Final Flashcards
What provides motor innervation to all intrinsic muscles except the cricothyroid?
RLN
Who is most at risk for latex allergy?
healthcare workers and spina bifida
What are some disadvantages for regional anesthesia of the eye?
potential for complications, usually need deep sedation for placement
What kind of murmur is caused by aortic regurgitation?
decrescendo diastolic at 2nd ICS RSB
What is the functional unit of the kidney?
nephron
The Laser-Flex tracheal tube (Nellcor) is flexible, stainless steel that is resistant to CO2 and KTP lasers- in the event of proximal cuff rupture, what happens?
distal cuff maintains tracheal seal and prevents anesthetic gases from leaking into path of laser beam
What are some risk factors for intraop awareness?
female, young (not children), obese, clinical experience, previous awareness, after normal hours operations, emergency procedures, OB/cardiac/thoracic cases, use of nondepolarizing relaxants
What are some things that reduce the effectiveness of hypoxic pulmonary vasoconstriction?
alkalosis, excessive TV or PEEP, hemodilution, hypervolemia, hypocapnia, hypothermia, prostacyclin, shunt fraction <20% or >80%, vasodilators, PDEIs, CCBs, volatile anesthetics >1.5 MAC
Why should you avoid hypotension in a patient with AS? What should you use to treat hypotension?
have to maintain coronary perfusion pressure; use neo
What are some complications of thoracic surgery?
ALI, low cardiac output from hemorrhage, hypovenolemia, R HF, heart hernation; bronchopleural fistula, thoracic duct injury, nerve injury (phrenic, spinal, RLN)
Which anesthesia drugs are known to decrease NK function?
propofol, thiopental, opioids, volatile agents
What is bleomycin known to cause?
blebs- pulmonary toxicity
What are effects on the lungs during establishment of pneumoperitoneum?
decreased VC, FRC, compliance
What are the components of an RCA?
what, where, who, when, how many
What are some some symptoms of hypocalcemia?
hyperexcitability of nerve and muscles due to lowered threshold potential- muscle cramps, paresthesias, hyperactive DTRs, tetany, restless, irritability, larygospasm, Chvostek and Trousseau
What is thromboxane a2?
COX product of arachadonic acid in platelets that is synthesized due to vascular damage- potent vasoconstrictor and stimulus for platelet aggregation (inhibits AC and CAMP)
What does vitamin D deficiency cause?
poor ingested calcium- rickets in children, osteomalacia in adults
How much can you increase tolerated apnea time by when preoxygenating an OSA patient with 100% FiO2 and 5-10 of CPAP?
50%
At what size is a thoracic aneurysm at risk of rupture in someone with Marfan syndrome or other connective tissue disease?
4-4.5 cm
What happens in the collecting duct?
water reabsorption under influence of ADH
What are some goals/anesthetic management for thoracic surgery?
maintain normovolemia, keep MAC <1.5, avoid N2O, ABGs as needed, air/O2 mix to maintain adequate PO2, minimize narcotics, extubate at the end of the case
What are some things that are neurotoxic to peds patients?
iso, sevo, propofol, barbiturates, nitrous, versed, ketamine
What vessels branch off of the aortic arch?
innominate/brachiocephalic, L common carotid, left subclavian
What things affect LV compliance?
structural properties of heart muscle, as well as state of contraction and relaxation (?)
Who is the second victim?
practitioner involved in unanticipated adverse event who becomes victimized and traumatized
What are some things that increase GFR?
afferent arteriole dilation, increased renal BF, efferent arteriole constriction
What is plasminogen?
proenzyme that is synthesized in the liver- it is incorporated into the clot as it is being formed but lays dormant until it is activated
What are the 3 requirements for fire to occur?
flammable agent (alcohol, benzoin, drapes, ETT, hair), source of ignition (lasers, light sources defibrillator), gas that supports combustion (oxygen, nitrous)
What does cryo contain and what do we give it for?
fibrinogen, factors V, VIII, XIII, vWF- hypofibrinogenemia, massive hemorrhage
How do you avoid airway fire?
keep FiO2 at a minimum (may discontinue temporarily during laser use), avoid N2O, vent excess O2 from under drapes
What does protamine do?
reverses effects of heparin
What drug should you avoid if a patient is on cyclophosphamide?
succs
What is the first thing you do with AAA rupture?
control the bleeding- establish large bore PIV and give blood
What provides motor innervation to the cricothyroid?
SLN
What allows excessive pressure to be vented out of the middle ear?
eustachian tube
What are some goals for a patient with sickle cell disease?
maintain normothermia, hydration, O2, and prevent acidosis and vascular stasis- maintain Hct 30-35%, manage pain (avoid drugs that impair renal function)
Between what range is autoregulation of the kidney maintained?
50-180
What gas may cause an acceleration in metastasis?
nitrous oxide
What does the RAA system result in?
Na/H20 reabsorption and vasoconstriction
What is sickle cell disease?
hereditary hemoglobinopathy- autosomal recessive abnormality of beta globin gene codes for production of variant hemoglobin, Hgb S
Are laser-resistant tubes laser-proof?
No- carry inherent risk of ignition
What does pRBCs contain and what do we give it for?
RBCs- symptomatic anemia, massive hemorrhage, decreased O2 carrying capacity
What are the forces that determine GFR?
pressure inside glomerular capillaries, pressure inside Bowman’s capsule, colloid oncotic pressure inside capillary
What compensatory response happens if the blood flow to the kidney is decreased?
afferent arteriole dilation
What happens to an obese patient’s lungs when you lie them flat?
abdominal contents pushed up –> decreased FRC, compliance, impaired gas exchange
What is TF? What does it do?
cofactor from coagulation cascade- activates clotting cascade pathway when vessel injury occurs
What percentage of emergency and elective AAA patients undergoing OAR have an MI?
emergency- >50%, elective- >25%
At what size is a descending thoracic aneurysm at risk for rupture?
> 6.5 cm
How does celecoxib work?
COX 2 inhibitor (antiplatelet)
What are absolute indications for OLV?
isolate 1 lung to prevent contamination, control distribution of ventilation, unilateral bronchopulmonary lavage
How many posterior and anterior spinal arteries are there? What supplies motor function?
2 posterior, 1 anterior; anterior provides motor function and receives most BF
What are some disadvantages of general anesthesia for eye procedures?
most invasive, PONV, sore throat, dental injury
Describe HIT type 1
heparin induced platelet aggregation 1-4 days after a large heparin dose which resolves spontaneously even if heparin is continued
Describe naturally active immunity
immune response generated after antigen/pathogens enter body (chicken pox)
What are some things you can do to improve intubating conditions in someone with OSA?
preoxygenate for 5 minutes with 100% O2 and CPAP, use ramp, minimize preop sedation, have an extra set of hands
Why might local anesthetics be beneficial for cancer patients?
they prevent tumor proliferation
What is vWD?
inherited or acquired coagulable disease characterized by lack or dysfunctional vWF- lifelong bleeding episodes, prolonged bleeding time
What are some things that may contribute to metastasis during surgery?
tumor manipulation, most anesthesia medications (especially opioids), stress response
What are some risk factors for OSA?
male, obese, micro/retrognathia, large tongue, large tonsils, large neck circumference, HTN
What happens in the loop of henle?
establishment of osmotic gradient
What are some complications of sickle cell disease?
vaso-occlusive crisis, acute chest syndrome, sequestration crisis, aplastic crisis, pneumococcal disease, pulmonary HTN
What are elements of good communication?
clear and concise, include context and intent, receive information (show listening), identify and address barriers
What kind of murmur is mitral stenosis?
diastolic rumbling murmur- heard best at apex
Describe the order of the intrinsic pathway
1) blood trauma/exposure to collage activates factor XII (Hageman)
2) Factor XII activates XI (PTA)- requires kininogen and is accelerated by prekallikrein
3) Factor XI activates IX (Christmas)
4) Factor IX and VIII (antihemophilic) activate X (SPF)
5) prothrombin activator and tissue phospholipids activate thrombin (factor II)- identical to last step of extrinsic pathway
How does desmopressin (DDAVP) work?
stimulates factor VIII and vWF release
What does desmopressin do?
stimulates release of vWF
What can methotrexate cause?
hepatic and renal toxicity
What does nitric oxide do?
potentiates prostacyclins which inhibits platelet adhesion, aggregation, and binding of fibrinogen between GpIIb/IIIa complexes; causes muscle relaxation and vasodilation; increases BF to wash away procoagulant mediators
What are some arteries that branch off the abdominal aorta?
celiac, superior mesenteric, renal, inferior mesenteric, common iliac, internal and external iliac, femoral
How does warfarin work?
vitamin K antagonist (anticoagulant)
Where does the artery of Adamkiewicz arise from?
radicular branches of the intercostals, T8-T12 (sometimes T5-L5)
What should you do if an airway fire occurs?
stop ventilation, disconnect circuit, remove ETT and place in a bucket of water, extinguish flame debris in pharynx with water or saline
What type of vWD is characterized by a complete absence of vWF? What should you give them?
type 3- cryo or purified vWF
What is vWF?
necessary cofactor for adherence of platelets to subendothelial layer
What factors lie in the vessel intima (endothelial layer)?
vWF, TF, prostacyclin, and nitric oxide
What are the risks in % of AAA rupture at certain sizes?
0.5-5% at 4-4.9 cm
3-15% at 5-5.9 cm
10-20% at 6-6.9 cm
20-40% at 7-7.9 cm
The LaserTubus (Rusch) is soft, white rubber that is resistant to argon, YAG, and CO2 lasers- the lower 17 cm is covered with laser guard wrap that does what? What can you do to decrease ignition potential? Who should you avoid this tube in?
dissipates laser light and prevents backscatter; soak the tube in water; latex allergy
What are some advantages of EVAR over OAR?
shorter procedure, fewer blood loss/fluid shifts/hemodynamic changes, less ischemia and end organ damage, fewer complications
When a surgeon deflates a leg tourniquet, what will you expect?
fall in core temperature, metabolic acidosis, fall in central venous oxygen, release of acid metabolites in systemic circulation, increase in end tidal CO2
What are relative indications for OLV?
surgical exposure, pulmonary edema after removal of PE, severe hypoxemia d/t unilateral lung disease
What are some things you can do to avoid metastasis?
avoid hypothermia, avoid giving blood, use regional technique when available, keep FiO2 <80%
What are the final cells of the lymphoid pathway?
T and B cells, NK cells
What does vitamin K do?
required for production of factors II, VII, IX, X and protein C and S (reverses effects of warfarin)
How does clopidogrel work?
ADP receptor inhibitor (antiplatelet drug)
What vessels branch off of the ascending aorta?
coronary arteries
At what size is an ascending thoracic aneurysm at risk for rupture?
> 5.5 cm
When do episodes of intraop awareness occur most often?
during maintenance of anesthesia
What are some connective tissue disorders? Specifically which one did Abe Lincoln have?
Marfan (Abe Lincoln), Ehlers Danlos, Loeys-Dietz
How do aminocaproic acid (amicar) and tranexamic acid (TXA) work?
plasminogen activation inhibitors
Describe naturally passive immunity
antibodies passed from mother to baby (short lived)
With a DLT, which lung is getting ventilated?
The dependent lung (nondependent lung is getting operated on and will be isolated)
After platelets aggregate, what completes a clot?
fibrin is incorporated into the platelet plug, and activated FSF (XIIIa) facilitates cross linkage of fibrin fibers
What were the problems with the metallic foil wraps around ETTs to protect them from lasers?
laser reflection damage, exposed tube, unprotected cuff, need for smaller ID tube, airway damage
How long from exposure may a latex allergy show a reaction?
30 minutes
What are the cellular elements of innate immune pathways?
neutrophils, macrophages, NK cells, monocytes
What does Vitamin K do?
stimulates action of factors II, V, VII, IX
What are some other anesthetic considerations for AAA rupture besides establishing lines and giving blood?
intubate immediately if LOC, do RSI with etomidate and succs, avoid coughing/bucking which can increase rate of bleeding
What should you place proximal to the ETT cuff during laser surgery?
saline moistened cotton gauze
What is one of the problems with the Bivona Fome-Cuf (Portex) laser resistant ETT?
inability to deflate the foam after cuff rupture
How does heparin work?
inhibits factor 2 and 10a (anticoagulant)
How long should you wait before a laser is used after reinflation of an ETT or repositioning for correction of a leak?
1 minute
Which has lower periop risk, EVAR or OAR? What about 2 year mortality?
EVAR has lower periop risk, but same 2 year mortality
What factors does Coumadin affect, and in what order?
Indirectly blocks the manufacturing of Vitamin K dependent factors (II, VII, IX, X, Protein C and S)
What are some advantages of general anesthesia for eye procedures?
useful for uncooperative patients and for longer surgeries, complete ocular anesthesia
What are the final cells of the myeloid pathway?
monocytes, macrophages, dendritic cells, eosinophils, mast cells, basophils, platelets
What might the use of nitrous oxide cause in middle ear procedures?
graft disruption, tympanic membrane rupture, N/V, serous otitis media, stapes disarticulation and hearing loss
What do platelets contain and what do we give it for?
platelets and clotting factors- thrombocytopenia, massive hemorrhage, platelet function deficit
How is plasminogen activated, and what does its activated form do?
tissue plasminogen activator (tPA) activates plasminogen into plasmin, which dissolve thrombi and restore blood flow
What is the lateral rectus muscle innervated by and what does it do?
supplied by CN 6 and causes abduction of the eye
What are some ways to minimize aspiration in someone with esophageal disorders?
NPO for 8 hours, prokinetics (Reglan), H2 blockers, PPIs, antacids, RSI if necessary, cuffed ETT, decompress stomach with NG if necessary
What is normal GFR?
125 ml/min
How soon should N2O be stopped before graft placement in a middle ear procedure?
30 minutes
What does the cricothyroid muscle do?
tenses and elongates the cords
What do the juxtaglomerular cells release in response to hypotension?
renin
How do argatroban and bivalrudin work?
inhibit thrombin (anticoagulant)
What happens in the proximal tubule?
sodium reabsorption
Describe HIT type 2
antiplatelet antibodies (IgG) attack factor 4 immune complexes which causes platelet aggregation and is resistant to heparin anticoagulation- this occurs after any heparin dose 5-14 days after administration and can lead to a hypercoagulable state with high risk of amputation and death
What are anesthetic considerations for mediastinoscopy?
2 large bore IVs, type and cross, A line or pulse ox on right, standard induction if asymptomatic, if obstruction- minimize preop sedation, do awake FOB, maintain spontaneous ventilation
What is a consideration of the cuffs of laser resistant ETTs? What should you confirm before a laser is used?
cuff rupture is often the prelude to airway fire- fill them with saline and possibly methylene blue to alert surgeon of cuff rupture; absence of air leak
What is adriamycin (doxorubicin) known to cause?
cardiac toxicity
How do aspirin and NSAIDs work?
COX 1-2 inhibitor (antiplatelet)
If a patient is getting an endovascular aortic repair, how would you treat hypertension? What drug should you avoid?
beta blocker before vasodilator (vasodilators change radius of vessel); sodium nitroprusside (associated with worse outcomes)
What can be facilitated by anesthesia during thoracic surgery?
isolate the movement of one lung during ventilation and create a quiet surgical field
How low can platelets drop with HIT type 2? What do you need to do?
<50k; need to d/c heparin and anticoagulate with direct thrombin inhibitor like bivalirudin or argatroban
Which type of immunity has a more delayed onset but is capable of developing memory and specific antigenic responses?
adaptive immunity
What are some advantages for regional anesthesia of the eye?
more complete anesthesia, eye is more likely to be immobile, less invasive
What is hemophilia?
X linked recessive disorder characterized by unpredictable bleeding patterns- either deficient in factor VIII or factor IX
How does abceximab work?
GpIIb/IIIa receptor antagonist (antiplatelet drug)
What are some indications for thoracic surgery?
tumor, infection, lavage, lung reduction sx, vascular sx, cardiac sx, spine sx
What does a TEG measure?
process of clot formation over time- gives indication of clot strength, platelet number and function, intrinsic pathway defects, thrombin formation, and rate of fibrinolysis
Which types of LeFort fractures are of concern to the anesthesia provider?
II and III- avoid nasal intubation due to possible disruption of cribiform plate
What are the different forms calcium exists in the body?
9% bound to anions, 41% bound to proteins, 50% ionized
What does FFP contain and what do we give it for?
all coag factors- warfarin bleeding, massive transfusion, TTP, coag factor deficiencies, ATIII deficiency
What are some arteries that branch off the descending thoracic aorta?
esophageal, bronchial, mediastinal, intercostals
What are physiologic effects of aortic cross clamping?
increased afterload (HTN), often increases in CVP and PAP, increased MAP and sVR, increased LV work (decreased CO), tissue ischemia
What is innate immunity?
immunity that is genetically determined
What do you want to ensure as far as IVs in robotic surgery?
2 IVs and possibly A-line established before tucking arms (make sure they work)
What is atrial natriuretic factor?
secreted by atria in response to stretch- acts as diuretic (antagonizes ADH)
What substances are released during the surgical stress response that may contribute to immunosuppression?
cortisol, cytokines
What is the only tube wrap that has FDA approval for ETT protection from lasers?
Merocel Laser-Guard
Where do we get Vitamin D? Where is it converted to its active form?
ingested food and ultraviolet light; liver and kidneys
What do the kidneys release in response to hypoxia?
EPO
Describe the order of the extrinsic pathway
1) tissue trauma liberates TF, which activates pathway
2) TF activates factor 7 (stable), which activates factor X (SPF) in presence of factor IV (Ca)
3) prothrombin activator and platelet phospholipids activate factor II (thrombin), and factor V (labile) acts as positive feedback mechanism that accelerates the continued production of prothrombin activator
Describe artificially active immunity
immunity developed from a vaccine
What provides sensory innervation to the superior epiglottis and base of the tongue?
glossopharyngeal
What factors lie in the vessel media (subendothelial layer)?
collagen and fibronectin
What are some triggers for sickle cell crisis?
pain, hypothermia, hypoxemia, acidosis, dehydration
What are elements of team working?
support, solving conflicts, exchanging info, coordinating activities
What are the most common allergens used in anesthesia?
NMBs (roc and succs), antibiotics (beta lactams, sulfas, vancomycin, quinolones), latex
What does active vitamin D do?
increases Ca, Mg, and phosphate ion concentrations by promoting their absorption across the intestinal epithelium to the ECF
What medication may stimulate NK cell activity and be a good drug of choice for cancer patients?
tramadol
When do you open fluids during robotic surgery?
when anastamosis are complete
What are some potential complications of EVAR?
failed deployment/malposition, rupture/dissection, contrast reactions, plaque embolization, ischemia, endoleak, infection, graft migration or thrombosis, postimplantation syndrome
Describe artificially passive immunity
preformed antibodies given via antiserum or antivenom (short lived)
How does tPA and streptokinase work?
activates plasminogen (fibrinolytic)
What are some concerns when doing a shared airway for head and neck surgery?
the bed may be 90-180 away (may need second anesthesia provider to monitor ventilation), ETT will be smaller, potential for neck flexion/extension and movement of ETT, need to use circuit and line extensions
What does prostacyclin do? How is it made?
powerful vasodilator that interferes with platelet formation and aggregration; derived from arachadonic acid and is synthesized by endothelial cells
What drugs have antiangiogenic and antitumor properties?
COX 2 inhibitors
What do you give someone with vWD?
depends on what type- desmopressin, vWF, immunoglobulins, plasma exchange
What supplies sensory innervation to the laryngeal mucosa below the vocal cords?
RLN
What happens in the distal tubule?
sodium reabsorbed in exchange for K under influence of aldosterone
What are the afferent and efferent limbs of the oculocardiac reflex?
afferent- trigeminal (CN V)
efferent- vagus (CN X)
What supplies sensory innervation to the laryngeal mucosa above the vocal cords?
SLN (internal branch)
What is the oculocardiac reflex? How do you treat it?
bradycardia and asystole caused by stimulus to the eye- stop stimulus, give anticholinergics (glyco, atropine)
Where is cancer ranked in leading causes of death?
2nd
What is the most common closed claim about anesthesia care outside the OR?
respiratory complications
