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NCE Review Material > Extra Questions > Flashcards

Extra Questions Flashcards

1
Q

When the patient goes from the supine position to the Head up position, what happens to the lung volumes?

A

Peak inspiratory pressure DECREASES

TLV INCREASES

FRC INCREASES

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2
Q

In the preoperative setting, what is the best way to assess for cardiovascular function?

A

Exercise tolerance

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3
Q

What would the PT/PTT look like for DIC?

A

INCREASED PT and PTT

INCREASED D dimer

Low PLT

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4
Q

What would the PT/PTT look like for Hemophilia A and B?

A

INCREASED PTT

No change in PT/INR

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5
Q

What would the PT/PTT look like for NSAIDS?

A

No change in PT/PTT

INCREASED Bleeding time

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6
Q

What would the PT/PTT look like for vWF?

A

INCREASED PTT

No change in PT

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7
Q

Hypotension, JVD, and Muffled heart sounds are all signs for what disease?

A

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

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8
Q

What is the max dose for EMLA CREAM for a 7-12 yrs and > 20kg?

A

Max Dose is 20g

Max area of application
200 cm2

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9
Q

What is the max dose for EMLA CREAM for a 1-6 yrs and > 10kg?

A

Max dose is 10 g

Max area of application
100cm2

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10
Q

What position is most likely to develop lower extremity compartment syndrome?

A

Lithotomy

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11
Q

What are some secondary variables for the Onset for LA?

A

Dose and concentration

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12
Q

What are some secondary variables for the Potency of LA?

A

Intrinsic vasodilating effect

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13
Q

What is the primary variable for the potency of LA?

A

Lipid solubility

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14
Q

What is the primary variable for the onset of LA?

A

pKa

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15
Q

Why is the spinal does in parturient reduced by 30%?

A

Decrease in CSF volume

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16
Q

Which two factors MOST influence dermatomal spread of epidural block?

A

Site of administration

Volume of LA administered

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17
Q

Vitreous bubble of sulfur or sulfur hexafluoride, how long after administration do you not give N20?

A

15 min before and 10 days after

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18
Q

Where is the most important site for pain modulation?

A

The most important site of modulation is the substantia gelatinosa in the DORSAL HORN (Rexed lamina II and III)

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19
Q

Where does the descending inhibitory pain pathway begin??

A

The descending inhibitory pain pathway begins int he Periadueductal gray and rostroventral medulla.

It projects to the substantia gelatinosa.

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20
Q

Pain is inhibited when the spinal neurons release (what two inhibitory neurotransmitters)?

A

GABA and Gylcine

The descending pain pathway release NE, 5-HT, and endorphins.

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21
Q

What is modulation?

A

It is when pain signal is modified (inhibited or augmented) as it advances towards the cerebral cortex.

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22
Q

Pain is augmented by (what two things)?

A

Central sensitization

and

Wind-up

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23
Q

Perception describes the processing of afferent pain signals in the (what areas of the brain)?

A

In the cerebral cortex and limbic system

This is “how we feel about pain”

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24
Q

What are the components of Cryoprecipitate?

A

Fibrinogen

Factor 8

Factor 13

vWF

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25
Q

Inflammation also contributes to allodynia, what is that?

A

Allodynia - Reduced threshold to pain stimulus

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26
Q

Inflammation also contributes to Hyperalgesia, what is that?

A

Hyperalgesia - Increased response to pain stimulus

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27
Q

What is transduction of pain?

A

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.

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28
Q

A-delta fibers transmit what kind of pain?

A

“Fast pain” that is sharp and well localized

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29
Q

C-fibers transmit what kind of pain?

A

“slow pain” that is dull and poorly localized

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30
Q

What is “transmission” of pain?

A

The pain signal is relayed through the three-neuron afferent pain pathway along the spinothalamic tract.

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31
Q

What Hepatocellular Injury lab test would suggest cirrhosis or alcoholic liver disease?

A

AST/ALT ratio GREATER than 2

AST is 10-40 units/L
ALT is 10-55 units/L

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32
Q

What lab test is the most specific indicator for biliary duct obstruction?

A

5’-Nucleotidase

0-11 units/L

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33
Q

What is present in all LA?

A

Amine group and Benzene ring

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34
Q

How far from the pacemaker should the electrocautery be used?

A

15 cm

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35
Q

What hormones are in the anterior pitutitary?

A

FLAT PiG

Follicle-stimulating hormone
Luteinizing hormone
Adrenocorticotropic hormone
Thyroid stimulating hormone
Prolactin
Growth hormone
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36
Q

What regulates Thyroid Releasing Hormone?

A

T3

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37
Q

What hormones are in the Posterior pituitary

A

Antidiuretic hormone

Oxytocin

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38
Q

Which cranial nerves control eye movement?

A

Oculomotor - III

Trochlear - IV

Abducens - VI

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39
Q

How many minutes before administering SF6 bubble should you shut off Nitrous Oxide?

A

15 min before SF6 is placed and avoid for 7-10 days after SF6 bubble is placed.

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40
Q

What are the landmarks for the popliteal block?

A

Biceps femoris (LATERAL

Semitendinosus (MEDIAL)

Politeal fossa crease

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41
Q

What Endogenous opioids are associated with MU, Kappa, and Delta?

A

MU - Endorphins

Kappa - Dynorphins

Delta - Enkephalins

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42
Q

Drag and drop.

Polygohydraminos

Olgohydraminos

Gestational diabetes

Pre-eclampsia

A

Polygohydraminos - Transephgeal fistula

Olgohydraminos - pulmonary hypoplasia

Gestational diabetes - birth trauma

Pre-eclampsia - small for gestational age

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43
Q

What are two know complications for Marphan Disease?

A

Spontaneous pneumothorax and Aortic dissection

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44
Q

What is the most common dysrhythmia associated with mitral stenosis?

A

Atrial fibrillation

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45
Q

What are 6 risk factors for perioperative cardiac morbidity and mortality for non-cardiac surgery?

A

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

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46
Q

What is the normal IRV?

A

3000mL

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47
Q

What is normal TV?

A

500mL

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48
Q

What is normal ERV?

A

1100mL

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49
Q

What is normal RV?

A

1200mL

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50
Q

What is normal TLC?

A

5800mL

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51
Q

What is normal VC?

A

4500mL

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52
Q

What is normal IC?

A

3500mL

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53
Q

What is normal FRC?

A

2300

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54
Q

What happens to FEV1/FVC ratio and FEF 25-75% in Obstructive disease?

A

Both decrease

Everything is normal (RV, FRC, and TLC are normal or increased if there is gas trapping)

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55
Q

What happens to FEV1/FVC ratio and FEF 25-75% in Restrictive disease?

A

Normal

(everything else is decreased)

This disease process prevents the lungs from expanding

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56
Q

What happens to PAOP after the clamp is placed On the aorta?

A

It increases

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57
Q

How can propofol injection pain be minimized?

A

Giving an opioid prior

Lidocaine before or mixed with prop

Injecting into a larger and more proximal vein

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58
Q

What is clearance inversely proportional to?

A

Half-life

Drug concentration in the central compartment

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59
Q

What is the clearance mechanism for propofol?

A

Liver (P450 enzymes) + extra hepatic metabolism (lungs)

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60
Q

What is MOA of proprofol?

A

Direct GABA-A agonist –>

INCREASE CL conductance–>

Neuronal hyperpolarization

(makes the cell more negative)

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61
Q

What is the duration to wait for elective surgery if a patient has a bare metal stent?

A

30 days (3 months preferred)

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62
Q

What is the duration to wait for elective surgery if a patient is s/p CABG?

A

6 weeks (3 months preferred)

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63
Q

What is the MOA for ketamine?

A

Ketamine is an NMDA receptor antagonists (antagonizes glutamate)

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64
Q

What are the secondary receptor targets for ketamine? (besides NMDA)

A 
Opioid, 
MAO, 
Serotonin, 
NE 
Muscarinic, 
NA+ channels
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65
Q

Ketamine dissociates sensory and awareness, what area of the brain are these located?

A

Ketamine dissociates the THALAMUS (sensory) and the LIMBIC SYSTEM (awareness)

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66
Q

What are the blood gas solubility for N20, Des, sevo, iso?

A

N20 - 0.46

Des - 0.42

Sevo - 0.65

Iso - 1.46

Order from Fastest to slowest induction (top to bottom).

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67
Q

What will happen to IV induction with a left to right shunt?

A

Slower IV induction

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68
Q

What will happen to a right to left shunt with IV induction?

A

Faster IV induction

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69
Q

What will happen to a right to left shunt with DES and ISO?

A

Des will have a fast induction (Low blood gas solubility)

ISO will have a slow induction (high blood gas solubility)

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70
Q

What drugs will increase MAC?

A 
Chronic alcohol consumption
Acute amphetamine intoxication
Acute cocaine intoxication
MAOIs
Ephedrine
Levodopa

(things that will increase metabolic rate??)

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71
Q

What electrolyte will increase MAC?

A

Hypernatremia (High Na)

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72
Q

What ages will increase MAC?

A

Increase in infants 1-6 months

Sevo is the same for neonates and infant

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73
Q

Will pheomelanin increase MAC?

A

Yes pheomelanin is another term for Red hair, which is a factor that increases MAC.

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74
Q

What are some factors that will increase FA/FI (faster onset, pushes the curve up)?

A 
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

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75
Q

Tidal volume of >5 mL/kg is associated with what percent of receptors occupied? (NMB)

A

80 percent

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76
Q

Single twitch is associated with what percent of receptors occupied? (NMB)

A

75-80 percent

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77
Q

Train of four is associated with what percent of receptors occupied? (NMB)

A

70-75 percent

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78
Q

Head life > 5 second is associated with what percent of receptors occupied? (NMB)

A

50 percent

Handgrip and/or bite on tongue blade sustained for 5 seconds is also associated with 50 percent

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79
Q

Sustained tetanus and double burst suppression is associated with what percent of receptors occupied? (NMB)

A

60 percent

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80
Q

Vital capacity > 20mL/kg is associated with what percent of receptors occupied? (NMB)

A

70

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81
Q

Between Atropine, Scopolamine, glyco, which has the most sedation, antisialagogue, mydriasis cycloplegia, and prevention of motion induced nausea?

A

Scopolamine

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82
Q

Rank the neuromuscular blockers according to their likelihood of causing anaphylaxis.

A

Succ

Atracruium

Ciastracurium

Roc

Vec

Ranked in highest to lowest likelihood

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83
Q

What are the elevated risk for a patient with Marfan syndrome?

A

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

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84
Q

What is Ehlers- Danlos syndrome?

A

It is an inherited disorder of procollagen and collagen.

There is an increased bleeding and hematoma is common.

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85
Q

What Trunks give rise to the Median nerve?

A

Superior and Inferior trunks

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86
Q

What procedure risk factors contribute to ION?

A

Prone position

Use of Wilson frame

Long duration of anesthesia

Large blood loss

Low ratio of colloid to crystalloid resuscitation

Hypotension

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87
Q

The spinal cord is perfused by how many arteries?

A

1 anterior spinal artery

2 posterior spinal arteries

6 - 8 radicular arteries

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88
Q

List the side effects common to acetylcholinesterase inhibitors (will not break down Ach, this will build up).

A

DUMBBELLS

Diarrhea
Urination
Miosis
Bradycardia (M2)
Bronchoconstriction (M3)
Emesis
Lacrimation
Laxation
Salivation
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89
Q

How do you asses the axillary nerve (sensory and motor)?

A

Sensory
-Pinch lateral aspect of shoulder

Motor
-Arm abduction (deltoid contraction)

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90
Q

How do you asses the Musculocutaneous nerve (sensory and motor)?

A

Sensory
-Pinch lateral aspect of forearm

Motor
-Elbow flexion (biceps contraction)

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91
Q

How do you asses the Median nerve (sensory and motor)?

A

Sensory
-Pinch index finger

Motor
-Thumb opposition

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92
Q

How do you asses the Radial nerve (sensory and motor)?

A

Sensory
-Pinch web space between thumb and index finger

Motor

  • Elbow extension (triceps contraction)
  • Wrist and finger extension
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93
Q

How do you asses the Ulnar nerve (sensory and motor)?

A

Sensory
-Pinch pinky finger

Motor
-Pinky finger abduction

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94
Q

Name 3 conditions that are associated with high risk of developing DIC.

A

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

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95
Q

What are some advantages of using colloids vs crystalloids?

A 
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

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96
Q

What are some advantages of using crystalloids vs colloids?

A

Replacement ratio = 3:1

Expands the ECF

Restores 3rd space loss

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97
Q

List the triggers that cause sickling of HgbS.

A

Pain

Hypothermia

Hypoxemia

Acidosis

Dehydration

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98
Q

On the CVP waveform, what happens On the Y descent?

A

RA empties through open tricuspid valve

Electrical Event = After T wave ends

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99
Q

On the CVP waveform, what happens On the A wave?

A

Right atrial contraction

Electrical event = Just after P wave (atrial depolarization)

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100
Q

On the CVP waveform, what happens On the C wave?

A

Right ventricular contraction
-bulging of tricuspid valve into RA

Electrical event = Just after QRS complex (ventricular depolarization)

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101
Q

On the CVP waveform, what happens On the V wave?

A

Passive filling of RA

Electrical event = Just after T wave begins (ventricular repolarization)

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102
Q

On the CVP waveform, what happens On the X descent?

A

RA relaxation

Electrical Event = ST segment

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103
Q

For urine osmolality, what would indicate prerenal oliguria (abnormally small amounts of urine)?

A

> 500 mOsm/kg

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104
Q

What is the most common cause of perioperative acute kidney injury?

A

The most common cause of perioperative kidney injury is ischemia-reperfusion injury.

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105
Q

How does rhabdomyolysis affect renal function?

A

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.

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106
Q

How can you prevent or minimize renal injury in the pt with rhabdomyolysis?

A

Maintenance of renal blood flow and tubular flow with IV hydration.

Osmotic diuresis with mannitol.

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107
Q

What steps can be taken to prevent nephrotoxicity from radiographic contrast media?

A

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.

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108
Q

What is the MOA of fenoldapam?

A

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.

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109
Q

How much of the renal blood flow is filtered at the glomerulus?

A

Renal blood flow = 1000 - 1250 mL/min

Glomerular filtration rate = 125 mL/min or about 20 percent of RBF

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110
Q

What are the key side effects of thiazide diuretics? (hydrocholorothiaxide, Metolazone, Indapamide)

A

These work in the distal tubule.

Side effects:

  • Hyperglycemia
  • Hypercalcemia
  • Hyperuricemia
  • Hypokalemic, Hypochloremic metabolic alkalosis
  • Hypovolemia
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111
Q

What is the treatment for acute hemolytic reaction?

A

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

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112
Q

In the body, hypoglycemia will stimulate the release of?

A

Glucagon (pancreatic alpha cells)

Epi (adrenal medulla)

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113
Q

What are some associated conditions that is associated with SIADH (too much ADH)?

A

Traumatic brain injury (most common)

Cancer (small-cell lung carcinoma)

Noncancerous lung disease

Carbamazepine (anticonvulsant)

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114
Q

What is the presentation of SIADH (Too much ADH)?

A

Hyponatremia

Plasma

  • Volume = Euvolemic (or hypervolemic)
  • Hypotonic (
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115
Q

What is the treatment for diabetic ketoacidosis?

A

Volume resuscitation, insulin, K after acidosis subsides.

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116
Q

How do you manage the patient with thyroid storm?

A

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)

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117
Q

What is the duration of action for very rapid acting insulin?

A

Lispro, Insulin aspart, Glulisine

2-4hr

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118
Q

What is the duration of action for rapid acting insulin?

A

Regular 6-8 hr

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119
Q

What is the duration of action for intermediate-acting insulin?

A

NPH 18-28 hr

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120
Q

What is the duration of action for long acting insulin?

A

Detemir 6-24 hr

Glargine 20-24+ hr

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121
Q

What are the s/sx of hypoglycemia?

A

SNS stimulation (tachycardia, HTN, diaphoresis)

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122
Q

What is the treatment for TURP syndrome?

A

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.

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123
Q

What is the pathophysiology for Left to right shunt?

A

DECREASED systemic blood flow

  • Low CO
  • Hypotension

INCREASED pulmonary blood flow

  • Pul HTN
  • RVH
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124
Q

What are the hemodynamic goals for Left to right shunt?

A

Avoid INCREASED SVR

Avoid DECREASED PVR

  • Decrease FiO2
  • Hypoventilation

(Hypoxemia and hypercarbia will increase PVR)

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125
Q

Describe the three stages of labor.

A

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

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126
Q

What is the pathophysiology of Right to left shunt?

A

DECREASED pulmonary blood flow

  • Hypoxemia
  • LV volume overload
  • LV dysfunction
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127
Q

What is the hemodynamic goals for a patient with a Right to left shunt?

A

Maintain SVR

DECREASED PVR

  • Hyperoxia
  • Hyperventilation (low co2)
  • Avoid lung hyperinflation
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128
Q

Who is at risk for aortocaval compression?

A

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)

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129
Q

What are the hemodynamic goals for tetralogy of Fallot?

A

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

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130
Q

What drugs are used in the treatment of carcinoid crisis?

A

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

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131
Q

What drugs should be avoided in the patient with carcinoid syndrome?

A

Histamine releasing drugs just as morphine, meperidine, atracurium, thiopental, and succinylcholine

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132
Q

What is the clinical presentation of croup?

A

Mild fever

Inspiratory stridor

Barking cough

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133
Q

What is the treatment for croup?

A

O2

Racemic epinephrine

Corticosteroids

Humidification

Fluids

Intubation rarely required

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134
Q

What are the risk factors for post intubation larygngeal edema?

A

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)

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135
Q

What is the best way to minimize the risk of post intubation laryngeal edema?

A

The best treatment is prevention!

Manometer to intermiitently measure cuff pressure.

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136
Q

Where is the central chemoreceptor?

A

Located in the medulla

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137
Q

What does the central chemoreceptor respond to?

A

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)

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138
Q

Where is the Peripheral chemoreceptors located?

A

Carotid bodies - Nerves of Hering –> Glossopharyngeal n. (CN IX)

Aortic arch - Vagus n. (CN X)

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139
Q

What do the peripheral chemoreceptors respond to?

A

Respond to DECREASED O2,
INCREASED CO2
INCREASED H+

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140
Q

Discuss the management of hypoxemia during one-lung ventilation.

A

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.

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141
Q

What drugs will increase pulmonary vascular resistance?

A

NITROUS Oxide

Ketamine

Desflurane

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142
Q

What are some ways to increase Pulmonary vascular resistance?

A

Hypoxemia
Hypercabia
Acidosis

SNS stimulation
Pain
Hypothermia

Increased intrathoracic pressure

  • PEEP
  • Atelectasis
  • Mechanical ventilation
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143
Q

What are some ways to decrease Pulmonary vascular resistance?

A

Increase PaO2

Hypocarbia (low Co2)

Alkalosis

Decrease intrathoracic pressure

  • Preventing coughing/straining
  • Normal lung volumes
  • Spontaneous ventilation
  • High frequency jet ventilation
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144
Q

What are some drugs that will decrease Pulmonary vascular resistance??

A

Inhaled NITRIC oxide

Nitroglycerin

Phosphodiesterase inhibitors (sildenafil)

Prostaglandins (PGE1 and PGI2)

CCB

ACEi

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145
Q

What are some disadvantages of colloids vs crystalloids?

A

Albumin bings to Ca –> hypocalcemia

Coagulopathy

  • Dextra > Hetastarch > Hetend
  • Dont exceed 20mL/kg
  • Not a problem with voluven

Anaphylactic potential
-Highest risk is Dextran

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146
Q

What are some disadvantages of crystalloids vs colloids?

A

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
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147
Q

What conditions impair atlanto-occipital joint mobility?

A

Degenerative joint disease
Rheumatic arthritis

Ankylosing spondylitis

Truama
Surgical fixation

Klippel-Feil
Down syndrome

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148
Q

Where do you measure the thyromental distance?

A

Tip of the thyroid cartilage to the tip of the mentum

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149
Q

Describe the pharmacologic prophylaxis of aspiration pneumonitis.

A

Antacids: Sodium citrate, Sodium bicarbonate, Mag trisilicate

H2 antagonists: Ranitidine, cimetidine, famotidine

GI simulants: Metocloproamide

Proton pump inhibitors: omeprazole, lansoprazole, pantoprazole

Antiemetics: droperidol, ondansetron

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150
Q

What are two common causes of angioedema?

A

Angiotensin converting inhibitors
-treat with epi, antihistamines, steroids (just like anaphylaxis)

Hereditary angioedema (C1 esterase deficiency)
-treat with C1 esterase concentrate of FFP
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151
Q

The lumen of the bronchial blocker can be used for (during OLV)?

A

Use for
-Insufflate O2 into the non-ventilated lung

-Suction air from the non-ventilated lung (improves surgical exposure)

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152
Q

The lumen of the bronchial blocker can NOT be used for (during OLV)?

A

NOT used for
-Ventilation

-Suction blood, pus, or secretions from the non-ventilated lung

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153
Q

When is the best time to use an airway exchange catheter?

A

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)
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154
Q

Stimulation of what receptor will contract the Uterus?

A

Alpha 1 will contract the Uterus

Alpha 1 = Gq (a1, M1/3/5, V1. H1)

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155
Q

Stimulation of what receptor will relax the Uterus?

A

Beta 2 will relax the uterus

Beta 2 = Gs (B1 B2 D1 V2 H2)

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156
Q

Stimulation of what receptor will Contract the Trigone and sphincter of the bladder?

A

Alpha 1 will contract the trigone and sphincter of the bladder

Alpha 1 = Gq (a1, M1/3/5, V1. H1)

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157
Q

Stimulation of what receptor will Relax the Detrusor of the bladder?

A

Beta 2 will relax the Detrusor of the bladder

Beta 2 = Gs (B1 B2 D1 V2 H2)

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158
Q

What receptors are assocatied with Gi?

A

A2

M2
M4

D2

(DECREASE cAMP)

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159
Q

What will impair the HPV?

A

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)

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160
Q

What hemodynamic conditions reduce cardiac output in the patient with hypertrophic cardiomyopathy?

A

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.

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161
Q

What is the risk of perioperative myocardial infarction in the patient with a previous MI?

A

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

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162
Q

What is the pathophysiology of protein C and S deficiency?

A

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.

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163
Q

What is the treatment for Protein C and S deficiency?

A

A thromboembolism is treated with heparin that is transitioned to warfarin.

Patients may or may not require life-long anticoagulation with warfarin.

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164
Q

List the possible causes of a non-gap acidosis.

A 
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)

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165
Q

What alpha receptors will cause the arteries to vasoconstrict more?

A

Alpha 1 > Alpha 2

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166
Q

What alpha receptors will cause the veins to vasoconstrict more?

A

Alpha 2 > Alpha 1

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167
Q

What regional technique can be used for the patient undergoing carotid endarterectomy?

A

Cervical plexus block (superficial or deep) at C2-C4

Local infiltration

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168
Q

Describe the presentation of hypermagnesemia.

A

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

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169
Q

What is the first sign of bronchial intubation?

A

Earliest manifestation of bronchial intubation is an increase in peak inspiratory pressure.

May also happen:
Asymmetrical chest expansion

Unilateral breath sounds

Hypoxemia

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170
Q

Which drug is difficult to be reversed by nalaxone d/t the high affinity for mu receptors?

A

Buprenorphine

Available via transdermal route

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171
Q

Butorphanol is useful for what post op condition?

A

Butorphanol is useful for post op shivering.

Kappa agonist

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172
Q

Phenytoin and carbamazepine will do what to hepatic enzymes?

A

They are hepatic inducers

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173
Q

What is the defining characteristic between type I and type II complex regional pain syndrome?

A

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).

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174
Q

What are some examples of Type I Immediate hypersensitivity?

A

Anaphylaxis

Extrinsic asthma

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175
Q

Describe the pathophysiology of Type I immediate hypersensitivity.

A

Antigen + antibody interaction in a patient who has been previously sensitized to the antigen.

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176
Q

What are some examples of Type II antibody-mediated hypersensitivity?

A

ABO-incompatibility

Heparin-induced thrombocytopenia

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177
Q

Describe the pathophysiology of Type II Antibody-mediated hypersensitivity.

A

IgG and IgM antibodies bind to cell surfaces or extracellular regions.

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178
Q

What are some examples of Type III immune complex hypersensitivity?

A

Snake venom reaction

Protamine induced vasoconstriction

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179
Q

Describe the pathophysiology of Type III immune complex mediated hypersensitivity.

A

An immune complex is formed and deposited into the patient’s tissue.

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180
Q

What are some examples of Type IV delayed hypersensitivity reaction?

A

Contact dermatitis

Graft-vs-host reaction

Tissue rejection

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181
Q

Describe the pathophysiology of Type IV delayed hypersensitivity.

A

Allergic reaction is delayed at least 12 hours following exposure.

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182
Q

What is Allodynia?

A

Pain due to a simulus that does not normally produce pain.

Ex. Fibromyalgia

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183
Q

What is Dysesthesia?

A

Abnormal and unpleasant sense of touch.

Ex. Burning sensation from diabetic neuropathy

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184
Q

What is Neuralgia?

A

Pain localized to a dermatome.

Ex. Herpes Zoster (shingles)

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185
Q

What is the modified Brooke formula?

A

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

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186
Q

What are 4 acyonotic shunts?

A

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
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187
Q

What are the 4 mechanisms of heat transfer? Rank them from the most to least important.

A

Radiation - Infrared (60 percent)

Convection - Air (30 percent)

Evaporation - Water loss (20 percent)

Conduction - Contact (<5 percent)

How well did you know this?
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2
3
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188
Q

Which has a covering present? Omphalocele or gastroschisis?

A

Omphalocele has a covering present

189
Q

Which is more urgent? Omphalocele or gastroschisis?

A

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

190
Q

What is less urgent?

Omphalocele or gastroschisis?

A

Omphalocele is less urgent

Requires cardiac workup first

191
Q

Which one presents with a defect On the midline - that involves the umbilicus? Omphalocele or gastroschisis?

A

Omphalocele has a midline defect that involves umbilicus

192
Q

Which one presents with an off midline defect that usually is to the right of the umbilicus? Omphalocele or gastroschisis?

A

Gastrocschisis usually has a defect that is off midline that is usually right of the umbilicus

193
Q

What is a co existing disease with gastroschisis?

A

Prematurity

194
Q

What are some co existing disease with omphalocele?

A

Trisomy 21

Cardiac defects

Beckwith-wiedemann syndrome

195
Q

How are TSH, T3, T4 levels affected by hyperthyroidism?

A

Hyperthyroidism:

Low TSH + High T3 and T4

196
Q

How are TSH, T3, and T4 levels affected by hypothyroidism?

A

Hypothyroidism:

High TSH + Low T3 and T4

197
Q

What are the absolute contraindications to extracoporeal shock wave lithotripsy?

A

Pregancy

Risk of bleeding (bleeding disorder or anticoagulation)

198
Q

According to RIFLE, what is considered “risk”?

A

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

199
Q

According to RIFLE, what is considered “injury”?

A

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

200
Q

According to RIFLE, what is considered “failure”?

A

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

201
Q

How much percentage is sodium reabsorbed in the PCT, LOH, DCT, Collecting duct, and the urine?

A

Proximal Tubule = 65 percent

Loop of Henle (thick ascending limb) = 20 percent

Distal tubule = 5 percent

Collecting duct = 5 percent

Urine = 5 percent

202
Q

What does FFP contain?

A

All of the clotting factors.

203
Q

A patient is acutely intoxicated with alcohol, how will this affect their MAC levels?

A

MAC is decreased in the acutely intoxicated patient.

204
Q

Regarding the extrinsic pathway, What activates it? What lab tests measures it? and what drug inhibits it?

A

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.

205
Q

Which cranial nerve will Abduct the eyes?

A

CN VI

Movement involves 3 4 and 6

206
Q

Which cranial nerve will make the eyes down inward and down at and angle?

A

CN IV

Movement involves 3 4 and 6

207
Q

What is the formula for cerebral perfusion pressure?

A

CPP = MAP - ICP (or CVP whichever is higher)

208
Q

What is the calculation for mean arterial blood pressure?

A

MAP = (1/3 x SBP) + (2/3 x DBP)

MAP = [(CO x SVR) / 80] + CVP

Normal = 70 - 105 mmHg

209
Q

What happens in the A C and V wave on the CVP waveform?

A

A wave = RA contraction

C wave = Tricuspid valve elevation into RA

V wave = RA passive filling

210
Q

What happens in the X and Y descents On the CVP waveform?

A

X descent = Downward movement of contracting RV

Y descent = RA empties through open tricuspid valve

211
Q

What is an under-damped system in the transducer system?

A

Baseline is re-established after several oscillations (SBP is over estimated, DBP is underestimated and MAP is accurate)

212
Q

What is the optimally damped system for the transducer system?

A

Baseline is re-established after 1 oscillation.

213
Q

What 2 things must you do in the event of an O2 supply line crossover?

A

Turn ON the O2 cylinder.

Disconnect the pipeline O2 supply. This is a key step!

214
Q

What is the gas pressure in psi for the intermediate pressure system?

A

50 psi if using pipeline and 45 psi if using the tank

215
Q

What causes remifentanil susceptible to hydrolysis by erythrocyte and tissue esterases?

A

Remifentanil contains an ester linkage.

This renders it susceptible to hydrolysis by erythrocyte and tissue esterases.

216
Q

In the obese patient, the rate of remifentanil infusion is calculated with?

A

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).

217
Q

Of all the opioids, which one has the fastest onset of action?

A

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.

218
Q

Grapefruit jurice, cimetdine, omeprozole, isoniazid, SSRIs, Erythromycin, and ketoconazole will all do what to hepatic enzymes?

A

They are all hepatic enzyme inhibitors.

219
Q

How does the intra-aortic balloon pump function during diastole?

A

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.
220
Q

How does the intra-aortic balloon pump function during systole?

A

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.
221
Q

What does Nitric oxide do to guanylate cyclase?

A

Nitric Oxide activates guanylate cyclase.

Guanylate cyclase converts guanosine triphosphate to cyclic guanosine monophosphate.

This leads to decrease Ca+2 and vasodilation.

222
Q

Describe the Frank-Starling relationship.

A

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.

223
Q

List the 5 phases of ventricular action potential and describe the ionic movement during each phase.

A

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

224
Q

What is the value of P50?

A

26.5

225
Q

What are 2 indications for retrograde intubation?

A

Unstable cervical spine (most common use of RI)

Upper airway bleeding (can’t visualize glottis)

226
Q

How is tobacco smoke harmful?

A

Smoking increases:

SNS tone
Sputum production

227
Q

What are the absolute indications for OLV?

A

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

228
Q

What are the short term cessation effects of smoking?

A

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)
229
Q

What are the intermediate term cessation effects of smoking?

A

The return of normal pulmonary function requires at least 6 weeks.

This includes:

  • Airway function
  • Mucociliary clearance
  • Sputum production
  • Pulmonary immune function
230
Q

What are the 4 things that must be proven in a law suit asserting malpractice?

A

Duty
Breach of duty
Causation
Damages

231
Q

What is Res Ipsa Loquitur?

A

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:

  1. If the injury would not have occurred in the absence of negligence
  2. The injury was caused by something under the complete control of the defendant (provider).
  3. The patient did not contribute in any way to the injury.
  4. The evidence for the explanation of events is sole under the control of the provider.
232
Q

What are the 6 elements of high-quality care?

A

Patient centered

Safe

Effective

Timely

Efficient

Equitable

233
Q

What is vicarious liability?

A

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.

234
Q

What is Nonmaleficence?

A

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).

235
Q

What is the presentation of an obturator nerve injury?

A

Inability to ADDuct the leg

Reduced sensation over the medial aspect of the thigh

236
Q

What is the etiology of an obturator nerve injury?

A

Excessive flexion of the thigh towards the groin

Excessive traction during lower abdominal surgery

Forceps delivery

237
Q

What is the presentation of the radial nerve injury?

A

Wrist drop

Inability to extend the hand at the wrist.

238
Q

What are the diagnostic indicators for metabolic syndrome?

A

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.

239
Q

What are the 5 categories in the Aldrete scoring system?

A

Activity

Respiration

Circulation

Consciousness

Oxygen Saturation

240
Q

Discuss the role of the cyclooxygenase enzyme in the arachidonic acid cascade.

A

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.
241
Q

What are the 6 elements of informed consent?

A

Competence

Decision-making capacity

Disclosure of information

Understanding of disclosed information

Voluntary consent

Documentation

242
Q

What are absolute contraindications for ECT?

A

Recent myocardial infarction (< 4-6 months)

Recent intracranial surgery (<3 months)
Recent stroke (<3 months)

Brain tumor
Unstable cervical spine
Pheochromocytoma

243
Q

What is the etiology and treatment of serotonin syndrome?

A

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

244
Q

The seizure caused by ECT results in profound physiologic changes. What are the initial and secondary response from the ANS?

A

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)

245
Q

What are some cardiovascular consequences of perioperative hypothermia?

A

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

246
Q

What are some pharmacologic consequences of perioperative hypothermia?

A

Slowed drug metabolism - prolonged effects of anesthetic agents

Increased solubility of volatile agents - Prolong emergence

247
Q

What are some causes of increased Hct?

A

Chronic lung disease

Dehydration

Chronic smoking

Living at high altitudes

Diuretics

248
Q

Which disorder has symptoms that improves with exercise?

A

Lambert - Eaton myastemic syndrome (LEMS)

249
Q

What is the partial pressure of room air at sea level?

A

0.21 x 760 = 159.6

160

250
Q

Where do the pre ganglionic parasympathetic nerves originate?

A

CN 3 7 9 10 in brainstem and S2-S4

Cranio sacral

251
Q

What is lacking in old blood?

A

Factors 5 and 8

252
Q

What is the seizure prophylaxis for PIH?

A

Mag loading does 4-6 gm IV 20-30 min

Infusion of 1-2 gm/hr up to 24 hrs postpartum.

253
Q

Which agents should be avoided in the patient with carcinoid syndrome?

A

Morphine and Ephedrine

Avoid Histamine release and SNS stimulation

254
Q

What is the anesthetic management for Obstructive hypertrophic cardiomyopathy?

A

INCREASE preload

DECREASE contractility

DECREASE Hr

DECREASE SNS

INCREASE intravascular volume

MAINTAIN afterload

255
Q

How long do you have to wait before surgery for a pt with a drug eluding stent?

A

1 year

256
Q

What are two inhibitory spinal cord neurotransmitter?

A

GABA and Glycine

257
Q

What would cause a large V wave On the CVP?

A

Tricuspid regurgitation

258
Q

What is the formula for sizing the ETT?

A

(Age/4) + 4 (uncuffed)

259
Q

What is the minimum psi for jet ventilation?

A

50 psi

260
Q

List the duration of action of the LA from shortest to longest.

A

Chloroprocaine (shortest)

procaine

Prilocaine

Lidocaine

Tetracaine

Mepivaciane

Ropivacaine

Bupivacaine (longest)

261
Q

Where do you place the BP cuff during a mediastoscopy?

A

BP left arm, the Aline On the right

262
Q

What is the treatment for ICP during traumatic brain injury?

A

3 percent saline

263
Q

What are the absolute contraindication for ESWL?

A

Pregnancy

Risk of bleeding

264
Q

Myelomeningocele is associated with what?

A

Hydrocephalus

Latex allergy

265
Q

What is the difference between practice guidelines and practice standards?

A

Guidelines = “should” be adhered to

Standards = “must” be adhered to

266
Q

Indomethacin can do what to the patent ductus arteriosus?

A

It can close it.

267
Q

What is the strongest bond?

A

Covalent bonds

268
Q

Capsacin, what kind of pain does it alleviate?

A

Neuropathic

Inflammatory

269
Q

Where does the dural sac end in pediatrics?

A

S3

270
Q

What ligament goes from the Forman magnum to the sacrum?

A

Supraspinous ligament

271
Q

What stimulates TSH, T3, T4 release?

A

Thyrotropin Release hormone

272
Q

A vital capacity of at least (BLANK) is required for an effective cough.

A

A vital capacity of at least 15 mL/kg is required for an effective cough.

273
Q

What region is affected with eaton-lambert syndrom?

A

Voltage-gated Ca2+ channel

Presynaptic neuron is affected

There is a decreased Ach release

274
Q

What region is affected with myasthenia gravis?

A

Nm receptor (postsynaptic)

Postsynaptic motor endplate is affected

There is a decrease response to Ach

275
Q

With syndrome has a sensitive response to succinylcholine and nondepolarizers?

A

Eaton-Lambert syndrome

276
Q

Which syndrome has a sensitive response to nondeplarizers and RESISTANT to succinylcholine?

A

Myasthenia gravis

277
Q

What causes a cough with ACE inhibitors?

A

Bradykinin (buildup of bradykinin contributes to the cough)

278
Q

In preeclampsia, what will increase thromboxane do?

A

Leads to increased vasoconstriction

279
Q

What is the reason why you have to increase the dose for succs in neonates?

A

They have an increased ECF

280
Q

What two things will worsen multiple sclerosis?

A

Hyperthermia

Spinal anesthesia

281
Q

Pseudocholinesterase is increased in which patient population?

A

Obese

282
Q

Pectus Excavatum can be found in a patient with what disease?

A

Marfan Syndrome

283
Q

In the circle of willis, if this artery was blocked, it would cause blindness, which artery is that?

A

The Ophthalmic artery (this was a hotspot)

284
Q

What two oropharyngeal airways can you intubate with?

A

Williams

Ovassapian

285
Q

How can you calculate the ejection fraction from the flow volume loop?

A

EF = (EDV - ESV) / EDV

286
Q

What would cause the A wave to disappear on the CVP waveform?

A

Atrial fib

Ventricular paced

287
Q

What is the most common excitatory neurotransmitter in the central nervous system?

A

Glutamate

288
Q

What IV drugs would cause a decrease in pulse ox reading when administered?

A

Indigo carmine

Methylene blue

289
Q

Etomidate, Thiopental, and Propofol will do what to cerebral vascular?

A

It will cause cerebral vasoconstriction (decrease ICP) (Decrease CMRO2)

290
Q

What is involved in humoral immunity?

A

B Lymphocyte

291
Q

What is the formula for Coronary Perfusion pressure?

A

CPP = AoDBP - LVEDP

292
Q

What cardiovascular changes happen with a pt in the prone position?

A

Decrease SVR

Decrease CO

Decrease BP

293
Q

What is the most common site of obstruction of CSF flow?

A

Aqueduct of silvas

294
Q

What would be the treatment if a patient saturation drops from 98 to 85 percent after Prilocaine was administered?

A

Methylene blue

295
Q

What kind of pain is considered Somatic pain?

A

Sharp, fast, localized

296
Q

Which drug can prolong seizures during ECT?

A

Etomidate

297
Q

Where does a serotonin agonist work?

A

Hippocampus

298
Q

What is the main reason for the extended duration of action for morphine in the elderly population?

A

Smaller Vd

Decreased clearance

299
Q

Major negative feedback mechanism for thyroxine stimulating hormone?

A

T3

300
Q

What population has a decreased plasma cholinesterase?

A

Obstetrics

301
Q

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).

A

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

302
Q

Cardiac output will come back to normal (HOW MANY HOURS) post delivery?

A

48 hours

303
Q

List the steroids from most to least potent.

A

Decadron

Methypednisom

Predinsone

Cortisol

Aldosterone

304
Q

What drug will you not give to G6 PD deficiency patients?

A

Methylene blue

305
Q

What is the most common complication of retrobulbar block?

A

Retrobulbar hemorrhage

306
Q

What would increase the concentration of barbiturates?

A

Liver disease

307
Q

Which drug do you not want to give to a breastfeeding mother?

A

Toradol (can close DA?)

308
Q

If a 4 year old needs to have their lung isolated during surgery, what can you do?

A

Rt main stem intubation with a regular ETT, since you cant use a bronchial blocker.

309
Q

What are three things that you can use to treat hypercalcemia intraop?

A

Lasix

Hyperventilate

Hydrate

310
Q

What electrolyte to neonates like to excrete?

A

Sodium

311
Q

You performed an ankle block, patient has sensation and movement in toes, what nerves didn’t get blocked?

A

Superficial peroneal

Deep Peroneal

312
Q

Hemophilia A has a disorder in what factor?

A

Factor 8

313
Q

Hemophilia B has a disorder in what factor?

A

Factor 9

314
Q

What would be the most appropriate anesthetic plan for an obese patient having a liver biopsy?

A

TIVA with spontaneous breathing

315
Q

What is the MOA for digoxin?

A

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.

316
Q

What is the expected MAC of sevoflurane in a 80 year old patient?

A

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

317
Q

Interscalene will block what part of the brachial plexus?

A

Roots

318
Q

Supraclavicular will block what part of the brachial plexus?

A

Trunks/division

319
Q

Infracalvicular will block what part of the brachial plexus?

A

Cords

320
Q

Axillary will block what part of the brachial plexus?

A

Branches

321
Q

What leads On the EKG look at the RCA?

A

Inferior heart RCA

II
III
aVF

322
Q

What leads On the EKG look at the CxA?

A

Lateral heart Circumflex

I
aVL
V5-V6

323
Q

What leads On the EKG look at the LAD?

A

Anterior septal LAD
V1 V2

Anterior LAD
V3 V4

324
Q

What gland regulates the thyroid the most?

A

Hypothalamus

T3

325
Q

Which drugs do you not give to a pt taking MAOIs?

A

Ephedrine

Meperidine

Cocaine

326
Q

Give a brief description of Transduction, transmission, modulation, and perception.

A

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

327
Q

In the pediatric population, what is the most common cause of liver failure?

A

Biliary atresia

328
Q

What causes heat loss in the first hour of redistribution?

A

Radiant heat loss

329
Q

What fluid would you give to a patient that is hypernatremic and dry?

A

Isotonic

330
Q

What position would compartment syndrome be mostly related to?

A

Lithotomy position

331
Q

What does the second stage regulator do?

A

Decreases the pressure from 50 psi to 16 psi

332
Q

Large bore IV catheter is an example of what law?

A

Pouseilles law

333
Q

Tension of a AAA is an example of what law?

A

La place law

334
Q

Velocity/flow based On Hct (viscosity) is an example of what law?

A

Laminar flow

335
Q

What drug can decrease the length of a seizure in an ECT?

A

Propofol

336
Q

The patient cannot curl toes, what nerve is damage?

A

Tibial nerve

337
Q

Which drugs should not be given to pts with known irritation to PABA?

A

Esters LA

338
Q

You see a delta wave On the EKG, what would you suspect?

A

Wolff-parkinson white syndrome

339
Q

How far should you advance a DLT for males and females?

A

Males = 29 cm

Females = 27 cm

340
Q

What happens to the chest wall compliance and pulmonary compliance in the neonate?

A

Chest wall compliance is INCREASED

Pulmonary compliance is DECREASED

341
Q

What happens to Albumin and Alpha-1 acid glycoprotein concentrations in the neonate?

A

They both are reduced

342
Q

Describe Addison’s disease.

A

Destruction of all cortical zones:

Decrease production of Mineralocorticoids, Glucocorticoids, and androgens

343
Q

What is cushings reflex?

A

Cushing reflex is due to inter cranial HTN

HTN

Bradycardia

Irreg resp

344
Q

What are the 5 examples of a cyanotic shunt?

A

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

345
Q

What are the 4 examples of a ACYANOTIC shunt?

A

Left to right shunt (acyanotic shunt)

Ventricular septal defect –> Esinemerges

Atrial septal defect

Patient Ductus Arteriosus

Coartation of the aorta

346
Q

What can you give if you need to urgently reverse warfarin?

A

FFP

347
Q

What is the effect of Nitric Oxide?

A

Smooth muscle relaxation

348
Q

What makes mapleson circuits different?

A

They have:

Bag

APL

FGF

349
Q

Best place to put the transducer in the sitting position?

A

Tragus of the ear

350
Q

Which drug is the gold standard for ECT?

A

Methohexital

351
Q

What nerve would cause a food drop?

A

Sciatic –> Common peroneal

352
Q

How does VA affect somatosensory evoke potential monitoring?

A

VA will INCREASE the latency and DECREASE the amplitude of SSEP in a dose-dependent fashion.

353
Q

What nerves can be injured during facemask ventilation?

A

Facial VII

Trigeminal V

354
Q

What nerve comes off of the posterior cord?

A

Radial

Axillary

355
Q

What electrolyte imbalance would you see in pyloric stenosis?

A

Hyponatermia

Hypokalemia

Hyocholremia

They are vomiting

You would see metabolic alkalosis + compensatory resp acidosis

356
Q

Normal Anion gap?

A

8 - 12 mEq/L

357
Q

What is the parkland formula?

A

4 mL of LR x percent TBSA burned x kg

358
Q

Steroids work On which fibers?

A

C fibers

359
Q

Nitropursside will vasodilate what system?

A

Arterial and venous

360
Q

How many molecules are carried by Hgb if sat is 50 percent?

A

2

361
Q

A patient with porphyria, what drugs do you not give?

A

Barbiturates

Etomidate

Glucocoticoids

Hydralazine

362
Q

Idonmethacin will do what to the arachidonic acid?

A

Idonomethcain will inhibit the conversion of arachidonic acid to prostaglandin H2

363
Q

What are the side effects of bone cement implantation syndrome?

A

Hypoxia
Hypotension

Cardiac arrhythmias

Increased PVR
LOC

Cardiac arrest

(treat like R heart failure?)

364
Q

What parameters are increased in an OB patient?

A

Increased:

O2 consumption

M/V

PaO2

CO

365
Q

What is the clotting factor deficiency in Hemophilia C?

A

Factor 11

366
Q

What is decreased in Banked blood?

A

Decreased:
2,3 DPG
ATP
pH

Increased:
K
Pro inflammatory mediators

Impaired ability to changed shape

Hemolysis

367
Q

What fluid is best to administer for hypernatremia and hypovolemia?

A

Isotonic (NaCl)

368
Q

State the MOA of these asthma drugs.

Montelukast
Cromolyn
Solumedrol
Atroptine/Ipratropium

A

Montelukast - Leukotriene modifier

Cromolyn - Mast cell stabilizer

Solumedrol - Corticosteroid

Atroptine/Ipratropium - Anticholinergic

369
Q

What is the vapor pressure of Sevo?

A

157

370
Q

What is the vapor pressure of Iso?

A

238

371
Q

What are the lung volume changes in the pregnant patient?

A

DECREASED TLC

No change in VC

INCREASED RR

DECREASED ERV

DECREASED RV

372
Q

What are the lung volume changes in the Elderly patient?

A

INCREASED FRC (RV not ERV)

No change in TLC

INCREASED CC

DECREASED VC

DECREASED FEV1

DECREASED ERV

373
Q

What are the lung volume changes in the Obese patient?

A

DECREASED TLC VC FRC ERV

No change in RV

INCREASED CC

INCREASED SVR

No change in HR

374
Q

What are the lung volume changes in the Neonate population?

A

DECRASED VC TLC FRC ERV

INCREASED RV

DECREASED lung compliance

INCREASED chest wall compliance

375
Q

What are some hepatic enzyme inhibitors?

A

Grapefruit juice

Omeprazole

SSRI

Isoniazid

Cimetidine

Eryhtomycin

376
Q

What are some hepatic enzyme INDUCERS?

A

Tobacco

Ethanol

Phenytoin

Barbiturates

Rifampin

377
Q

The administration of glycine would increase?

A

Ammonia levels

Which would lead to decreased LOC

Transient postoperative visual syndrome (blindness or blurriness; glycine inhibits NT in the eye)

378
Q

Anemia would do what to the pulse ox waveform?

A

It would over estimate it

379
Q

What block uses the landmark of the coracoid process?

A

Infraclavicular block

380
Q

Give examples of:

Ignition source

Oxidizer

Fuel

A

Ignition source: Electrosurgical cautery, laster

Oxidizer: O2 N2O

Fuel: ET tube, drapes, surgical supplies

381
Q

Lumbar plexus emerges between what two muscles?

A

Quadriceps

Psoas major

382
Q

What are the disadvantages of Hetastarch?

A

Coagulopathy

Anaphylaxis

383
Q

Match the side of effects of the following drugs:

Phencyclidine

Methamphetamine

Heroin

Miosis, Mydraisis, Nystagmus

A

Phencyclidine: Nystamgus

Methamphetamine: Mydriasis

Heroin: Miosis

384
Q

Why does morphine have an increased efficacy in the elderly?

A

Decreased Vd of hydrophilic drugs

Increased Vd for lipophilic drugs

Decreased muscle mass

385
Q

What is the Labatt’s position?

A

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.

386
Q

State where these drugs work in the nephron:

Acetazolamide

Osmotic diuretics

Furosemide

Thiazide

Spironolactone

A

Acetazolamide - PCT

Osmotic diuretics - Descending PCT

Furosemide - Ascending PCT

Thiazide - DCT

Spironolactone - Collecting duct

387
Q

What are some criteria for Pickwickian syndrome?

A

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

388
Q

What are some things that do not affect the O2 pulse ox?

A

Hgb S

Hgb F

Jaundice

Polycythemia

Acrylic nails

Fluorescein

389
Q

What is the Oxygen delivery formula?

A

DO2 = CO x [(Hgb x SaO2 x 1.34) + (PaO2 x 0.003)] x 10

390
Q

Which chemical structure of a non-depolarizing neuromuscular blocker will make it more lipid soluble?

A

Benzene ring?

391
Q

What are the s/sx of epiglottitis?

A 
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

392
Q

Which excitatory neurotransmitter is released On the afferent side?

A

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

393
Q

What lung volume would you expect to increase with a patient with COPD?

A

RV

FRC

TLV

A FEV1/FVC ratio of <70 percent after bronchodilator therapy is a diagnostic of COPD

394
Q

What cells has humoral immunity??****

A

B Lymphocytes**

395
Q

What laws does Fick’s incorporate?

A

Grahams

Henrys

396
Q

What is the different between anaphylaxis and anaphylactoid?

A

Anaphylaxis - Prior sensitization or cross reactivity

Anaphylactoid - No prior exposure needed

397
Q

For the DOA of LA, what are some secondary variables that would effect the DOA?

A

Lipid solubility

Intrinsic vasodilating effect

Addition of vasoconstrictors

The primary variable would be protein binding

398
Q

State what system each drug will affect:

Doxirubicin

Bleomycin

Vincristine

5-Fluorouracil

A

Doxirubicin - Cardiac

Bleomycin - Pulmonary

Vincristine - Neuropathy

5-Fluorouracil - Bone marrow suppression

399
Q

Calculate the maximum dose for neostigmine in mcg/kg

A

70 mcg/kg

5000mcg

400
Q

Which position has the most V/Q mismatch?

A

Trendelenburg

401
Q

What is the anesthetic management for a patient with hypertrophic cardiomyopathy?

A

DECREASE HR

INCREASE Preload

INCREASE Afterload

DECREASE Contractility? (maintain)

402
Q

Which Mapelson system is the best for ventilation?

A

D

403
Q

Which Mapelson system is the best for spontaneous ventilation?

A

A

404
Q

Which Mapelson system has no bag?

A

E

Spontaneous ventilation only

405
Q

Describe the posterior superior and anterior borders for the Larsons.

A

Posterior - Mastoid process

Superior - Skill base

Anteriorly - Displace mandible

406
Q

What lung volumes will decrease with age?

A

VC

FEV1

PaO2

Elasticity

No change in TLC

407
Q

What lung volumes will increase with age?

A

FRC (INCREASEd RV, normal ERV)

CC

Compliance

408
Q

Give examples of some SSRIs

A

Amitriptyline

Nortriptyline

Imipramine

Venlafaxine

Duloxetine

Milnacipran

Fluoxetine

Citalopram

409
Q

What are some drugs that would affect the BIS monitor?

A

N2O

Ketamine

Precedex

410
Q

Metoclopramide will inhibit pseudocholinesterase, therefor it will prolong which drug?

A

Succinylcholine

411
Q

Describe what the PT/PTT would look like for the following disease.

DIC

Hemophilia A and B

NSAIDS

vWF

A

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

412
Q

What is Pulsus Parasdoxus?

A

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

413
Q

Discuss the TURP fluid complications for the following:

Sobitol
NS
Distilled water
Glycine
Mannitol
A

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)

414
Q

What drug has the least amount of protein binding?

A

Ketamine

Next is etomidate

415
Q

What is the least toxic LA to the fetus?

A

2 Chloroprocaine

416
Q

Where do you block the ulnar nerve at the wrist?

A

Inject medial to and under the flexor carpi ulnaris tendon

417
Q

What is normal cerebral oxygenation levels?

A

50-70 percent

418
Q

What receptors dose Methadone work On?

A

Mu and kappa AGONIST

NMDA ANATAGONIST

MAOI

Can cause prolong QT

419
Q

What factors are decreased in pregnancy?

A

Factor 11

Factor 13

Protein C and S

420
Q

Anion gap formula.

A

[Na - (Cl + bicarb)]

Normal is 8-12

421
Q

What do you mix dantrolene with?

A

Bacteriostatic water

422
Q

Which fibers have golgi bodies spindles?

A

A alpha

423
Q

How would a transmural injury appear on the EKG?

A

ST elevation

424
Q

What medications can prolong QT?

A

Sevo

Methadone

Droperidol

Haloperidol

Zofran

Amiodarone

Quinidine

Hypokalemia

Hypocalcemia

Hypomagnesemia

425
Q

What drugs should you not use with a patient and porphyria?

A

Phenytoin

Lidocaine

Thiopental

Etomidate

Barbs

426
Q

Opioid potency. How can you use “Superman Rescued Five American Heroes Monday Morning”

A

Superman Rescued Five American Heroes Monday Morning

Sufenta

Remi = Fentanyl

Alfenta

Hydromorphone

Morphine

Meperidine

427
Q

What would you see on Aline waveform with the following disease?

LV HF
Cardiac tamponande
Aortic Stenosis
Aortic regurgitation

A

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)

428
Q

What is COLT-P?

A

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)

429
Q

What does TIPPED stand for?

A

Tibial Inversion Plantar Flexion

+

Peroneal Eversion Dorsiflexion

430
Q

What are the side effects of mannitol?

A

CHF

Pulmonary edema

Cerebral edema if BBB not intact

431
Q

What is the classic triad for TUPR syndrome?

A

HTN

Bradycardia

Hyponatremia

432
Q

What causes an S4 sound?

A

Caused by atrial systole

Head before S1

433
Q

Which LA is least affected when added with epi?

A

Chloro
Ropi or BUPI*

These do not have intrinsic vasodilating effects

Lido is the most affected by epi

434
Q

What is the triple H therapy for cerebral vasospasm?

A

Hemodilution Hct 30 percent

HTN

Hypervolemia

Plus Nimodipine

435
Q

How much will 1 PRBC increase Hct and Hgb?

A

Hgb 1 g/dL

Hct 2-3 percent

436
Q

What factors affect the spread of LA in a epdirual/spinal?

A

Spinal: Baricity, position, dose, site, vol/density of CSF

Epidural: Volume

437
Q

What will happen to a pt with myotonic dystrophy if you give them succs?

A

Will cause sustained contractures

Hypothermia and neostigmine reversal can also cause this.

438
Q

When do you give FFP?

A

PT and/or PTT 1.5x the normal

Normal PT 12-14 seconds

Normal PTT 25-32 seconds

439
Q

What are normal PT and PTT?

A

Normal PT 12-14 seconds

Normal PTT 25-32 seconds

440
Q

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

A

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)

441
Q

What does thromboxane do in pre ecamplsia?

A

In Pre eclampsia up to 7x more thromboxane than prostacyclin is produced creating an environment that favors:

Platelet aggregation

Vasoconstriction

Decreased uterine blood flow

442
Q

Where is ADH and oxytocin made?

A

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.

443
Q

FEF 25-75 percent, is this effort dependent or independent?

A

Independent

444
Q

What hormone is secreted by the hypothalamus that stimulates the release of other thyroid sections?

A

Hypothalamus (TRH) –>

Anterior pituitary (TSH) –>

TSH –> Thyroid gland to release T4 (prohormone) –>

T3

445
Q

What are the medial and lateral landmarks for the Deep peroneal landmark?

A

Medial - Tibialis anterior tendon

Lateral - Extensor hallucis longus tendon

446
Q

What parameters increases in pregnancy?

A

MV TV CO

FACTORS 1 7 8 9 10 12

Sensitivity to LA

GFR

447
Q

What parameters decrease in pregnancy?

A

FACTORs 11 and 13 Proteins C and S

MAC

LES tone

Gastric pH

448
Q

MOA of H2 antagonist?

A

Decrease volume

Increase pH

449
Q

How many L of air is in a E is in a cylinder?

A

625L 2000Psi

O2: 660L 2000 psi

N2O: 1590L 745 psi

450
Q

What is the position of the median nerve in relation to the axillary artery?

A

The median nerve is located anterior and medial to the axillary artery.

451
Q

What is the position of the ulnar nerve in relation to the axillary artery?

A

The ulnar nerve lies posterior and medial to the axillary artery.

452
Q

What is the position of the radial nerve in relation to the axillary artery?

A

The radial nerve lies posterior and lateral to the axillary artery.

453
Q

What is the position of the musculocutaneous nerve in relation to the axillary artery?

A

The musculocutaneous nerve lies anterior and lateral to the axillary artery.

454
Q

What is the reason for cardiac instability after the aortic cross clamp is removed?

A

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
455
Q

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
A

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)

456
Q

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
A

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)

457
Q

What is R time and normal value?

A

R time = Time to begin forming clot

Normal value = 6-8 minutes

Problem area = Coagulation factors

Treatment = FFP

458
Q

What is K time and normal value?

A

K time = Time until clot has achieved fixed strength

Normal value = 3-7 minutes

Problem area = Fibrinogen

Treatment = Cryo

459
Q

What is the Alpha angle (On the TEG) and what is the normal value?

A

Alpha angle - Speed of fibrin accumulation

Normal Value = 50-60 degrees

Problem area = Fibrinogen

Treatment = Cryo

460
Q

What is the Maximum Amplitude (MA) and normal value?

A

Maximum Amplitude (MA) = Highest vertical amplitude On the TEG

Measures clot strength

Normal value = 50-60 mm

Problem area = Platelets

Treatment = Plts +/- DDAVP

461
Q

What is the Amplitude at minutes After Maximum Amplitude (A60) and normal value?

A

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

462
Q

What resp mechanics are similar between elderly and peds?

A

INCREASED MV

INCREASED CC

INCREASED RV

DECREASED VC

463
Q

What drugs are based on IBW?

A

Water soluble drugs (hydrophilic)

Propofol (induction)

Vec/roc

Sufentanil

Remifentanil

464
Q

What is difference between Nitroglycerine and Sodium Nitroprusside?

A

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

465
Q

If the BP cuff location is above the heart, what can you expect the reading?

A

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.

466
Q

If the BP cuff location is below the heart, what can you expect the reading?

A

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.

467
Q

What cardiac parameters will a pnumoperitoneum increase?

A

INCREASED SVR MAP PVR

Decrease Sphenic and renal blood flow

468
Q

What can cause an ANION GAP ACIDOSIS?

A

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)

469
Q

What can cause NON-GAP ACIDOSIS?

A

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.

NCE Review Material (8 decks)

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