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facts Flashcards

1
Q

MELD components

A

creatinine
bilirubin
INR

range 6-40

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2
Q

Pre-e criteria

A

Mild is 1, 2 or 3 of:
BP>140/90 (2 times, 4 hrs apart)
proteinuria >300mg over 24 hrs
non-pedal edema

Severe
SBP>160 or DBP>110
proteinuria>5gm over 24 hrs
e/o severe end-organ damage w severe oliguria
cerebral headache or visual changes
pulmonary edema
epigastric pain
intrauterine growth retardation
HELLP syndrome is a form of severe pre-e characterized by hemolysis, elevated liver enzymes, and low platelets
Low plts may occur due to adherence of hte platelets at sites of endothelial damage, resulting in a consumptive coagulopathy

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3
Q

pao2 rule of thumb

A

fio2 times 5 = Pao2

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4
Q

ARDS criteria

A

1 PaO2/FiO2 ratio <300
2 acute onset (within 7 days of inciting event, e.g. sepsis, trauma, aspiration, etc)
3 bilateral infiltrates identified by chest radiography
4 respiratory failure that is not fully explained by cardiac failure or fluid overload

(mild ARDS if PaO2/FiO2 ratio is 200-300)

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5
Q

Aortic stenosis transvalvular gradients

A

mild <25
moderate 25-40
severe 40-50
critical > 50

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6
Q

Aortic stenosis valve area

A 
normal 2.5 - 4
mild stenosis 1.5-2
moderate 1.0-1.5
severe 0.7-1.0
critical < 0.7
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7
Q

Aortic stenosis jet velocity

A

mild <3
moderate 3-4
severe 4-4.5
critical > 4.5

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8
Q

intraop factors contributing to arrhythmias

A

General anesthetics - volatiles, ketamine
Local anesthetics
Abnormal ABG/electrolytes (pH, hypoxia, hypercarbia)
sympathetic response to stimulation/laryngoscopy
Reflexes (vagal - brady, AV block, asystole; carotid sinus stim - brady; oculocardiac reflex - brady/asystole)
CNS stim
Dysfunction of autonomic nervous system
Pre-existing cardiac disease (MI, CHF, cardiomyopathy, valvular disease, conduction system abnormalities)
Central venous cannulation
Surgical manipulation of the cardiac structures (atrial sutures, venous bypass cannulas)
Location of the surgery (Dental - stim para and sympathetic NS; trigeminal stim can lead to stim of ANS)
Pain
Hypovolemia
Hypotension
Anemia
Endocrine abnormalities - Hyperthyroid, pheo
Temperature abnormalities (Hypo/er)

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9
Q

normal CI

A

2.6-4.2

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10
Q

normal PCWP

A

2-15 mmHg

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11
Q

normal PA pressure

A

15-30/4-12 mmHg

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12
Q

Normal mixed venous O2 sat

A

65-75%

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13
Q

Signs and symptoms of PE

A 
dyspnea
chest pain
cough
blood-tinged sputum
fever
tachycardia
tachypnea
coarse breath sounds
new S4 heart sound
accentuation of the pulmonic component of the S2 heart sound
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14
Q

GCS

A

Eye Opening Response
• Spontaneous–open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point

Verbal Response
• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point

Motor Response
• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point

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15
Q

c-spine clearance criteria

A 
absence of cervical pain/tenderness
absence of paresthesias/neuro deficits
normal mental status
no distracting pain
>4 years old
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16
Q

potential complications lithium

A

polyuria, skeletal muscle weakness, ataxia, cognitive changes, widening QRS, AV block, hypotension, seizures

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17
Q

anesthetic management changes for patient on lithium

A

1 eval for signs of toxicity (weakness, cognitive changes, ataxia, widening qrs, av block, hypoT, seizures

2 determine current lithium level

3 avoid any drugs that could lead to toxicity (thiazide diuretics, NSAIDs, ACE-i)

4 administer sodium containing fluids to prevent excessive renal reabsorption of lithium

5 watch EKG for lithiu-induced av blockade or dysrhythmias

6 closely monitor both anesthetic depth and neuromuscular blockae throughout the case (lithium can reduce anesthetic requirements and prolong effects of depol and non depol muscle relaxants)

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18
Q

alpha stat vs pH stat management

A

alpha-stat, CO2 is NOT added to maintain a PaCO2 of 40 and a pH of 7.40

pH-stat: CO2 IS added to maintain a PaCO2 of 40 and a pH of 7.40

Alpha stat = improved neuro outcome in adults (primary mechanism of brain injury is embolic not ischemic)

Pediatrics: Primary mechanism is ischemic, so pH-stat strategy is preferred (enhanced cerebral blood flow)

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19
Q

PCW tracing waves and what they represent

A

c wave - elevation of mitral valve during early ventricular systole

v wave - venous return against a closed mitral valve

x descent - downward displacement of atrium during ventricular contraction

y descent - decline in atrial pressure as MV opens during diastole

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20
Q

Kerley A lines

A

Kerley A lines are linear opacities extending from the periphery to the hila caused by distention of anastomotic channels between peripheral and central lymphatics

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21
Q

Kerley B lines

A

Kerley B lines are small, horizontal, peripheral straight lines demonstrated at the lung bases that represent thickened interlobular septa on CXR. They represent edema of the interlobular septa and though not specific, they frequently imply left ventricular failure

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22
Q

what is pulsus paradoxus

A

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus

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23
Q

pulsus paradoxus ddx

A

cardiac tamponade, airway obstruction, COPD, PE

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24
Q

CRPS-1 diagnosis

A 
initiating event
burning pain
allodynia or hyperalgesia
cyanosis
edema
cutaneous vasomotor instability (changes in blood flow)
sudomotor instability (sweating)

over time, also get
smooth/glossy skin
bone demineralization
stiff/painful joints

must exclude other causes for pain/dysfunction

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25
Q

dif between crps 1 and 2

A

CRPS-1 has specific noxious inciting event
examples of noxious events: crush injuries, lacerations, fractures, surgery, sprains or burns.

CRPS-2 develops following nerve injury, with characteristic symptoms not limited to the distribution of the injured nerve.

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26
Q

treatment options for crps

A 
PT
CBT
anticonvulsants (gabaP)
andtidepressants (amitriptylline)
opioids
sympathetic nerve blockade (stellate ganglion block)
somatic blockade
IV ketamine gtt
TENS
spinal cord stimulation
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27
Q

Pacemaker code

A 
Paced - O, A, V, D
Sensed - O, A, V, D
Response - O, T, I, D
Rate modulation - O, R
Multisite pacing - O, A, V, D
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28
Q

Defibrillator code

A

Stock chambers - O, A, V, D
Antitachycardia pacing chambers - O, A, V, D
Tachycardia detection - E, H
Antibradycardia pacing chambers - O, A, V, D

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29
Q

What does a magnet do to pacemaker?

to ICD?

A

pacemaker to asynchronous mode

does not affect pacing mode of ICD

disable tachydysrhythmia sensing and treatment of ICDs (most)

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30
Q

What drugs are in ACLS and for what situations?

A

Amiodarone (300mg, then 150mg) - VF/PVT 2 min after epi

Lidocaine (1-1.5mg/kg, then half that) - VF/PVT 2 min after epi

Epi infusion 0.1-0.5mcg/kg/min post-cardiac arrest

Dopamine infusion 5-10 mcg/kg/min post cardiac-arrest

Norepinephrine infusion 0.1-0.5 mcg/kg/min

Atropine 1mg - bradycardia with a pulse (repeat up to 3mg)

Dopamine IV gtt 5-20 mcg/kg/min - brady with pulse

epi gtt 2-10mcg/min brady with pulse

Adenosine 6mg, then 12mg - stable wide QRS tachycardia

Procainamide 20-50mg/min - stable wide QRS tachycardia

Amiodarone IV 150mg over 10 min, then 1mg/min for 6 hours - stable wide QRS tachycardia

Sotalol - 100mg over 5 min, avoid if prolonged QT - stable wide QRS tachycardia

Adenosine - Stable, narrow QRS

B-blocker - stable narrow QRS

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31
Q

type of vtach for unsynchronized shock

A

polymorphic

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32
Q

BP classifications

A

normal 120/80 or less
pre-hypertensive: 120-139/80-89
stage 1 HTN: 140-159/90-99
stage 2: SBP 160+ or 100+ DBP

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33
Q

Signs of end-organ damage from HTN

A 
LVH
Angina
MI
CHF
Stroke
TIA
CKD
Retinopathy
PAD
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34
Q

implications of LBBB

A

LBBB pattern hides ST-segment, making MI difficult to diagnose
Widened QRS could cause SVT to appear as VT
PA cath can lead to third-degree block 2/2 transient RBBB during placement

LBBB stronger association than RBBB with ischemic heart dz, aortic valve dz, LVH, CHF, HTN

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35
Q

avoid dobutamine (stress echo) for who

A

severe HTN
serious arrhythmias
hypotension

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36
Q

EKG abnormalities that hinder accurate computerized ST-segment analysis

A 
LBBB
WPW
acute pericarditis
LVH with strain
digitalis effect
hypokalemia
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37
Q

Protamine reactions

A

1 - pharmacologic; histamine-induced

2 - immunologic; anaphylactic vs anaphylactoid vs delayed anaphylactoid that causes noncardiogenic pulm edema

3 - catastrophic pulm HTN -> right heart failure and sig hypotension

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38
Q

thyroiditis ass’d with

A

myasthenia gravis

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39
Q

difficulty swallowing could be

A

myasthenia bulbar sx

40
Q

myasthenia gravis treatment

A

anticholinesterase (pyridostigmine)

immunosuppresive drugs (steroids, azathioprine, cyclophosphamide, cyclosporine)

thymectomy

41
Q

why avoid sux in myasthenia gravis

A

because the pyridostigmine may result in decreased plasma cholinesterase activity. ok to give if not yet on pyridostigmine (undiagnosed), as they will likely be resistant to sux but it may still work

42
Q

cholinergic crisis signs

A 
constricted pupils
weakness/fasiculations
bradycardia
bronchorrea
salivation
nausea
vomiting
abdominal cramps
diarrhea
urinary frequency and urgency
pallor
diaphoresis
43
Q

drug to determine if myasthenia or cholinergic crisis

A

edrophonium
improves strength if MG
worsens symptoms if cholinergic crisis

44
Q

cholinergic crisis
cause
sx
tx

A

cause: overstimulation of nicotinic and muscarinic receptors at the neuromuscular junctions (usually 2/2 inhibition of acetylcholinesterase)

symptoms: 
S- Salivation
L- Lacrimation
U -Urinary frequency
D-Diarrhea
G- Gastrointestinal cramping and pain
E- Emesis
M- Miosis
treatment: 
consider intubation
discontinue anticholinesterase
administer antimuscarinics (atropine)
provide supportive care
consider plasmaphoresis or IV IG
45
Q

neuroleptic malignant syndrome
cause
symptoms
treatment

A

cause - adverse reaction to neuroleptic or antipsychotic drugs.

symptoms - high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction

treatment - Generally, intensive care is needed. The neuroleptic or antipsychotic drug is discontinued, and the fever is treated aggressively. A muscle relaxant may be prescribed. Dopaminergic drugs, such as a dopamine agonist, have been reported to be useful.

46
Q

circle system advantages

A

more effective preservation of heat/humidity

reduced waste of anesthetic agents

reduced operating room pollution

reduced dead space

47
Q

normal fibrinogen levels

A

adults 200-400
possible DIC if below 100
severe if below 50 mg/dl

give cryo if below 50

48
Q

inferior leads

A

ii, iii, avf

49
Q

anterior leads

A

v3, v4

50
Q

lateral leads

A

i, avL, v5, v6

51
Q

dose epi gtt

A

0.01-0.05 mcg/kg/min

52
Q

dose milrinone gtt

A

0.375-0/75 mcg/kg/min

53
Q

dose NTG gtt

A

20-250 mcg/min

54
Q

dose Nitroprusside

A

0.5 - 10 mcg/kg/min

doses less than 0.5 mg/kg/hr have minimal cyanide toxicity risk

55
Q

dose norepi gtt

A

0.02 - 1.0 mcg/kg/min

56
Q

phenylephrine dose gtt

A

0.1-5 mcg/kg/min

57
Q

vasopressin gtt dosing

A

0.01-0.04 units/min

58
Q

treatment for cyanide toxicity

A

discontinue offending agent
100% o2

drugs:
1 sodium thiosulfate
2 amyl nitrate or sodium nitrate
3 hydroxocobalamin

59
Q

systemic effects of chronic renal failure

A

metabolic derangements (hyperkalemia, hyponatremia, hypOcalcemia, hypermagnesemia, hyperphosphatemia, hypoalbuminemia, uric acid accumulation, met acidosis)

periph/autonomic neuropathy
seizures
uremic encephalopathy
anorexia
delayed gastric emptying
insulin resistance
cardiac arrhythmias
conduction blocks
accelerated atherosclerosis
renal osteodystrophy
uremic pericarditis
HTN -> LVH, CHF, CAD, CVD
pulmonary edema
restrictive pulm dysfunction
anemia
platelet dysfunction
60
Q

brain swelling from hyponatremia disapears at what level

A

130

61
Q

cancel case form hyponatremia and why?

A

120
that level may result in serious manifestatinos (cerebral edema, cardopulm arrest, seizures, coma, brain stem herniation)

62
Q

discharge criteria from same day surgery

A 
PADSS system
vital signs
activity
n/v
pain
surgical bleeding

2 points each. 9 or higher fit for discharge

63
Q

aldrete

A 
activity
breathing
circulation
consciousness
o2 sat

score 9 or greater to dc

64
Q

lung cancer association

A

lambert eaton

65
Q

thymoma or mediastinal mass association

A

myasthenia gravis

66
Q

von Willebrand dz:
defect of what factor
how does that factor work
type 1 vs other types

A

qual or quant defect in vW factor

vWF mediates platelet adhesion and aggregation and is carrier protein and stabilizer for factor VIII

type 1 = quantitative defect, impaired release but stores ar enormal

type 2 = qualitative

type 3 = extremely low levels

67
Q

abnormal labs for vWF dz

A 
mild = normal labs
severe = prolonged bleeding, thrombocytopenia, prolonged PTT depending on type of dz
68
Q

DDAVP treatment for vWF what types

A

good for type 1

bad for type 2B (causes thrombocytopenia)

69
Q

prophylactic vWF replacement

A

cryoprecipitate or Humate P

70
Q

goal in vWF dz for prophylaxis for major surgery

A

vWF:RCo and factor VIII levels greater than 100

71
Q

direct acting inotrope

A

isoproterenol

72
Q

list of antihypertensive drugs

A 
nitroglycerin
sodium nitroprusside
phentolamine
esmolol
labetolol
magnesium
diltiazem?
73
Q

apnea-hypopnea index formula and scale

A

dividing the number of apnea events by the number of hours of sleep

severe >30
moderate 16-30
mild 5-15

74
Q

RVSP pulm htn severity scale

A

normal <35
Mild 35-45
moderate 46-60
severe >60

75
Q

Mean PA Pressure pulm htn severity

A

mild <30
moderate 30-45
severe >45

76
Q

Systolic PA Pressure pulm htn severity

A

mild 40-60
moderate 60-90
severe >90

77
Q

lipophilic drug classes

A

benzos, opioids, barbiturates

78
Q

hydrophilic drug example

A

neuromusclar blocking agents

79
Q

initial loading dose lipophilic based on what weight

A

total body weight bc larger volume of distribution 2/2 increased deposition into body fat

80
Q

maintenance dose lipophilic drugs base on what weight

A

ideal (increased clearance time)

81
Q

reasonable approach to dosing drugs for obesity

A

start with IBW, then titrate to effect as effects of obesity on drugs is unpredictable.

82
Q

post op management and

predictors of severe myasthenia

A

Ensure that the patient is reminded prior to induction of the possibility of a prolonged intubation.

Extubation: performed on awake patients and hopefully close to his/her baseline status. Reinstitute anticholinesterase medication, either by IV infusion or by reimplementation of the patient’s oral regimen.

Leventhal criteria: Predictive scoring system for the need for postoperative ventilation

1) duration of disease for 6 years or longer
2) chronic comorbid pulmonary disease
3) pyridostigmine dose >750 mg/d
4) VC <2.9L
5) Other indicators include preoperative use of steroids, and previous episode of respiratory failure.

These predictors have not been widely validated. (1)

Drugs to avoid: Calcium Channel blockers, Magnesium, Aminoglycoside antibiotics as all of these may contribute to muscle weakness

Post-Op Bed: Patients should be monitored in either a ICU or step-down unit but NOT to a conventional surgical ward.

83
Q

closed circle system

A 
gas reservoir bag - yes
rebreathing exhaled gases - total
chemical neutralization of co2 - yes
unidirectional valves - three
fresh gas inflow rate - low

advantages: maximal humidification and warming, less pollution of atmosphere, economy in use of anesthetics
disadvantages: inability to rapidly change the delivered concentration of anesthetic gases and o2 becasue of low FGF, unpredictable concentration of o2, unknown conc of anesthetic gas

84
Q

semiclosed circle system

A

this is what our vents are

gas reservoir bag - yes
rebreathing exhaled gases - partial
chemical neutralization of co2 - yes
unidirectional valves - three
fresh gas inflow rate - moderate

some conservation of heat and moisture
decreased pollution of surrounding atmosphere

increased resistance from valves/co2 absorbent
enhanced opportunity for malfunction 2/2 complexity of apparatus

85
Q

semiopen circle system

A

Maplesons

gas reservoir bag - all but E
rebreathing exhaled gases - no (if adequate FGF)
chemical neutralization of co2 - no
unidirectional valves - one (none in E)
fresh gas inflow rate - high
For mapeson F (Jackson-Rees)
disadvantages: 
need for high FGF
possibility of high airway pressure/barotrauma
lack of humidification
86
Q

open circle system

A 
gas reservoir bag - no
rebreathing exhaled gases - no
chemical neutralization of co2 - no
unidirectional valves - no
fresh gas inflow rate - unknown
87
Q

fena prerenal

A

less than 1%

88
Q

post op delirium vs post op cognitive dysfunction

A 
delirium
1-3 days post op
acute state of confusion
significant morbidity
multiple causes: metabolic, sepsis, pain, disorientation, etc
treat underlying cause
may benefit from haloperidol
POCD
not acutely confused of agitated
weeks/months later
usually resolves in 6-12 months
increased mortality rate
unknown role of anesthetics
89
Q

Where mixed venous blood drawn from

A

tip of PA catheter
it is usually higher than ScvO2 (ScvO2 contains predominantly SVC blood - brain has higher O2 extraction, but anesthesia can alter that)

90
Q

porphyra

A

defect in heme biosynthetic pathway -> overproduction of porphyrins

type of porphyria depends on enzyme deficiency

acute forms of porphyria are inducible by medication, can be life-threatening. ab pain, n/v, psych disturb, ANS instability, electrolyte disturb, hypovolemia, seizures, weakness, resp failure

preop: H&P, severity, precipitating factors, treatment, symptoms; neuropathy, ANS intability, weakness, electrolytes, fluid status

if in exacerbation, delay elective surgery

reduce risk: avoid fasting, dehydration, stress, infection, D10NS, check what drugs are safe

use regional

porphyric crisis treatment: dc pophyrinogenic drugs, supportive care, D10NS, treat nausea, correct lytes, treat seizures with benzo or prop; if no improvement after 2 days, consider hematin

91
Q

physiologic effects of ECT

A

parasympathetic before sympathetic

92
Q

drug keeps pda open

A

prostaglandins

NSAIDs inhibit prostaglandins

93
Q

after ect: disorientation, inability to consistently follow commands, motor agitation

A

postictal agitation

treat with benzo or dexmedetomidine

94
Q

Recurrent and superior laryngeal nerve interaction and function and how to block

A

recurrent laryngeal - sensory cords and trachea, intrinsic muscles of larynx; transtracheal block

superior laryngeal - sensation above cords (internal), cricothyroid muscle (external); block with needle at greater cornu hyoid bone

95
Q

APGAR score

A 
Appearance
Pulse 0, 0-100, 100+
Grimace
Activity
Respirations
96
Q

anticholinergic does what to bronchi

A

bronchodilates

**Oral Boards (7 decks)

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