Extra Questions Flashcards
When the patient goes from the supine position to the Head up position, what happens to the lung volumes?
Peak inspiratory pressure DECREASES
TLV INCREASES
FRC INCREASES
In the preoperative setting, what is the best way to assess for cardiovascular function?
Exercise tolerance
What would the PT/PTT look like for DIC?
INCREASED PT and PTT
INCREASED D dimer
Low PLT
What would the PT/PTT look like for Hemophilia A and B?
INCREASED PTT
No change in PT/INR
What would the PT/PTT look like for NSAIDS?
No change in PT/PTT
INCREASED Bleeding time
What would the PT/PTT look like for vWF?
INCREASED PTT
No change in PT
Hypotension, JVD, and Muffled heart sounds are all signs for what disease?
Becks Triad in Cardiac tamponade
Hypotension - decreased stroke volume
JVD - Impaired venous return to the R heart
Muffled heart sounds - Fluid accumulation attenuates sound waves
What is the max dose for EMLA CREAM for a 7-12 yrs and > 20kg?
Max Dose is 20g
Max area of application
200 cm2
What is the max dose for EMLA CREAM for a 1-6 yrs and > 10kg?
Max dose is 10 g
Max area of application
100cm2
What position is most likely to develop lower extremity compartment syndrome?
Lithotomy
What are some secondary variables for the Onset for LA?
Dose and concentration
What are some secondary variables for the Potency of LA?
Intrinsic vasodilating effect
What is the primary variable for the potency of LA?
Lipid solubility
What is the primary variable for the onset of LA?
pKa
Why is the spinal does in parturient reduced by 30%?
Decrease in CSF volume
Which two factors MOST influence dermatomal spread of epidural block?
Site of administration
Volume of LA administered
Vitreous bubble of sulfur or sulfur hexafluoride, how long after administration do you not give N20?
15 min before and 10 days after
Where is the most important site for pain modulation?
The most important site of modulation is the substantia gelatinosa in the DORSAL HORN (Rexed lamina II and III)
Where does the descending inhibitory pain pathway begin??
The descending inhibitory pain pathway begins int he Periadueductal gray and rostroventral medulla.
It projects to the substantia gelatinosa.
Pain is inhibited when the spinal neurons release (what two inhibitory neurotransmitters)?
GABA and Gylcine
The descending pain pathway release NE, 5-HT, and endorphins.
What is modulation?
It is when pain signal is modified (inhibited or augmented) as it advances towards the cerebral cortex.
Pain is augmented by (what two things)?
Central sensitization
and
Wind-up
Perception describes the processing of afferent pain signals in the (what areas of the brain)?
In the cerebral cortex and limbic system
This is “how we feel about pain”
What are the components of Cryoprecipitate?
Fibrinogen
Factor 8
Factor 13
vWF
Inflammation also contributes to allodynia, what is that?
Allodynia - Reduced threshold to pain stimulus
Inflammation also contributes to Hyperalgesia, what is that?
Hyperalgesia - Increased response to pain stimulus
What is transduction of pain?
Injured tissues release a variety of chemicals that activate PERIPHERAL NERVES and/or cause immune cells to release proinflammatory compounds.
The peripheral nerves transduce this CHEMICAL SOUP INTO AN ACTION POTENTIAL, so that the extent of tissue injury can ultimately be interpreted by the brain.
A-delta fibers transmit what kind of pain?
“Fast pain” that is sharp and well localized
C-fibers transmit what kind of pain?
“slow pain” that is dull and poorly localized
What is “transmission” of pain?
The pain signal is relayed through the three-neuron afferent pain pathway along the spinothalamic tract.
What Hepatocellular Injury lab test would suggest cirrhosis or alcoholic liver disease?
AST/ALT ratio GREATER than 2
AST is 10-40 units/L
ALT is 10-55 units/L
What lab test is the most specific indicator for biliary duct obstruction?
5’-Nucleotidase
0-11 units/L
What is present in all LA?
Amine group and Benzene ring
How far from the pacemaker should the electrocautery be used?
15 cm
What hormones are in the anterior pitutitary?
FLAT PiG
Follicle-stimulating hormone Luteinizing hormone Adrenocorticotropic hormone Thyroid stimulating hormone Prolactin Growth hormone
What regulates Thyroid Releasing Hormone?
T3
What hormones are in the Posterior pituitary
Antidiuretic hormone
Oxytocin
Which cranial nerves control eye movement?
Oculomotor - III
Trochlear - IV
Abducens - VI
How many minutes before administering SF6 bubble should you shut off Nitrous Oxide?
15 min before SF6 is placed and avoid for 7-10 days after SF6 bubble is placed.
What are the landmarks for the popliteal block?
Biceps femoris (LATERAL
Semitendinosus (MEDIAL)
Politeal fossa crease
What Endogenous opioids are associated with MU, Kappa, and Delta?
MU - Endorphins
Kappa - Dynorphins
Delta - Enkephalins
Drag and drop.
Polygohydraminos
Olgohydraminos
Gestational diabetes
Pre-eclampsia
Polygohydraminos - Transephgeal fistula
Olgohydraminos - pulmonary hypoplasia
Gestational diabetes - birth trauma
Pre-eclampsia - small for gestational age
What are two know complications for Marphan Disease?
Spontaneous pneumothorax and Aortic dissection
What is the most common dysrhythmia associated with mitral stenosis?
Atrial fibrillation
What are 6 risk factors for perioperative cardiac morbidity and mortality for non-cardiac surgery?
High risk surgery
History of ischemic heart disease (unstable angina confers the greatest risk of perioperative MI)
History of CHF
History of cerebrovascular disease
DM
Serum creatinine> 2mg/dL
What is the normal IRV?
3000mL
What is normal TV?
500mL
What is normal ERV?
1100mL
What is normal RV?
1200mL
What is normal TLC?
5800mL
What is normal VC?
4500mL
What is normal IC?
3500mL
What is normal FRC?
2300
What happens to FEV1/FVC ratio and FEF 25-75% in Obstructive disease?
Both decrease
Everything is normal (RV, FRC, and TLC are normal or increased if there is gas trapping)
What happens to FEV1/FVC ratio and FEF 25-75% in Restrictive disease?
Normal
(everything else is decreased)
This disease process prevents the lungs from expanding
What happens to PAOP after the clamp is placed On the aorta?
It increases
How can propofol injection pain be minimized?
Giving an opioid prior
Lidocaine before or mixed with prop
Injecting into a larger and more proximal vein
What is clearance inversely proportional to?
Half-life
Drug concentration in the central compartment
What is the clearance mechanism for propofol?
Liver (P450 enzymes) + extra hepatic metabolism (lungs)
What is MOA of proprofol?
Direct GABA-A agonist –>
INCREASE CL conductance–>
Neuronal hyperpolarization
(makes the cell more negative)
What is the duration to wait for elective surgery if a patient has a bare metal stent?
30 days (3 months preferred)
What is the duration to wait for elective surgery if a patient is s/p CABG?
6 weeks (3 months preferred)
What is the MOA for ketamine?
Ketamine is an NMDA receptor antagonists (antagonizes glutamate)
What are the secondary receptor targets for ketamine? (besides NMDA)
Opioid, MAO, Serotonin, NE Muscarinic, NA+ channels
Ketamine dissociates sensory and awareness, what area of the brain are these located?
Ketamine dissociates the THALAMUS (sensory) and the LIMBIC SYSTEM (awareness)
What are the blood gas solubility for N20, Des, sevo, iso?
N20 - 0.46
Des - 0.42
Sevo - 0.65
Iso - 1.46
Order from Fastest to slowest induction (top to bottom).
What will happen to IV induction with a left to right shunt?
Slower IV induction
What will happen to a right to left shunt with IV induction?
Faster IV induction
What will happen to a right to left shunt with DES and ISO?
Des will have a fast induction (Low blood gas solubility)
ISO will have a slow induction (high blood gas solubility)
What drugs will increase MAC?
Chronic alcohol consumption Acute amphetamine intoxication Acute cocaine intoxication MAOIs Ephedrine Levodopa
(things that will increase metabolic rate??)
What electrolyte will increase MAC?
Hypernatremia (High Na)
What ages will increase MAC?
Increase in infants 1-6 months
Sevo is the same for neonates and infant
Will pheomelanin increase MAC?
Yes pheomelanin is another term for Red hair, which is a factor that increases MAC.
What are some factors that will increase FA/FI (faster onset, pushes the curve up)?
Increase was in: High FGF High Alveolar ventilation Low FRC Low time constant Low anatomic dead space
Or Decrease uptake:
Low solubility (DES 0.42)
Low CO
Low Pa-Pv difference
Tidal volume of >5 mL/kg is associated with what percent of receptors occupied? (NMB)
80 percent
Single twitch is associated with what percent of receptors occupied? (NMB)
75-80 percent
Train of four is associated with what percent of receptors occupied? (NMB)
70-75 percent
Head life > 5 second is associated with what percent of receptors occupied? (NMB)
50 percent
Handgrip and/or bite on tongue blade sustained for 5 seconds is also associated with 50 percent
Sustained tetanus and double burst suppression is associated with what percent of receptors occupied? (NMB)
60 percent
Vital capacity > 20mL/kg is associated with what percent of receptors occupied? (NMB)
70
Between Atropine, Scopolamine, glyco, which has the most sedation, antisialagogue, mydriasis cycloplegia, and prevention of motion induced nausea?
Scopolamine
Rank the neuromuscular blockers according to their likelihood of causing anaphylaxis.
Succ
Atracruium
Ciastracurium
Roc
Vec
Ranked in highest to lowest likelihood
What are the elevated risk for a patient with Marfan syndrome?
Aortic dissection
Aortic insufficiency
Mitral valvue prolapse
Mitral regurgitation
As well as cardiac tamponade (becks triad - JVD, hypotension, muffled hear sounds)
Spontaneous pneumothorax is very common
What is Ehlers- Danlos syndrome?
It is an inherited disorder of procollagen and collagen.
There is an increased bleeding and hematoma is common.
What Trunks give rise to the Median nerve?
Superior and Inferior trunks
What procedure risk factors contribute to ION?
Prone position
Use of Wilson frame
Long duration of anesthesia
Large blood loss
Low ratio of colloid to crystalloid resuscitation
Hypotension
The spinal cord is perfused by how many arteries?
1 anterior spinal artery
2 posterior spinal arteries
6 - 8 radicular arteries
List the side effects common to acetylcholinesterase inhibitors (will not break down Ach, this will build up).
DUMBBELLS
Diarrhea Urination Miosis Bradycardia (M2) Bronchoconstriction (M3) Emesis Lacrimation Laxation Salivation
How do you asses the axillary nerve (sensory and motor)?
Sensory
-Pinch lateral aspect of shoulder
Motor
-Arm abduction (deltoid contraction)
How do you asses the Musculocutaneous nerve (sensory and motor)?
Sensory
-Pinch lateral aspect of forearm
Motor
-Elbow flexion (biceps contraction)
How do you asses the Median nerve (sensory and motor)?
Sensory
-Pinch index finger
Motor
-Thumb opposition
How do you asses the Radial nerve (sensory and motor)?
Sensory
-Pinch web space between thumb and index finger
Motor
- Elbow extension (triceps contraction)
- Wrist and finger extension
How do you asses the Ulnar nerve (sensory and motor)?
Sensory
-Pinch pinky finger
Motor
-Pinky finger abduction
Name 3 conditions that are associated with high risk of developing DIC.
Sepsis - highest risk is gram-negative bacilli
Obstetric complications - highest risk is preeclampsia, placental abruption, and amniotic fluid embolism
Malignancy - highest risk is adenocarcinoma, leukemia, and lymphoma
What are some advantages of using colloids vs crystalloids?
Replacement ratio = 1:1 Increase plasma volume (3-6 hours) Smaller volume needed Less peripheral edema Albumin has anti-inflammatory properties
Dextran 40 reduces blood viscosity
-Improves microcirculatory flow in vascular surgery
What are some advantages of using crystalloids vs colloids?
Replacement ratio = 3:1
Expands the ECF
Restores 3rd space loss
List the triggers that cause sickling of HgbS.
Pain
Hypothermia
Hypoxemia
Acidosis
Dehydration
On the CVP waveform, what happens On the Y descent?
RA empties through open tricuspid valve
Electrical Event = After T wave ends
On the CVP waveform, what happens On the A wave?
Right atrial contraction
Electrical event = Just after P wave (atrial depolarization)
On the CVP waveform, what happens On the C wave?
Right ventricular contraction
-bulging of tricuspid valve into RA
Electrical event = Just after QRS complex (ventricular depolarization)
On the CVP waveform, what happens On the V wave?
Passive filling of RA
Electrical event = Just after T wave begins (ventricular repolarization)
On the CVP waveform, what happens On the X descent?
RA relaxation
Electrical Event = ST segment
For urine osmolality, what would indicate prerenal oliguria (abnormally small amounts of urine)?
> 500 mOsm/kg
What is the most common cause of perioperative acute kidney injury?
The most common cause of perioperative kidney injury is ischemia-reperfusion injury.
How does rhabdomyolysis affect renal function?
Rhabdomyolysis and myoglobinemia are sequelae of direct muscle trauma, muscle ischemia, and prolonged immobilization.
Myoglobin binds to O2 inside the myocyte, when it is filtered at the glomerulus, it will precipitate in the proximal tubule.
This results in tubular obstruction and acute tubular necrosis.
Myoglobin scavengers nitric oxide (this vasodilator), and will lead to renal vasoconstriction and ischemia.
How can you prevent or minimize renal injury in the pt with rhabdomyolysis?
Maintenance of renal blood flow and tubular flow with IV hydration.
Osmotic diuresis with mannitol.
What steps can be taken to prevent nephrotoxicity from radiographic contrast media?
Use nonionic iso- or low-osmolar contrast instead of hyperosmolar contrast.
IV hydration with NaCl prior to administration of contrast.
Sodium bicarbonate injection or infusion.
What is the MOA of fenoldapam?
Fenoldopam is a selective DA1 receptor agonist that increases renal blood flow.
At low doses it will vasodilate the kidneys and increase RBF, GFR, and facilitates Na excretion without affecting arterial blood pressure.
How much of the renal blood flow is filtered at the glomerulus?
Renal blood flow = 1000 - 1250 mL/min
Glomerular filtration rate = 125 mL/min or about 20 percent of RBF
What are the key side effects of thiazide diuretics? (hydrocholorothiaxide, Metolazone, Indapamide)
These work in the distal tubule.
Side effects:
- Hyperglycemia
- Hypercalcemia
- Hyperuricemia
- Hypokalemic, Hypochloremic metabolic alkalosis
- Hypovolemia
What is the treatment for acute hemolytic reaction?
Maintain UO of > 75-100 mL/hr with:
- IV fluids
- Mannitol 12.5-25g
- Furosemide 20-40 mg if IVF and mannitol fail to provide an adequate response
Alkalinize the urine with sodium bicarbonate
In the body, hypoglycemia will stimulate the release of?
Glucagon (pancreatic alpha cells)
Epi (adrenal medulla)
What are some associated conditions that is associated with SIADH (too much ADH)?
Traumatic brain injury (most common)
Cancer (small-cell lung carcinoma)
Noncancerous lung disease
Carbamazepine (anticonvulsant)
What is the presentation of SIADH (Too much ADH)?
Hyponatremia
Plasma
- Volume = Euvolemic (or hypervolemic)
- Hypotonic (
What is the treatment for diabetic ketoacidosis?
Volume resuscitation, insulin, K after acidosis subsides.
How do you manage the patient with thyroid storm?
Avoid aspirin
Beta blockers (esmolol)
Acitve cooling measures (Cold IVF, ice packs)
Treat fever with acetaminophen
PTU or methimzaole (via OGT/NGT if during usrgery)
What is the duration of action for very rapid acting insulin?
Lispro, Insulin aspart, Glulisine
2-4hr
What is the duration of action for rapid acting insulin?
Regular 6-8 hr
What is the duration of action for intermediate-acting insulin?
NPH 18-28 hr
What is the duration of action for long acting insulin?
Detemir 6-24 hr
Glargine 20-24+ hr
What are the s/sx of hypoglycemia?
SNS stimulation (tachycardia, HTN, diaphoresis)
What is the treatment for TURP syndrome?
Support oxygenation and cardiovascular support
If Na > 120 mEq/L, then restrict fluids and give furosemide (loop diuretic)
If Na < 120 mEq/L, then give 3 percent NaCl at < 100 mL/hr (discontinue when Na > 120 mEq/L)
Correcting serum Na to quickly increase the risk of central pontine myelinolysis.
Midazolam may be used for seizures.
What is the pathophysiology for Left to right shunt?
DECREASED systemic blood flow
- Low CO
- Hypotension
INCREASED pulmonary blood flow
- Pul HTN
- RVH
What are the hemodynamic goals for Left to right shunt?
Avoid INCREASED SVR
Avoid DECREASED PVR
- Decrease FiO2
- Hypoventilation
(Hypoxemia and hypercarbia will increase PVR)
Describe the three stages of labor.
Stage 1: Beginning of regular contractions to full cervical dilation (10 cm)
Stage 2: Full cervical dilation to delivery of the fetus (Pain in the perineum begins during stage 2)
Stage 3: Delivery of the placenta
What is the pathophysiology of Right to left shunt?
DECREASED pulmonary blood flow
- Hypoxemia
- LV volume overload
- LV dysfunction
What is the hemodynamic goals for a patient with a Right to left shunt?
Maintain SVR
DECREASED PVR
- Hyperoxia
- Hyperventilation (low co2)
- Avoid lung hyperinflation
Who is at risk for aortocaval compression?
In the supine position, the gravid uterus compresses both the vena cava and the aorta.
This decreases venous return to the heart as well as arterial flow to the uterus and lower extremities.
Decreased CO compromises fetal perfusion and can also cause the mother to lose consciousness.
Treatment is by elevating the mother’s right torso 15 degrees (for anyone in their 2nd to 3 rd trimester)
What are the hemodynamic goals for tetralogy of Fallot?
INCREASE SVR with Phenylephrine
DECREASE PVR with nitric oxide or reverse hypercarbia, hypoxia, and acidosis
Maintain contractility and HR with Esmolol
INCREASE Preload with Crystalloid or albumin 5percent
What drugs are used in the treatment of carcinoid crisis?
Somatostatin (octreotide or lanreotide) inhibits release of vasoactive substances
Antihistamines (H1 and H2: diphenhtdramine + ranitidine or cimetidine)
5-HT3 antagonists: ondasetron
Steroids
Phenylephrine or vasopressin for hypotension
What drugs should be avoided in the patient with carcinoid syndrome?
Histamine releasing drugs just as morphine, meperidine, atracurium, thiopental, and succinylcholine
What is the clinical presentation of croup?
Mild fever
Inspiratory stridor
Barking cough
What is the treatment for croup?
O2
Racemic epinephrine
Corticosteroids
Humidification
Fluids
Intubation rarely required
What are the risk factors for post intubation larygngeal edema?
Age < 4 years
ETT is too large
ETT cuff volume is too high
Prolonged intubation
Head or neck surgery (Tonsilectomy)
Trisomy 21
History of infectious or post-intubation croup
Head repositioning during surgery
Traumatic or multiple intubation attempts (dont use an uncuffed tube)
What is the best way to minimize the risk of post intubation laryngeal edema?
The best treatment is prevention!
Manometer to intermiitently measure cuff pressure.
Where is the central chemoreceptor?
Located in the medulla
What does the central chemoreceptor respond to?
Responds to the H+ concentration in the CSF.
The H+ in the CSF is a function of the PaCO2 of the blood (remember, the PaCO2 is the primary stimulus to breathe)
Where is the Peripheral chemoreceptors located?
Carotid bodies - Nerves of Hering –> Glossopharyngeal n. (CN IX)
Aortic arch - Vagus n. (CN X)
What do the peripheral chemoreceptors respond to?
Respond to DECREASED O2,
INCREASED CO2
INCREASED H+
Discuss the management of hypoxemia during one-lung ventilation.
100 percent FiO2
Confirm DLT position with bronchoscope
CPAP 10 cm H2O to NON DEPENDENT (NON Ventilated) lung
PEEP 5-10 cm H2O to DEPENDENT (Ventilated) lung
Alveolar recruitment maneuver
CLAMP pulmonary to the NON DEPENDENT (NON Ventilated) lung
Resume two-lung ventilation
*If hypoxemia is severe, then it’s prudent to resume two lung ventilation promptly.
What drugs will increase pulmonary vascular resistance?
NITROUS Oxide
Ketamine
Desflurane
What are some ways to increase Pulmonary vascular resistance?
Hypoxemia
Hypercabia
Acidosis
SNS stimulation
Pain
Hypothermia
Increased intrathoracic pressure
- PEEP
- Atelectasis
- Mechanical ventilation
What are some ways to decrease Pulmonary vascular resistance?
Increase PaO2
Hypocarbia (low Co2)
Alkalosis
Decrease intrathoracic pressure
- Preventing coughing/straining
- Normal lung volumes
- Spontaneous ventilation
- High frequency jet ventilation
What are some drugs that will decrease Pulmonary vascular resistance??
Inhaled NITRIC oxide
Nitroglycerin
Phosphodiesterase inhibitors (sildenafil)
Prostaglandins (PGE1 and PGI2)
CCB
ACEi
What are some disadvantages of colloids vs crystalloids?
Albumin bings to Ca –> hypocalcemia
Coagulopathy
- Dextra > Hetastarch > Hetend
- Dont exceed 20mL/kg
- Not a problem with voluven
Anaphylactic potential
-Highest risk is Dextran
What are some disadvantages of crystalloids vs colloids?
Large volume of NaCl –> Hyperchloremic metabolic acidosis (Increase Cl –> Increase HCO3- excretion by the kidney)
Dilution effect On albumin
-Reduces capillary oncotic pressure
Dilutional effect On coagulation factors
Limited ability to expand plasma volume
- Increase plasma volume (20-30min)
- Higher potential for peripheral edema
What conditions impair atlanto-occipital joint mobility?
Degenerative joint disease
Rheumatic arthritis
Ankylosing spondylitis
Truama
Surgical fixation
Klippel-Feil
Down syndrome
Where do you measure the thyromental distance?
Tip of the thyroid cartilage to the tip of the mentum
Describe the pharmacologic prophylaxis of aspiration pneumonitis.
Antacids: Sodium citrate, Sodium bicarbonate, Mag trisilicate
H2 antagonists: Ranitidine, cimetidine, famotidine
GI simulants: Metocloproamide
Proton pump inhibitors: omeprazole, lansoprazole, pantoprazole
Antiemetics: droperidol, ondansetron
What are two common causes of angioedema?
Angiotensin converting inhibitors
-treat with epi, antihistamines, steroids (just like anaphylaxis)
Hereditary angioedema (C1 esterase deficiency) -treat with C1 esterase concentrate of FFP
The lumen of the bronchial blocker can be used for (during OLV)?
Use for
-Insufflate O2 into the non-ventilated lung
-Suction air from the non-ventilated lung (improves surgical exposure)
The lumen of the bronchial blocker can NOT be used for (during OLV)?
NOT used for
-Ventilation
-Suction blood, pus, or secretions from the non-ventilated lung
When is the best time to use an airway exchange catheter?
It is the most common device used to manage extubation of the difficult airway.
It can be used to:
-Measure EtCO2
- Jet ventilation (via Luer-lock adapter)
- O2 insufflation (via 15 mm adapter)
Stimulation of what receptor will contract the Uterus?
Alpha 1 will contract the Uterus
Alpha 1 = Gq (a1, M1/3/5, V1. H1)
Stimulation of what receptor will relax the Uterus?
Beta 2 will relax the uterus
Beta 2 = Gs (B1 B2 D1 V2 H2)
Stimulation of what receptor will Contract the Trigone and sphincter of the bladder?
Alpha 1 will contract the trigone and sphincter of the bladder
Alpha 1 = Gq (a1, M1/3/5, V1. H1)
Stimulation of what receptor will Relax the Detrusor of the bladder?
Beta 2 will relax the Detrusor of the bladder
Beta 2 = Gs (B1 B2 D1 V2 H2)
What receptors are assocatied with Gi?
A2
M2
M4
D2
(DECREASE cAMP)
What will impair the HPV?
Halogenated anesthetics > 1-1.5 MAC
Phosphodiesterase inhibitors
Dobutamine
Vasodilators
*IV anestehtics do NOT inhibit HPV.
Anything that inhibits HPV INCREASES SHUNT b/c it will dilate the vessels (perfusion without ventilation)
What hemodynamic conditions reduce cardiac output in the patient with hypertrophic cardiomyopathy?
Conditions that will reduce CO:
INCREASED HR (treat with Bblockers or CCBS) INCREASED contractility (treat with Bblockers or CCBS)
DECREASED Preload (treat w/ volume) DECREASED afterload (treat with phenylephrine)
Therefore you want to reduce HR and contractility will increasing preload and afterload.
What is the risk of perioperative myocardial infarction in the patient with a previous MI?
Risk of perioperative MI in the pt with previous MI:
General population = 0.3 percent
MI if > 6 months = 6 percent
MI if 3-6 months = 15 percent
MI < 3 months = 30 percent
Greatest within 30 days of an acute MI
What is the pathophysiology of protein C and S deficiency?
Protein C produces an anticoagulant effect by inhibiting factors Va and VIIIa.
This creates a feedback mechanism that prevents unnecessary clot formation.
Protein S is a co-factor of protein C (Protein S helps protein C do its job).
A deficiency of protein C or S can produce a HYERCOAGULABLE STATE, increasing the risk of thrombosis.
What is the treatment for Protein C and S deficiency?
A thromboembolism is treated with heparin that is transitioned to warfarin.
Patients may or may not require life-long anticoagulation with warfarin.
List the possible causes of a non-gap acidosis.
HARDUP Hypoaldosteronism Acetazolamide (excrete bicarb) Renal tubular acidosis Diarrhea
Ureterosignmoid fistula
Pancreatic fistula
*Large volume resuscitation with NaCl solutions can cause non-gap metabolic acidosis with hyperchloremia (think trauma)
What alpha receptors will cause the arteries to vasoconstrict more?
Alpha 1 > Alpha 2
What alpha receptors will cause the veins to vasoconstrict more?
Alpha 2 > Alpha 1
What regional technique can be used for the patient undergoing carotid endarterectomy?
Cervical plexus block (superficial or deep) at C2-C4
Local infiltration
Describe the presentation of hypermagnesemia.
Loss Depp tendon reflex: 4-6.5 mEq/L or 10-12 mg/dL
Respiratory depression = 6.5-7.5 mEq/L or > 18 mg/dL
Cardiac arrest => 10 mEq/L or > 25 mg/dL
What is the first sign of bronchial intubation?
Earliest manifestation of bronchial intubation is an increase in peak inspiratory pressure.
May also happen:
Asymmetrical chest expansion
Unilateral breath sounds
Hypoxemia
Which drug is difficult to be reversed by nalaxone d/t the high affinity for mu receptors?
Buprenorphine
Available via transdermal route
Butorphanol is useful for what post op condition?
Butorphanol is useful for post op shivering.
Kappa agonist
Phenytoin and carbamazepine will do what to hepatic enzymes?
They are hepatic inducers
What is the defining characteristic between type I and type II complex regional pain syndrome?
Type I: Reflex sympathetic dystrophy
Type II: Causalgia
Complex regional pain syndrome is characterized by neuropathic pain with autonomic involvement.
Type II CRPS is ALWAYS preceded by nerve injury (type I is not).
What are some examples of Type I Immediate hypersensitivity?
Anaphylaxis
Extrinsic asthma
Describe the pathophysiology of Type I immediate hypersensitivity.
Antigen + antibody interaction in a patient who has been previously sensitized to the antigen.
What are some examples of Type II antibody-mediated hypersensitivity?
ABO-incompatibility
Heparin-induced thrombocytopenia
Describe the pathophysiology of Type II Antibody-mediated hypersensitivity.
IgG and IgM antibodies bind to cell surfaces or extracellular regions.
What are some examples of Type III immune complex hypersensitivity?
Snake venom reaction
Protamine induced vasoconstriction
Describe the pathophysiology of Type III immune complex mediated hypersensitivity.
An immune complex is formed and deposited into the patient’s tissue.
What are some examples of Type IV delayed hypersensitivity reaction?
Contact dermatitis
Graft-vs-host reaction
Tissue rejection
Describe the pathophysiology of Type IV delayed hypersensitivity.
Allergic reaction is delayed at least 12 hours following exposure.
What is Allodynia?
Pain due to a simulus that does not normally produce pain.
Ex. Fibromyalgia
What is Dysesthesia?
Abnormal and unpleasant sense of touch.
Ex. Burning sensation from diabetic neuropathy
What is Neuralgia?
Pain localized to a dermatome.
Ex. Herpes Zoster (shingles)
What is the modified Brooke formula?
First 24 hours:
Crystalloid = 2mL LR x Precent TBSA burned x kg (1/2 in 1st 8 hours then 1/2 in next 16 hrs)
Second 24 hours:
Crystalloid = DW5 maintenance rate
Colloid = 0.5 mL x Percent TBSA x kg
What are 4 acyonotic shunts?
An acyanotic shunt is also called a left-to-right shunt.
It describes a situation where blood in the left side of the heart recirculates through the lungs instead of perfusing the body.
Examples:
- Ventricular septal defect (most common)
- Atrial septal defect
- Patent ductus arteriosus
- Coarctation of the aorta
What are the 4 mechanisms of heat transfer? Rank them from the most to least important.
Radiation - Infrared (60 percent)
Convection - Air (30 percent)
Evaporation - Water loss (20 percent)
Conduction - Contact (<5 percent)
Which has a covering present? Omphalocele or gastroschisis?
Omphalocele has a covering present
Which is more urgent? Omphalocele or gastroschisis?
Gastroschisis is more urgent (within 24 hours)
At higher risk of fluid and heat loss (due to no covering)
IVF 150-300 mL/kg/day
What is less urgent?
Omphalocele or gastroschisis?
Omphalocele is less urgent
Requires cardiac workup first
Which one presents with a defect On the midline - that involves the umbilicus? Omphalocele or gastroschisis?
Omphalocele has a midline defect that involves umbilicus
Which one presents with an off midline defect that usually is to the right of the umbilicus? Omphalocele or gastroschisis?
Gastrocschisis usually has a defect that is off midline that is usually right of the umbilicus
What is a co existing disease with gastroschisis?
Prematurity
What are some co existing disease with omphalocele?
Trisomy 21
Cardiac defects
Beckwith-wiedemann syndrome
How are TSH, T3, T4 levels affected by hyperthyroidism?
Hyperthyroidism:
Low TSH + High T3 and T4
How are TSH, T3, and T4 levels affected by hypothyroidism?
Hypothyroidism:
High TSH + Low T3 and T4
What are the absolute contraindications to extracoporeal shock wave lithotripsy?
Pregancy
Risk of bleeding (bleeding disorder or anticoagulation)
According to RIFLE, what is considered “risk”?
Risk:
Serum Cr and GFR Criteria:
Increased Serum Cr 50 percent or Decreased GFR > 25 percent
Urine output criteria:
UO < 0.5 mL/kg/mL x 6 hr
According to RIFLE, what is considered “injury”?
Injury:
Serum Cr and GFR Criteria:
Increased Serum Cr 100 percent or Decreased GFR > 50 percent
Urine output criteria:
UO < 0.5 mL/kg/mL x 12 hr
According to RIFLE, what is considered “failure”?
Failure:
Serum Cr and GFR Criteria:
Increased Serum Cr 200 percent or Decreased GFR > 75 percent or Serum Cr >= 4 mg/dL (with acute rise of 0.5 mg/dL)
Urine output criteria:
UO < 0.3 mL/kg/mL x 24 hr or anuria x 12 hr
How much percentage is sodium reabsorbed in the PCT, LOH, DCT, Collecting duct, and the urine?
Proximal Tubule = 65 percent
Loop of Henle (thick ascending limb) = 20 percent
Distal tubule = 5 percent
Collecting duct = 5 percent
Urine = 5 percent
What does FFP contain?
All of the clotting factors.
A patient is acutely intoxicated with alcohol, how will this affect their MAC levels?
MAC is decreased in the acutely intoxicated patient.
Regarding the extrinsic pathway, What activates it? What lab tests measures it? and what drug inhibits it?
The extrinsic pathway is activated by vascular injury (tissue trauma liberates tissue factor from the sub endothelium).
It is measured by the PT and INR.
It is inhibited by coumadin.
Which cranial nerve will Abduct the eyes?
CN VI
Movement involves 3 4 and 6
Which cranial nerve will make the eyes down inward and down at and angle?
CN IV
Movement involves 3 4 and 6
What is the formula for cerebral perfusion pressure?
CPP = MAP - ICP (or CVP whichever is higher)
What is the calculation for mean arterial blood pressure?
MAP = (1/3 x SBP) + (2/3 x DBP)
MAP = [(CO x SVR) / 80] + CVP
Normal = 70 - 105 mmHg
What happens in the A C and V wave on the CVP waveform?
A wave = RA contraction
C wave = Tricuspid valve elevation into RA
V wave = RA passive filling
What happens in the X and Y descents On the CVP waveform?
X descent = Downward movement of contracting RV
Y descent = RA empties through open tricuspid valve
What is an under-damped system in the transducer system?
Baseline is re-established after several oscillations (SBP is over estimated, DBP is underestimated and MAP is accurate)
What is the optimally damped system for the transducer system?
Baseline is re-established after 1 oscillation.
What 2 things must you do in the event of an O2 supply line crossover?
Turn ON the O2 cylinder.
Disconnect the pipeline O2 supply. This is a key step!
What is the gas pressure in psi for the intermediate pressure system?
50 psi if using pipeline and 45 psi if using the tank
What causes remifentanil susceptible to hydrolysis by erythrocyte and tissue esterases?
Remifentanil contains an ester linkage.
This renders it susceptible to hydrolysis by erythrocyte and tissue esterases.
In the obese patient, the rate of remifentanil infusion is calculated with?
In the obese pt, remifentanil infusion is calculated with LEAN BODY WEIGHT (it does not distribute throughout the body fat because it is metabolized so quickly).
Of all the opioids, which one has the fastest onset of action?
Alfentanil
Its pKa is 6.5, which is less than physiologic pH.
It is around 90 percent unionized and 10 percent ionized.
Highly unionized and it doesn’t have a large Vd, makes this drug more available to enter the brain.
Grapefruit jurice, cimetdine, omeprozole, isoniazid, SSRIs, Erythromycin, and ketoconazole will all do what to hepatic enzymes?
They are all hepatic enzyme inhibitors.
How does the intra-aortic balloon pump function during diastole?
The intra-aortic balloon pump is counter pulsation device that improves myocardial O2 supply while reducing myocardial O2 demand.
Diastole:
- Pump inflation augments coronary perfusion
- Inflation correlates with the dicrotic notch On the aortic pressure waveform.
How does the intra-aortic balloon pump function during systole?
The intra-aortic balloon pump is counter pulsation device that improves myocardial O2 supply while reducing myocardial O2 demand.
Systole:
- Pump deflation reduces afterload and improves cardiac output.
- Deflation correlates with R wave On the EKG.
What does Nitric oxide do to guanylate cyclase?
Nitric Oxide activates guanylate cyclase.
Guanylate cyclase converts guanosine triphosphate to cyclic guanosine monophosphate.
This leads to decrease Ca+2 and vasodilation.
Describe the Frank-Starling relationship.
The Frank-Starling relationship describes the relationship between ventricular volume (preload) and ventricular output (cardiac output):
INCREASED preload –> Increased myocyte stretch –> Increased ventricular output
DECREASED preload –> decreased myocyte stretch –> Decreased ventricular output
Increased preload increases ventricular output, but only up to a point. To the right of the plateau, additional volume overstretches the ventricular sarcomeres, decreasing the number of cross bridges that can be formed and ultimately reducing cardiac output. This contributes to pulmonary congestion and increases PAOP.
List the 5 phases of ventricular action potential and describe the ionic movement during each phase.
Phase 0: Depolarization –> Na influx
Phase 1: Initial repolarization –> K efflux and Cl influx
Phase 2: Plateau –> Ca influx
Phase 3: Repolarization –> K efflux
Phase 4: Na/K pump restores resting membrane potential
What is the value of P50?
26.5
What are 2 indications for retrograde intubation?
Unstable cervical spine (most common use of RI)
Upper airway bleeding (can’t visualize glottis)
How is tobacco smoke harmful?
Smoking increases:
SNS tone
Sputum production
What are the absolute indications for OLV?
Isolation of OL to avoid contamination:
- Infection
- Massive hemorrhage
Control of Distribution of Ventilation:
- Bronchopleural fistula
- Surgical opening of major airway
- Large unilateral lung cyst or bulla
- Life threatening hypoxemia r/y lung disease
Unilateral Bronchopulmonary Levage:
-Pulmonary alveolar proteinosis
What are the short term cessation effects of smoking?
Short term cessation does NOT reduce the risk of postoperative pulmonary complications.
- SNS stimulating effects of nicotine dissipate after 20-30 minutes
- P50 returns to near normal in 12 hours (CaO2 improves)
What are the intermediate term cessation effects of smoking?
The return of normal pulmonary function requires at least 6 weeks.
This includes:
- Airway function
- Mucociliary clearance
- Sputum production
- Pulmonary immune function
What are the 4 things that must be proven in a law suit asserting malpractice?
Duty
Breach of duty
Causation
Damages
What is Res Ipsa Loquitur?
Res ipsa loquitur (“the thing speaks for itself”) can shift the burden of proof from plaintiff to the defendant. This can occur if 4 conditions can be established:
- If the injury would not have occurred in the absence of negligence
- The injury was caused by something under the complete control of the defendant (provider).
- The patient did not contribute in any way to the injury.
- The evidence for the explanation of events is sole under the control of the provider.
What are the 6 elements of high-quality care?
Patient centered
Safe
Effective
Timely
Efficient
Equitable
What is vicarious liability?
One person (or entity) may be liable for the actions of another person.
For instance, a physician might be held liable for the actions of a PA. This concept typically does not apply to CRNAs working under a physician.
Respondeat superior is often used interchangeably with vicarious liability.
What is Nonmaleficence?
Nonmaleficence asserts that a provider has an obligation not to inflict hurt or harm - in other words, the hippocratic oath primum non nocere (first do no harm).
What is the presentation of an obturator nerve injury?
Inability to ADDuct the leg
Reduced sensation over the medial aspect of the thigh
What is the etiology of an obturator nerve injury?
Excessive flexion of the thigh towards the groin
Excessive traction during lower abdominal surgery
Forceps delivery
What is the presentation of the radial nerve injury?
Wrist drop
Inability to extend the hand at the wrist.
What are the diagnostic indicators for metabolic syndrome?
Large waist circumference (men> 40 inches and women > 35 inches)
Triglycerides > 150 mg/dL
High density lipoprotein (HDL) < 40 mg/dL for men and < 50 mg/dL for women)
Blood pressure > 130/85
Fasting glucose > 100 mg/dL
Metabolic syndrome (syndrome X) incorporates a number of disease states that coincide with obesity. Cardiovascular risk is 50-60 percent greater than the general population. In order to be diagnosed with metabolic syndrome, one most have at least 3 of the following above.
What are the 5 categories in the Aldrete scoring system?
Activity
Respiration
Circulation
Consciousness
Oxygen Saturation
Discuss the role of the cyclooxygenase enzyme in the arachidonic acid cascade.
COX-1 is always present.
- It maintains normal physiologic fxn.
- Inhibition of COX-1 enzyme impairs platelet function, causes gastric irritation, and reduces renal blood flow. (NSAIDS/aspirin)
COX-2 is not always present.
- It is expressed during inflammation.
- Inhibition of COX-2 enzyme produces analgesia, anti inflammatory, and antipyretic effects. Unlike opioids, there is a ceiling effect to analgesia. (NSAIDs, Aspirin, and COX-2 inhibitors.
What are the 6 elements of informed consent?
Competence
Decision-making capacity
Disclosure of information
Understanding of disclosed information
Voluntary consent
Documentation
What are absolute contraindications for ECT?
Recent myocardial infarction (< 4-6 months)
Recent intracranial surgery (<3 months) Recent stroke (<3 months)
Brain tumor
Unstable cervical spine
Pheochromocytoma
What is the etiology and treatment of serotonin syndrome?
Serotonin syndrome occurs when there’s excess 5-HT activity in the CNS and PNS. Key drug interactions that increase the risk of serotonin syndrome include:
SSRI and:
Meperidine
Fentanyl
Methylene blue
MAOI and:
Meperidine
Ephedrine
The seizure caused by ECT results in profound physiologic changes. What are the initial and secondary response from the ANS?
Initial response: INCREASED PNS activity during the tonic phase (last about 15 seconds)
Secondary response: INCREASED SNS activity during the clonic phase (lasts several minutes)
What are some cardiovascular consequences of perioperative hypothermia?
SNS stimulation - Myocardial ischemia and dysrhythmias
Shifts oxyhemoglobin dissociation curve to left - Decreased O2 available to tissues
Vasoconstriction + decreased tissue PO2 - surgical site infection
Coagulopathy + platelet dysfunction - increased blood loss
Sickling of hemoglobin S - risk of sickle cell crisis
What are some pharmacologic consequences of perioperative hypothermia?
Slowed drug metabolism - prolonged effects of anesthetic agents
Increased solubility of volatile agents - Prolong emergence
What are some causes of increased Hct?
Chronic lung disease
Dehydration
Chronic smoking
Living at high altitudes
Diuretics
Which disorder has symptoms that improves with exercise?
Lambert - Eaton myastemic syndrome (LEMS)
What is the partial pressure of room air at sea level?
0.21 x 760 = 159.6
160
Where do the pre ganglionic parasympathetic nerves originate?
CN 3 7 9 10 in brainstem and S2-S4
Cranio sacral
What is lacking in old blood?
Factors 5 and 8
What is the seizure prophylaxis for PIH?
Mag loading does 4-6 gm IV 20-30 min
Infusion of 1-2 gm/hr up to 24 hrs postpartum.
Which agents should be avoided in the patient with carcinoid syndrome?
Morphine and Ephedrine
Avoid Histamine release and SNS stimulation
What is the anesthetic management for Obstructive hypertrophic cardiomyopathy?
INCREASE preload
DECREASE contractility
DECREASE Hr
DECREASE SNS
INCREASE intravascular volume
MAINTAIN afterload
How long do you have to wait before surgery for a pt with a drug eluding stent?
1 year
What are two inhibitory spinal cord neurotransmitter?
GABA and Glycine
What would cause a large V wave On the CVP?
Tricuspid regurgitation
What is the formula for sizing the ETT?
(Age/4) + 4 (uncuffed)
What is the minimum psi for jet ventilation?
50 psi
List the duration of action of the LA from shortest to longest.
Chloroprocaine (shortest)
procaine
Prilocaine
Lidocaine
Tetracaine
Mepivaciane
Ropivacaine
Bupivacaine (longest)
Where do you place the BP cuff during a mediastoscopy?
BP left arm, the Aline On the right
What is the treatment for ICP during traumatic brain injury?
3 percent saline
What are the absolute contraindication for ESWL?
Pregnancy
Risk of bleeding
Myelomeningocele is associated with what?
Hydrocephalus
Latex allergy
What is the difference between practice guidelines and practice standards?
Guidelines = “should” be adhered to
Standards = “must” be adhered to
Indomethacin can do what to the patent ductus arteriosus?
It can close it.
What is the strongest bond?
Covalent bonds
Capsacin, what kind of pain does it alleviate?
Neuropathic
Inflammatory
Where does the dural sac end in pediatrics?
S3
What ligament goes from the Forman magnum to the sacrum?
Supraspinous ligament
What stimulates TSH, T3, T4 release?
Thyrotropin Release hormone
A vital capacity of at least (BLANK) is required for an effective cough.
A vital capacity of at least 15 mL/kg is required for an effective cough.
What region is affected with eaton-lambert syndrom?
Voltage-gated Ca2+ channel
Presynaptic neuron is affected
There is a decreased Ach release
What region is affected with myasthenia gravis?
Nm receptor (postsynaptic)
Postsynaptic motor endplate is affected
There is a decrease response to Ach
With syndrome has a sensitive response to succinylcholine and nondepolarizers?
Eaton-Lambert syndrome
Which syndrome has a sensitive response to nondeplarizers and RESISTANT to succinylcholine?
Myasthenia gravis
What causes a cough with ACE inhibitors?
Bradykinin (buildup of bradykinin contributes to the cough)
In preeclampsia, what will increase thromboxane do?
Leads to increased vasoconstriction
What is the reason why you have to increase the dose for succs in neonates?
They have an increased ECF
What two things will worsen multiple sclerosis?
Hyperthermia
Spinal anesthesia
Pseudocholinesterase is increased in which patient population?
Obese
Pectus Excavatum can be found in a patient with what disease?
Marfan Syndrome
In the circle of willis, if this artery was blocked, it would cause blindness, which artery is that?
The Ophthalmic artery (this was a hotspot)
What two oropharyngeal airways can you intubate with?
Williams
Ovassapian
How can you calculate the ejection fraction from the flow volume loop?
EF = (EDV - ESV) / EDV
What would cause the A wave to disappear on the CVP waveform?
Atrial fib
Ventricular paced
What is the most common excitatory neurotransmitter in the central nervous system?
Glutamate
What IV drugs would cause a decrease in pulse ox reading when administered?
Indigo carmine
Methylene blue
Etomidate, Thiopental, and Propofol will do what to cerebral vascular?
It will cause cerebral vasoconstriction (decrease ICP) (Decrease CMRO2)
What is involved in humoral immunity?
B Lymphocyte
What is the formula for Coronary Perfusion pressure?
CPP = AoDBP - LVEDP
What cardiovascular changes happen with a pt in the prone position?
Decrease SVR
Decrease CO
Decrease BP
What is the most common site of obstruction of CSF flow?
Aqueduct of silvas
What would be the treatment if a patient saturation drops from 98 to 85 percent after Prilocaine was administered?
Methylene blue
What kind of pain is considered Somatic pain?
Sharp, fast, localized
Which drug can prolong seizures during ECT?
Etomidate
Where does a serotonin agonist work?
Hippocampus
What is the main reason for the extended duration of action for morphine in the elderly population?
Smaller Vd
Decreased clearance
Major negative feedback mechanism for thyroxine stimulating hormone?
T3
What population has a decreased plasma cholinesterase?
Obstetrics
Retinal vasculogenesis normally begins at the sixteenth week of gestation and is complete by 44 weeks, after this time the risk of retinopathy of prematurity is (BLANK).
Retinal vasculogenesis normally begins at the sixteenth week of gestation and is complete by 44 weeks, after this time the risk of retinopathy of prematurity is NEGLIGIBLE
Cardiac output will come back to normal (HOW MANY HOURS) post delivery?
48 hours
List the steroids from most to least potent.
Decadron
Methypednisom
Predinsone
Cortisol
Aldosterone
What drug will you not give to G6 PD deficiency patients?
Methylene blue
What is the most common complication of retrobulbar block?
Retrobulbar hemorrhage
What would increase the concentration of barbiturates?
Liver disease
Which drug do you not want to give to a breastfeeding mother?
Toradol (can close DA?)
If a 4 year old needs to have their lung isolated during surgery, what can you do?
Rt main stem intubation with a regular ETT, since you cant use a bronchial blocker.
What are three things that you can use to treat hypercalcemia intraop?
Lasix
Hyperventilate
Hydrate
What electrolyte to neonates like to excrete?
Sodium
You performed an ankle block, patient has sensation and movement in toes, what nerves didn’t get blocked?
Superficial peroneal
Deep Peroneal
Hemophilia A has a disorder in what factor?
Factor 8
Hemophilia B has a disorder in what factor?
Factor 9
What would be the most appropriate anesthetic plan for an obese patient having a liver biopsy?
TIVA with spontaneous breathing
What is the MOA for digoxin?
Inhibits the Na/K ATPase transporter pump.
This increases the intracellular Na and Ca, resulting in a DECREASE SLOP OF PHASE 4 and a prolonged AV nodal refractory period.
What is the expected MAC of sevoflurane in a 80 year old patient?
6 percent each decade after 40 years.
4 x 6 percent = 24 percent
100-24 percent = 76
MAC of sevo is 2 x 0.76 = 1.52
MAC of sevo fo an 80 yr old = 1.5 percent
Interscalene will block what part of the brachial plexus?
Roots
Supraclavicular will block what part of the brachial plexus?
Trunks/division
Infracalvicular will block what part of the brachial plexus?
Cords
Axillary will block what part of the brachial plexus?
Branches
What leads On the EKG look at the RCA?
Inferior heart RCA
II
III
aVF
What leads On the EKG look at the CxA?
Lateral heart Circumflex
I
aVL
V5-V6
What leads On the EKG look at the LAD?
Anterior septal LAD
V1 V2
Anterior LAD
V3 V4
What gland regulates the thyroid the most?
Hypothalamus
T3
Which drugs do you not give to a pt taking MAOIs?
Ephedrine
Meperidine
Cocaine
Give a brief description of Transduction, transmission, modulation, and perception.
Transduction = noxious stimuli becomes a nerve impulse
Transmission = impulse travels from periphery to brain
Modulation = Amplification or dampening of pain in the dorsal horn of the spinal cord
Perception = Conscious awareness of pain
In the pediatric population, what is the most common cause of liver failure?
Biliary atresia
What causes heat loss in the first hour of redistribution?
Radiant heat loss
What fluid would you give to a patient that is hypernatremic and dry?
Isotonic
What position would compartment syndrome be mostly related to?
Lithotomy position
What does the second stage regulator do?
Decreases the pressure from 50 psi to 16 psi
Large bore IV catheter is an example of what law?
Pouseilles law
Tension of a AAA is an example of what law?
La place law
Velocity/flow based On Hct (viscosity) is an example of what law?
Laminar flow
What drug can decrease the length of a seizure in an ECT?
Propofol
The patient cannot curl toes, what nerve is damage?
Tibial nerve
Which drugs should not be given to pts with known irritation to PABA?
Esters LA
You see a delta wave On the EKG, what would you suspect?
Wolff-parkinson white syndrome
How far should you advance a DLT for males and females?
Males = 29 cm
Females = 27 cm
What happens to the chest wall compliance and pulmonary compliance in the neonate?
Chest wall compliance is INCREASED
Pulmonary compliance is DECREASED
What happens to Albumin and Alpha-1 acid glycoprotein concentrations in the neonate?
They both are reduced
Describe Addison’s disease.
Destruction of all cortical zones:
Decrease production of Mineralocorticoids, Glucocorticoids, and androgens
What is cushings reflex?
Cushing reflex is due to inter cranial HTN
HTN
Bradycardia
Irreg resp
What are the 5 examples of a cyanotic shunt?
Right to left shunt (cyanotic shunt)
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid valve abnormality (Ebsteins anomaly)
Truncas arteriosus
Total anomalus pulmonary venous connection
What are the 4 examples of a ACYANOTIC shunt?
Left to right shunt (acyanotic shunt)
Ventricular septal defect –> Esinemerges
Atrial septal defect
Patient Ductus Arteriosus
Coartation of the aorta
What can you give if you need to urgently reverse warfarin?
FFP
What is the effect of Nitric Oxide?
Smooth muscle relaxation
What makes mapleson circuits different?
They have:
Bag
APL
FGF
Best place to put the transducer in the sitting position?
Tragus of the ear
Which drug is the gold standard for ECT?
Methohexital
What nerve would cause a food drop?
Sciatic –> Common peroneal
How does VA affect somatosensory evoke potential monitoring?
VA will INCREASE the latency and DECREASE the amplitude of SSEP in a dose-dependent fashion.
What nerves can be injured during facemask ventilation?
Facial VII
Trigeminal V
What nerve comes off of the posterior cord?
Radial
Axillary
What electrolyte imbalance would you see in pyloric stenosis?
Hyponatermia
Hypokalemia
Hyocholremia
They are vomiting
You would see metabolic alkalosis + compensatory resp acidosis
Normal Anion gap?
8 - 12 mEq/L
What is the parkland formula?
4 mL of LR x percent TBSA burned x kg
Steroids work On which fibers?
C fibers
Nitropursside will vasodilate what system?
Arterial and venous
How many molecules are carried by Hgb if sat is 50 percent?
2
A patient with porphyria, what drugs do you not give?
Barbiturates
Etomidate
Glucocoticoids
Hydralazine
Idonmethacin will do what to the arachidonic acid?
Idonomethcain will inhibit the conversion of arachidonic acid to prostaglandin H2
What are the side effects of bone cement implantation syndrome?
Hypoxia
Hypotension
Cardiac arrhythmias
Increased PVR
LOC
Cardiac arrest
(treat like R heart failure?)
What parameters are increased in an OB patient?
Increased:
O2 consumption
M/V
PaO2
CO
What is the clotting factor deficiency in Hemophilia C?
Factor 11
What is decreased in Banked blood?
Decreased:
2,3 DPG
ATP
pH
Increased:
K
Pro inflammatory mediators
Impaired ability to changed shape
Hemolysis
What fluid is best to administer for hypernatremia and hypovolemia?
Isotonic (NaCl)
State the MOA of these asthma drugs.
Montelukast
Cromolyn
Solumedrol
Atroptine/Ipratropium
Montelukast - Leukotriene modifier
Cromolyn - Mast cell stabilizer
Solumedrol - Corticosteroid
Atroptine/Ipratropium - Anticholinergic
What is the vapor pressure of Sevo?
157
What is the vapor pressure of Iso?
238
What are the lung volume changes in the pregnant patient?
DECREASED TLC
No change in VC
INCREASED RR
DECREASED ERV
DECREASED RV
What are the lung volume changes in the Elderly patient?
INCREASED FRC (RV not ERV)
No change in TLC
INCREASED CC
DECREASED VC
DECREASED FEV1
DECREASED ERV
What are the lung volume changes in the Obese patient?
DECREASED TLC VC FRC ERV
No change in RV
INCREASED CC
INCREASED SVR
No change in HR
What are the lung volume changes in the Neonate population?
DECRASED VC TLC FRC ERV
INCREASED RV
DECREASED lung compliance
INCREASED chest wall compliance
What are some hepatic enzyme inhibitors?
Grapefruit juice
Omeprazole
SSRI
Isoniazid
Cimetidine
Eryhtomycin
What are some hepatic enzyme INDUCERS?
Tobacco
Ethanol
Phenytoin
Barbiturates
Rifampin
The administration of glycine would increase?
Ammonia levels
Which would lead to decreased LOC
Transient postoperative visual syndrome (blindness or blurriness; glycine inhibits NT in the eye)
Anemia would do what to the pulse ox waveform?
It would over estimate it
What block uses the landmark of the coracoid process?
Infraclavicular block
Give examples of:
Ignition source
Oxidizer
Fuel
Ignition source: Electrosurgical cautery, laster
Oxidizer: O2 N2O
Fuel: ET tube, drapes, surgical supplies
Lumbar plexus emerges between what two muscles?
Quadriceps
Psoas major
What are the disadvantages of Hetastarch?
Coagulopathy
Anaphylaxis
Match the side of effects of the following drugs:
Phencyclidine
Methamphetamine
Heroin
Miosis, Mydraisis, Nystagmus
Phencyclidine: Nystamgus
Methamphetamine: Mydriasis
Heroin: Miosis
Why does morphine have an increased efficacy in the elderly?
Decreased Vd of hydrophilic drugs
Increased Vd for lipophilic drugs
Decreased muscle mass
What is the Labatt’s position?
The single sciatic nerve block is done following this technique.
The patient is first placed in the lateral position with the side of the be blocked up.
State where these drugs work in the nephron:
Acetazolamide
Osmotic diuretics
Furosemide
Thiazide
Spironolactone
Acetazolamide - PCT
Osmotic diuretics - Descending PCT
Furosemide - Ascending PCT
Thiazide - DCT
Spironolactone - Collecting duct
What are some criteria for Pickwickian syndrome?
Pickwickian syndrome aka Obesity hypoventilation snydrome.
BMI>30
Resting Co2>45mmHg
Dysfunctional breathing during sleep
DECREASED FRC ERV VC TLC PaO2 and lung compliance
No change in RV
What are some things that do not affect the O2 pulse ox?
Hgb S
Hgb F
Jaundice
Polycythemia
Acrylic nails
Fluorescein
What is the Oxygen delivery formula?
DO2 = CO x [(Hgb x SaO2 x 1.34) + (PaO2 x 0.003)] x 10
Which chemical structure of a non-depolarizing neuromuscular blocker will make it more lipid soluble?
Benzene ring?
What are the s/sx of epiglottitis?
Rapdi onset < 24hr Thumb up sign Tripod position 2-6 years of age 4 Ds (Drooling dysphonia dysphagia dyspnea)
Treatment: O2, urgent airway management, antibx, induction with spontaneous ventilation, ENT presence
Which excitatory neurotransmitter is released On the afferent side?
Substance P - Releases from afferent nociceptor C fibers
Glutamate - Major excitatory neurotransmitter in the CNS and releases from the A-delta and C afferent fibers
What lung volume would you expect to increase with a patient with COPD?
RV
FRC
TLV
A FEV1/FVC ratio of <70 percent after bronchodilator therapy is a diagnostic of COPD
What cells has humoral immunity??****
B Lymphocytes**
What laws does Fick’s incorporate?
Grahams
Henrys
What is the different between anaphylaxis and anaphylactoid?
Anaphylaxis - Prior sensitization or cross reactivity
Anaphylactoid - No prior exposure needed
For the DOA of LA, what are some secondary variables that would effect the DOA?
Lipid solubility
Intrinsic vasodilating effect
Addition of vasoconstrictors
The primary variable would be protein binding
State what system each drug will affect:
Doxirubicin
Bleomycin
Vincristine
5-Fluorouracil
Doxirubicin - Cardiac
Bleomycin - Pulmonary
Vincristine - Neuropathy
5-Fluorouracil - Bone marrow suppression
Calculate the maximum dose for neostigmine in mcg/kg
70 mcg/kg
5000mcg
Which position has the most V/Q mismatch?
Trendelenburg
What is the anesthetic management for a patient with hypertrophic cardiomyopathy?
DECREASE HR
INCREASE Preload
INCREASE Afterload
DECREASE Contractility? (maintain)
Which Mapelson system is the best for ventilation?
D
Which Mapelson system is the best for spontaneous ventilation?
A
Which Mapelson system has no bag?
E
Spontaneous ventilation only
Describe the posterior superior and anterior borders for the Larsons.
Posterior - Mastoid process
Superior - Skill base
Anteriorly - Displace mandible
What lung volumes will decrease with age?
VC
FEV1
PaO2
Elasticity
No change in TLC
What lung volumes will increase with age?
FRC (INCREASEd RV, normal ERV)
CC
Compliance
Give examples of some SSRIs
Amitriptyline
Nortriptyline
Imipramine
Venlafaxine
Duloxetine
Milnacipran
Fluoxetine
Citalopram
What are some drugs that would affect the BIS monitor?
N2O
Ketamine
Precedex
Metoclopramide will inhibit pseudocholinesterase, therefor it will prolong which drug?
Succinylcholine
Describe what the PT/PTT would look like for the following disease.
DIC
Hemophilia A and B
NSAIDS
vWF
DIC - INCREASED PT/PTT, INCREASED D dimer, Low plt
Hemophilia A and B - INCREASED PTT, no change w/ PT/INR
NSAIDS - NO Change in PT/PTT, INCREASED bleeding time
vWF - INCREASED PTT, no change in PT
What is Pulsus Parasdoxus?
Happens in Cardiac tamponade.
Decreased in SBP by > 10 mmHg during inspiration
Negative intrathoracic pressure on inspiration –> INCREASED venous return to the RV –> Bowing of the ventricular septum toward the LV –> DECREASED SV –> DECREASED CO –> DECREASED SBP
Discuss the TURP fluid complications for the following:
Sobitol NS Distilled water Glycine Mannitol
Sobitol - hyperglycemia (osmotic diuresis, lactic acidosis) 165 osm
NS - Risk of electrocution 203 osm
Distilled water - 0 osm Hemolysis (hyponatremia, hemoglobinuria –> renal failure
Glycine - Transient blindness, increased ammonia (200 osm)
Mannitol - Osmotic diuresis, transient plasma expansion (275 osm)
What drug has the least amount of protein binding?
Ketamine
Next is etomidate
What is the least toxic LA to the fetus?
2 Chloroprocaine
Where do you block the ulnar nerve at the wrist?
Inject medial to and under the flexor carpi ulnaris tendon
What is normal cerebral oxygenation levels?
50-70 percent
What receptors dose Methadone work On?
Mu and kappa AGONIST
NMDA ANATAGONIST
MAOI
Can cause prolong QT
What factors are decreased in pregnancy?
Factor 11
Factor 13
Protein C and S
Anion gap formula.
[Na - (Cl + bicarb)]
Normal is 8-12
What do you mix dantrolene with?
Bacteriostatic water
Which fibers have golgi bodies spindles?
A alpha
How would a transmural injury appear on the EKG?
ST elevation
What medications can prolong QT?
Sevo
Methadone
Droperidol
Haloperidol
Zofran
Amiodarone
Quinidine
Hypokalemia
Hypocalcemia
Hypomagnesemia
What drugs should you not use with a patient and porphyria?
Phenytoin
Lidocaine
Thiopental
Etomidate
Barbs
Opioid potency. How can you use “Superman Rescued Five American Heroes Monday Morning”
Superman Rescued Five American Heroes Monday Morning
Sufenta
Remi = Fentanyl
Alfenta
Hydromorphone
Morphine
Meperidine
What would you see on Aline waveform with the following disease?
LV HF
Cardiac tamponande
Aortic Stenosis
Aortic regurgitation
LV HF - Pulsus Alternans: Beat to beat alternation in pulse size and intensity
Cardiac tamponande - Pulsus Paradoxus: A gradual decrease in BP with inspiration
Aortic Stenosis - Pulsus Parvus: Narrow pulse pressure with small amplitude (looks like an A)
Aortic regurgitation - Bisferiens Pulse: Biphasic systolic peaks (looks like an M)
What is COLT-P?
Describes the order where the diuretics work
Carbonic Anhydrase ( prox tubule ie Acetazolamide, dorzalamide)
Osmotic diuretics (proximal tubule/loop of henle ie. Mannitol isosorbide glycerin)
Loop (thick ascending limb ie lasix bumetandie ethacrynic acid)
Thiazides (distal tubule ie. HCTZ chlothialidone metaolazone indapamide)
Potassium sparking (collecting ducts ie Amiloride/triamterne)
What does TIPPED stand for?
Tibial Inversion Plantar Flexion
+
Peroneal Eversion Dorsiflexion
What are the side effects of mannitol?
CHF
Pulmonary edema
Cerebral edema if BBB not intact
What is the classic triad for TUPR syndrome?
HTN
Bradycardia
Hyponatremia
What causes an S4 sound?
Caused by atrial systole
Head before S1
Which LA is least affected when added with epi?
Chloro
Ropi or BUPI*
These do not have intrinsic vasodilating effects
Lido is the most affected by epi
What is the triple H therapy for cerebral vasospasm?
Hemodilution Hct 30 percent
HTN
Hypervolemia
Plus Nimodipine
How much will 1 PRBC increase Hct and Hgb?
Hgb 1 g/dL
Hct 2-3 percent
What factors affect the spread of LA in a epdirual/spinal?
Spinal: Baricity, position, dose, site, vol/density of CSF
Epidural: Volume
What will happen to a pt with myotonic dystrophy if you give them succs?
Will cause sustained contractures
Hypothermia and neostigmine reversal can also cause this.
When do you give FFP?
PT and/or PTT 1.5x the normal
Normal PT 12-14 seconds
Normal PTT 25-32 seconds
What are normal PT and PTT?
Normal PT 12-14 seconds
Normal PTT 25-32 seconds
Describe percent occupied with NMB.
Vt >5mL/kg
TOF no fade
VC >/= 20mL/kg
Sust. Tetany and no fade & DBS
Insp. force > -40 cmH20 and Head lift > 5 sec
Hand grip x5 seconds, Bite tongue blade
Vt >5mL/kg (80 percent occupied)
TOF no fade (70 percent )—–> 1/4 (<90 percent blocked);
2/4 (80-90 percent );
3/4 (70-80 percent)
VC >/= 20mL/kg (70 percent)
Sust. Tetany and no fade & DBS (60 Percent)
Insp. force > -40 cmH20 and Head lift > 5 sec (50 percent)
Hand grip x5 seconds, Bite tongue blade (50 percent)
What does thromboxane do in pre ecamplsia?
In Pre eclampsia up to 7x more thromboxane than prostacyclin is produced creating an environment that favors:
Platelet aggregation
Vasoconstriction
Decreased uterine blood flow
Where is ADH and oxytocin made?
In the Hypothalamus ADH is created in the Supraoptic nuclei and Oxytocin is made in the paraventricular nuclei.
They are then carried by axonal transport along the pituitary stalk.
The posterior pituitary releases them to the circulation.
FEF 25-75 percent, is this effort dependent or independent?
Independent
What hormone is secreted by the hypothalamus that stimulates the release of other thyroid sections?
Hypothalamus (TRH) –>
Anterior pituitary (TSH) –>
TSH –> Thyroid gland to release T4 (prohormone) –>
T3
What are the medial and lateral landmarks for the Deep peroneal landmark?
Medial - Tibialis anterior tendon
Lateral - Extensor hallucis longus tendon
What parameters increases in pregnancy?
MV TV CO
FACTORS 1 7 8 9 10 12
Sensitivity to LA
GFR
What parameters decrease in pregnancy?
FACTORs 11 and 13 Proteins C and S
MAC
LES tone
Gastric pH
MOA of H2 antagonist?
Decrease volume
Increase pH
How many L of air is in a E is in a cylinder?
625L 2000Psi
O2: 660L 2000 psi
N2O: 1590L 745 psi
What is the position of the median nerve in relation to the axillary artery?
The median nerve is located anterior and medial to the axillary artery.
What is the position of the ulnar nerve in relation to the axillary artery?
The ulnar nerve lies posterior and medial to the axillary artery.
What is the position of the radial nerve in relation to the axillary artery?
The radial nerve lies posterior and lateral to the axillary artery.
What is the position of the musculocutaneous nerve in relation to the axillary artery?
The musculocutaneous nerve lies anterior and lateral to the axillary artery.
What is the reason for cardiac instability after the aortic cross clamp is removed?
Removal of AoX creates a central hypovolemia by:
- Restoring venous capacity
- Shifting a greater proportion of blood to the lower body
- Capillary leak contributes to the loss of intravascular volume
- Venous return decreases
Clamping starves distal tissues of O2. These cells convert to anaerobic metabolism, which results in:
- INCREASED lactic acid production –> metabolic acidosis
- INCREASED prostaglandins
- INCREASED activated complement
- INCREASED myocardial depressant factors
- DEREASED temperature
What happens after aortic clamp PLACEMENT?
Venous Return CO MAP SVR PAOP LV Wall Stress MVO2 Coronary Blood Q Renal Blood Q Total body VO2 SvO2
Venous Return - Increased (Blood volume shifts proximal to clamp)
CO - Decrease (Depends On CV reserve)
MAP - Increase (Increased preload and SVR)
SVR - Increased (mechanical effect of clamp – Increase catecholamine release and RAAS activation)
PAOP - Increase (Increase venous return–depends On CV reserve)
LV Wall Stress - Increase (Increase preload and afterload)
MVO2 - Increase (increase prelaod, wall stress, and afterload)
Coronary Blood Q - Increase (increase AoDBP)
Renal Blood Q - Decrease (even with infrarenal clamp, >30 min increase risk ARF)
Total body VO2 - Decrease (decrease O2 delivery distal to clamp –> anaerobic metabolism
SvO2 - Increased (decrease total body VO2 – less O2 consumed so more is left over)
What happens after aortic clamp REMOVAL?
Venous Return CO MAP SVR PAOP LV Wall Stress MVO2 Coronary Blood Q Renal Blood Q Total body VO2 SvO2
Venous Return - Decrease (central hypovolemia and capillary leak)
CO - Decrease (reduced preload and contractility)
MAP - Decrease (decreased preload and SVR)
SVR - Decrease (Washout of anaerobic metabolites leads to vasodilation)
PAOP - Increased (lactic acidosis leads to increased PVR)
LV Wall Stress - Decrease (decreased preload and afterload)
MVO2 - Decreased (decrease preload and afterload – if increased PAOP –> increased PVR and increased MVO2)
Coronary Blood Q - Decreased (decreased AoDBP)
Renal Blood Q - Decreased (depends On MAP)
Total body VO2 - Increased (cells distal to clamp receive O2 –> aerobic metabolism)
SvO2 - Decrease (increase total body VO2 (more O2 consumed so less is left over)
What is R time and normal value?
R time = Time to begin forming clot
Normal value = 6-8 minutes
Problem area = Coagulation factors
Treatment = FFP
What is K time and normal value?
K time = Time until clot has achieved fixed strength
Normal value = 3-7 minutes
Problem area = Fibrinogen
Treatment = Cryo
What is the Alpha angle (On the TEG) and what is the normal value?
Alpha angle - Speed of fibrin accumulation
Normal Value = 50-60 degrees
Problem area = Fibrinogen
Treatment = Cryo
What is the Maximum Amplitude (MA) and normal value?
Maximum Amplitude (MA) = Highest vertical amplitude On the TEG
Measures clot strength
Normal value = 50-60 mm
Problem area = Platelets
Treatment = Plts +/- DDAVP
What is the Amplitude at minutes After Maximum Amplitude (A60) and normal value?
Amplitude at Minutes After Maximum Amplitude (A60) = Height of vertical amplitude 60 minutes after the maximum amplitude
Normal value = MA - 5
Problem area = Excess fibrinolysis
Treatment = Tranexamic acid
Aminocaproic acid
What resp mechanics are similar between elderly and peds?
INCREASED MV
INCREASED CC
INCREASED RV
DECREASED VC
What drugs are based on IBW?
Water soluble drugs (hydrophilic)
Propofol (induction)
Vec/roc
Sufentanil
Remifentanil
What is difference between Nitroglycerine and Sodium Nitroprusside?
Nitroglycerine - Venodilator (increase nitric oxide –> vasdilation)
-Decrease venous return (preload)
Sodium Nitropursside (and hydralazine)- Increase nitric oxide --> vasodilation -Decrease SVR (afterload)
NOTE that SNP dilates A and V equally
If the BP cuff location is above the heart, what can you expect the reading?
If the BP cuff location is above the heart,
The BP reading will be falsely decreased (there is less hydrostatic pressure)
For every 10cm change, the BP changes by 7.4 mmHg.
For every inch change, the bP changes by 2 mmHg.
If the BP cuff location is below the heart, what can you expect the reading?
If the BP cuff location is below the heart,
The BP reading will be falsely increased (there is more hydrostatic pressure).
For every 10cm change, the BP changes by 7.4 mmHg.
For every inch change, the bP changes by 2 mmHg.
What cardiac parameters will a pnumoperitoneum increase?
INCREASED SVR MAP PVR
Decrease Sphenic and renal blood flow
What can cause an ANION GAP ACIDOSIS?
Anion Gap Acidosis (pH < 7.35 AND Anion gap > 14
MUDPULES
Methanol
Uremia
Diabetic ketoacids
Paraldehyde
Isoniazid
Lactate (decrease DO2, sepsis, cyanide poisoning)
Ethanol, ethylene glycol
Salicylates (inhibits Krebs cycle)
What can cause NON-GAP ACIDOSIS?
Non-Gap Acidosis (pH <7.35 AND Anion gap <14)
HARDUP
Hypoaldosteronism
Acetazolamide
Renal tubular acidosis
Diarrhea
Ureterosignmoid fistula
Pancreatic fistula
*Large volume resuscitation NaCl solutions can cause non-gap metabolic acidosis with hyperchloremia.
