nims tube is used for hyperparathyroid surgery

A

false

158
Q

t or f- use short acting nmb during parathyroid removal for hyperthyroidism

A

t- watch nerves innervating larynx/airway

159
Q

what lab test is best measure of renal function

A

GFR

160
Q

what lab test should be looked at before toradol admin

A

creatinine
avoid if >1

161
Q

what is the most common cause of aki

A

ischemia reperfusion injury

162
Q

how can aki be prevented

A

avoid low volume/low bp/low co to perfused kidneys

163
Q

why can ckd patient have low blood levels and not get blood

A

chronic compensated anemia

164
Q

what electrolyte should be checked with renal disease/esrd

A

potassium

165
Q

what should be expected after intubation with renal disease

A

they are dry- so hypotension on intubation

166
Q

what are anesthesia considerations for ckd/renal disease patient

A

fluids- micro ns
art line
labs-potassium
last day of dialysis

167
Q

if patient had dialysis the day of surgery, how can you prevent hypotension during induction

A

neo drip
albumin
trickle in fluids

168
Q

what meds should be avoided w/carcinoid syndrome to avoid carcinoid crisis

A

succ, mivacurium, atracurium
epi, isoproterenol
thiopental
demerol

169
Q

what is the main treatment for carcinoid tumor/syndrome

A

octreotide
24-48 hrs before surgery
and before manipulation of tumor

170
Q

what things are necessary to manage carcinoid patient

A

-art line
-octreotide pre op and before manipulation of tumor
-general anesthesia= delayed awakening from increased serotonin
-epidural is safe
-zofran

171
Q

how can GETA be affected by carcinoid syndrome

A

carcinoid syndrome= increased serotonin= delayed awakening

172
Q

what are the four volume loops she mentioned

A

obstructive
normal
restrictive
fixed

173
Q

what kind of flow volume loop is tracheal stenosis

A

fixed obstruction

174
Q

what is a flow volume loop shifted to the right

A

restrictive

175
Q

what is a flow volume loop shifted to the left

A

obstructive

176
Q

what are some causes of obstructive flow volume loop- 4

A

copd
asthma
emphysema
bronchitis

177
Q

how do you help patient with obstructive flow volume loop

A

change i:e ratio from 1:1 to 1:1.5 or 1:2

178
Q

what are some causes of restrictive flow volume loop- 4

A

interstitial lung disease
chest wall deformity
scoliosis
marked obesity

179
Q

which flow volume loop is able to deflate but has difficulty inflating characterized by shallow breaths

A

restrictive

180
Q

which flow volume loop has a difficult time exhaling

A

obstructive

181
Q

how do intubate patient with tracheal stenosis

A

-awake intubation
-videoscope
-armored small tube (protects from bovi)
-2nd provider present*
-fiber optic available
-difficult airway cart available
-have ent in OR when inducing

182
Q

when is systolic pressure considered high in pulmonary artery

A

> 30 mmhg

183
Q

when is mean pulmonary artery pressure considered high

A

> 25 mmhg

184
Q

pulmonary htn causes which kind of heart failure

A

right sided

185
Q

what are some causes of pulm htn

A

smoking
drugs-cocaine
alcohol
copd
lupus
left sided heart failure

186
Q

what are s/s of right sided heart failure

A

edema, JVD, enlarged liver, abd ascites

187
Q

what are some s/s of pulm htn

A

exercise intolerance
sob
coughing
weakness/fatigue
abdominal distention
syncope
angina
parasternal lift
murmurs
jvd/peripheral edema/hepatomegaly/ascites

188
Q

pulmonary htn can lead to _________________ regurgitation

A

tricuspid

189
Q

t or f- pulmonary htn can lead to scarring in vessels

A

true

190
Q

what murmurs are associated with pulm htn

A

pulmonic insufficiency
tricuspid regurg

191
Q

what type of irregular heart sound can be heard during pulm htn

A

s2 s3 gallop

192
Q

what are some s/s of pulm htn that has developed into right heart failure

A

jvd
peripheral edema
hepatomegaly
ascites

193
Q

how can you assess functional status of pulm htn patient

A

6 min walk test

194
Q

how do you assess parasternal lift

A

heel of hand to the left of sternum, fingers lifted slightly off of chest
normal: none or inward
pulm htn: heal of hand is lifted off chest w/systole

195
Q

how will pulm htn affect ecg- 5

A

right axis deviation
right ventricular strain
right ventricular hypertrophy
complete/incomplete rbbb
P pulmonale

196
Q

what lead should be looked at for p wave abnormalities

A

2

197
Q

how will p waves be affected during pulmonary htn

A

peaked, larger

198
Q

what leads should be looked at for rbbb

A

v1- upright, odd complex

199
Q

what leads should be looked at for Lbbb

A

v1- wide complex, not upright

200
Q

what happens if you see a new bundle branch block when getting back to the OR

A

if non-emergent, cancel case and get cardiac eval

201
Q

which is worse- right or left bbb

A

left

202
Q

where is nitric oxide distributed in lung

A

alveoli causing vasodilation
-improves v/q matching and oxygenation

203
Q

what case would nitric oxide be used in OR

A

cabg with severe pulmonary htn

204
Q

t or f- nitric oxide has many systemic effects, which limits its use

A

f- inactive in pulmonary circulation so systemic effects are minimized

205
Q

what induction meds should be avoided w/ pulmonary htn patient

A

ketamine
etomidate
-suppress pulmonary vasorelaxation mechanisms

206
Q

can an epidural be used for pulm htn patient

A

yes- but watch intravascular volume and SVR

207
Q

you are using nitric oxide for your pulmonary htn patient, what are they at risk for

A

inhibit platelet function
at risk for bleeding

208
Q

what should you have available for pulmonary htn patient receiving nitric oxide

A

platelets

209
Q

what are three drugs that increase pvr

A

nitrous oxide
ketamine
desflurane

210
Q

what are three things that increase intrathoracic pressure, and thus pvr

A

peep
atelectasis
mechanical ventilation

211
Q

what are 6 causes of increased pvr

A

hypoxemia
hypercarbia
acidosis
sns stimulation
pain
hypothermia

212
Q

what are 3 causes of decreased pvr

A

increased pao2
hypocarbia
alkalosis

213
Q

what are 4 causes of decreased intrathoracic pressure, thus causing decreased pvr

A

preventing coughing/straining
normal lung volumes
spont ventilation
high frequency jet vent

214
Q

what are 6 drugs that decrease pvr

A

inhaled nitric oxide
nitroglycerin
pde5- sildenafil
prostaglandins- PGE1, PGI2
ccb
ace inhibitors

215
Q

what is the scooped out portion on the obstructive flow volume loop

A

premature airway closure during exhalation

216
Q

t or f- flow can be increased on exhalation in obstructive resp diseases by increasing exhalation effort

A

false

217
Q

which flow volume loop is a mini normal flow volume loop

A

restrictive

218
Q

which flow volume loop has decreased residual volume

A

restrictive

219
Q

what is normal residual volume on flow volume loop

A

2

220
Q

which flow volume loop has increased residual volume 4L

A

obstructive

221
Q

where is total lung capacity on flow volume loop

A

very end of inspiration/beginning of exhalation where flow is 0L

222
Q

on flow volume loop, what is the space from residual volume to total lung capacity called- aka the width of the flow volume loop

A

vital capacity

223
Q

how is flow measured in flow volume loop

A

L/sec

224
Q

what is the max volume the lungs can hold

A

total lung capacity

225
Q

t or f- asthma patients can have air trapping

A

true

226
Q

what is the major clinical sign of bronchospasm and asthma

A

wheezing

227
Q

t or f- asthma airways have a hypersensitive response and is considered a reactive airway

A

true

228
Q

how can you manage reactive airway (asthma) during intubation

A

-LTA
-RSI- get tube in quicker
-succ
-deep anesthesia

229
Q

how should extubation take place for asthma vs sleep apnea

A

asthma: deep
osa: awake

230
Q

what should you make sure to assess pre op for asthma/reactive airway patient

A

airway- listen for wheezing

231
Q

what meds should be given preop for asthma/reactive airway

A

albuterol/zopinex- wheezing
versed-anxiety
robinul-secretions

232
Q

when did she mention to give albuterol for asthmatic patients- 2 different times

A

pre op
intraop: right before intubation

233
Q

t or f- LTA’s work well with videoscopes

A

f- difficult placement

234
Q

what should NOT be happening before induction of asthma patient if possible

A

wheezing

235
Q

what patient would you want to send to pre anesthesia eval 1 week before surgery

A

asthmatic patient with hx of emergent events, unstabilized asthma

236
Q

which beta blockers should be given for asthmatic patient-3

A

-selective beta 1 blocker
atenolol
metoprolol
esmolol

237
Q

what are the non selective beta blockers

A

carvedilol
labetalol
propranolol
timolol

238
Q

what is a good beta blocker to control hemodynamic changes during induction

A

esmolol

239
Q

what are some good induction meds for asthma patient

A

propofol
ketamine
volatiles except desflurane
robinul
benzos
etomidate
fentanyl
nimbex/roc

240
Q

which meds are not good for asthma patient

A

desflurane
nitrous oxide
methohexital
demerol/morphine?
succ-histamine release
morphine-histamine release
nsaids-toradol, ibuprofen
asa

241
Q

what is the most effective bronchodilator of the volatiles

A

sevoflurane

242
Q

what should you do if you have des running and patient bronchospasms

A

turn off des
turn on sevo
get patient deep

243
Q

t or f- give succ for smooth muscle relaxation during bronchospasm

A

f- terbutaline

244
Q

what is the dose of terbutaline for bronchospasm

A

subq 0.25mg= 0.25 ml q 15-30 min x 2

245
Q

what is the most common med to cause allergic reactions intraop

A

nmb- abx

246
Q

what meds can you give in preop to prevent anaphylaxis/allergic reaction

A

pepcid
benadryl
decadron

247
Q

what method of securing airway is best if it is possible to use-for-asthma-pt.

A

LMA

248
Q

how do you manage vent for asthma patient

A

no peep
higher i:e ratio
no suctioning

249
Q

how should you remove LMA in asthma patient

A

deep

250
Q

what can happen if you don’t keep asthmatic patient deeply sedated enough

A

bronchospasm
laryngospasm

251
Q

how do you decrease/treat auto peep

A

d/c from circuit
increase flows
increase e on i:e ratio
decrease tidal volume
no peep

252
Q

what happens to pip with auto peep

A

increased

253
Q

how does flow volume loop look when auto peep is present

A

exhalation side is flat

254
Q

t or f- auto peep effects venous return

A

t- can cause hypotension by poor venous return

255
Q

t or f- increase peep with hypotensive patient to help with venous return

A

f- turn off peep

256
Q

what are the signs of bronchospasm while under anesthesia

A

-wheezing
-up sloping etco2 -narrow/peaked
-decreased tidal volume
-decreased/absent etco2
-increased pip
-hypoxemia

257
Q

in a patient with pulmonary disease, should you give suggamadex vs neostigmine/robinul

A

neostigmine/robinul
-less risk of bronchospasm

258
Q

t or f- if bronchospasm is going on, reverse nmb to wake up patient

A

f- do not reverse at this time

259
Q

what is best way to extubate asthmatic patient-deep or awake

A

deep
avoid coughing, irritant, spasms
-do not extubate deep if they are at risk for aspiration

260
Q

who has the highest risk of bronchospasm

A

uncontrolled asthma

261
Q

what are the best indicators of severity of asthma before surgery

A

pef
fev1
>80% projected personal best=normal

262
Q

what is samter’s triad

A

-Asthma
-asa/nsaid sensitivity
-sinusitis w/nasal polyps

263
Q

what factors should be looked at before giving toradol

A

bleeding
kidney function
asthma

264
Q

how long should patients quit smoking before surgery to decrease post op complications the most

A

> 8 weeks

265
Q

what is the single principle factor that predisposes a patient to copd

A

cigarette smoking

266
Q

what is the single best action the patient can take to treat copd

A

stop smoking

267
Q

how should ventilator be managed for copd patient

A

low tidal volume
increase e time
slow inspiratory flow rate to optimize v/q matching
low or no peep

268
Q

you have a patient with sarcoidosis. which flow volume loop will they show

A

restrictive

269
Q

your patient aspirates and develops aspiration pneumonitis. what flow volume loop will they show

A

restrictive

270
Q

how do you treat aspiration pneumonitis

A

o2 and peep

271
Q

which pulmonary edema is caused by laryngospasm, obesity, or osa in spontaneously breathing patients

A

negative pressure pulmonary edema

272
Q

what are s/s of negative pressure pulmonary edema

A

tachypnea
cough
failure to maintain o2 above 95%
htn

273
Q

how do you maintain airway in negative pressure pulmonary edema

A

self limited
clear obstruction

274
Q

what is an example of chronic intrinsic restrictive lung disease

A

sarcoidosis

275
Q

what is an example of acute restrictive lung disease

A

pulmonary edema

276
Q

what is the most common sign of pe

A

acute dyspnea, sudden onset

277
Q

what are the manifestations of PE during anesthesia

A

unexplained hypoxemia
hypotension
tachycardia
bronchospasm
ekg= pulm htn/rv dysfunction
decreased etco2=increase in dead space ventilation
positive d dimer***
elevated troponin

278
Q

what is the gold standard for diagnosing PE

A

pulmonary arteriography

279
Q

how would ecg appear with PE

A

increased p wave in lead 2
rbbb in V1
decreased etco2

280
Q

how can pe be treated- 2

A

anticoags: heparin, lovenox, coumadin- 6 months
ivc filter

281
Q

what is the greatest risk factor for osa

A

obesity

282
Q

osa can lead to __________________ heart failure

A

chronic

283
Q

what are some symptoms of osa

A

frequent arousal while asleep
always tired
irritable
cannot think clearly
impaired sensory/motor skills

284
Q

what assessment should be completed preop for potential osa patient

A

stopbang assessment

285
Q

what are some questions in the stopbang assessment

A

s- snoring
t-tired
o-obersvation
p-blood pressure
b-bmi >35
a- age >50
n- neck >40cm, or 17/16 inch
g- gender= male

286
Q

the stop bang questionnair has an overall sensitivity of ____% in predicting moderate to severe OSA

A

93%

287
Q

how many questions does patient need to answer yes on stopbang to be at high risk for osa

A

3

288
Q

how should patient with osa be extubated

A

fully awake
semi upright position
full nmb reversal

289
Q

where is the safest location for osa patient to have surgery

A

hospital

290
Q

what can 100% o2 cause if given for prolonged periods of time via ventilator

A

absorption atelectasis

291
Q

what are the normal tidal volume, rr, and peep for male vs female

A

f: 500 tv, rr: 12, peep 5
m: 600 tv, rr: 12, peep 5

292
Q

what is normal range for sevo to hit 1 mac

A

1.7-2%

293
Q

what is normal range for iso to hit 1 mac

A

0.6-1%

294
Q

what should fgf be for sevo

A

1L o2
1L medical air
= 2 Liters

295
Q

what should fgf be for iso

A

0.5 L o2
0.5L medical air
= 1 Liter

296
Q

what is A

A

Liters

297
Q

what is B

A

L/Sec

298
Q

what is C

A

expiration

299
Q

what is D

A

inspiration

300
Q

what is E

A

obstructive

301
Q

what is F

A

normal

302
Q

what is G

A

restrictive

303
Q

what is H

A

fixed

304
Q

what is A (x axis)

A

volume

305
Q

what is B

A

vital capacity

306
Q

what is C (y axis)

A

flow

307
Q

what is D

A

peak expiratory flow rate

308
Q

what is E

A

normal

309
Q

what is G

A

obstruction

310
Q

what is A

A

Vt

311
Q

what is B

A

expiration

312
Q

what is C

A

L/sec

313
Q

what is D

A

total lung capacity

314
Q

what is E

A

residual volume

315
Q

what is F

A

functional residual capacity

316
Q

what is G

A

vital capacity

317
Q

What disease is shown and how would you intubate

A

acromegaly
-rsi with glidescope

318
Q

what disease is shown here and what med should be given preop to treat it

A

carcinoid syndrome
-octreotide 24-48 hours before surgery, plus before manipulation of tumor intraop

Principles of Anesthesia (4 decks)

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