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Patho > FINAL EXAM > Flashcards

FINAL EXAM Flashcards

1
Q

CO2 is used for insufflation because…

A
  • does NOT support combustion
  • safe use of cautery
  • residual pneumoperitoneum is readily absorbed
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2
Q

Describe Crohn’s disease

A
  • chronic diffuse disease
  • can affect entire GI tract from mouth to anus
  • full-thickness involvement can lead to fistula/abscess
  • RLQ pain/tenderness
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3
Q

Describe chronic UC

A
  • acute/subacute bloody diarrhea
  • mucosal disease
  • may see toxic megacolon, obstructive jaundice
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4
Q

Describe diverticulitis

A
  • microscopic perf of thin wall of diverticular sac
  • 3x more common on L>R
  • LLQ pain
  • predisposed to liver abscess
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5
Q

Describe cholecystitis

A
  • lodged stone in cystic duct
  • distension of gallbladder irritates nerves of parietal peritoneum
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6
Q

Describe pancreatic carcinoma

A
  • most likely cause of obstructive jaundice
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7
Q

Presentation of hepatic cysts

A
  • hx of abd infxn
  • jaundice
  • RUQ pain
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8
Q

Describe multiple endocrine neoplasia (MEN) type II

A
  • medullary carcinoma of thyroid gland, pheochromocytoma, & PTH hyperplasia
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9
Q

Describe insulinoma

A
  • endogenous hyperinsulinism
  • elevated C peptide levels
  • most true insulinomas are benign islet cell tumors of the pancreas
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10
Q

Classic triad of pancreatitis

A
  • abd pain
  • malabsorption
  • DM
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11
Q

S/s of adrenal insufficiency

A
  • postural HoTN
  • hyperpigmentation
  • hypoNa+
  • hyperK+
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12
Q

IBS is 3xmore common in ___

A

women

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13
Q

Most complications with laparoscopic sx occur…

A

at time of abd access for camera/port placement (50%)

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14
Q

Instrument used for initial access to peritoneal cavity
Why is it so dangerous?

A

Veress needle
- placed blindly
- often implicated as cause of distal aortic or iliac vessel injury

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15
Q

MAJOR vascular injuries r/t abd access

A
  • aorta
  • IVC
  • iliac vessels
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16
Q

MINOR vascular injuries r/t abd access

A
  • abd wall
  • mesentery
  • other organs
    more often a cause for transfusion, open procedure, or reop
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17
Q

2 vessels particularly prone to injury with laparoscopic sx

A

1) distal aorta (lies directly beneath umbilicus)
2) R common iliac artery (crosses the midline)

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18
Q

T/F: longer trocars and Veress needles may be needed for obese patients having laparoscopic sx

A

True

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19
Q

Factors that contribute to physiologic changes with lap. sx

A
  • CO2 insufflation
  • positioning
  • co-existing comorbidities
  • neurohumor effects of absorbed CO2
  • anesthetic agents
  • intravascular volume
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20
Q

3 common CV changes with laparoscopy

A
  • increased SVR
  • increased MAP
  • increased cardiac filling pressures
    minimal changes in CI and HR in healthy patients
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21
Q

Causes for increased SVR with laparoscopy

A
  • increased sympathetic output from CO2 absorption
  • neuroendocrine response to pneumo
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22
Q

Effect of increased SVR

A

increased myocardial O2 demand

d/t increased myocardial wall tension

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23
Q

Causes for increased cardiac filling pressures with laparoscopy

A
  • compression of liver & spleen
  • increased IAP d/t sympathetic output or pneumo
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24
Q

Moderate insufflation pressures <18mmHg have what effect on preload

A
  • increased preload (force blood out of abdominal vessels)
    –> increased CVP, MAP, CO
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25
Q

Higher insufflation pressures >18mmHg have what effect on preload

A
  • impede venous return (compress IVC)
    –> decreased CVP, MAP, CO
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26
Q

First line treatment for HoTN associated with pneumoperitoneum

A

ask sx to lower insufflation pressure

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27
Q

Impact of insufflation on veins and arteries

A

veins: initial increase then decrease in preload
arteries: increase SVR, increase MAP, decrease CI

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28
Q

Physiologic changes r/t laparoscopy/insufflation
cerebral:
hepatic:
bowel:
renal:
femoral veins:

A
  • cerebral: increased cerebral BF & ICP
  • hepatic: decreased total hepatic BF
  • bowel: reduced gut perfusion
  • renal: reduced renal BF & UO
  • femoral veins: reduced BF (increased r/f DVT)
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29
Q

Pulmonary effects of insufflation

A
  • increased peak pressures
  • increased dead space
  • increased V/Q mismatch
  • decreased compliance
  • decreased FRC
    exacerbated with obesity, lung dz, and Trendelenburg
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30
Q

Drugs of choice to treat pneumoperitoneum-related HTN

A

Esmolol or Labetalol
(hypnotic-sedatives or opioids may delay emergence)

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31
Q

Pros/Cons to using N2O with laparoscopy

A
  • use is controversial d/t potential to diffuse into bowel lumen & cause distention
  • insignificant emetic effect
  • omission may increase r/f awareness
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32
Q

PONV management in lap. sx

A
  • TIVA (less PONV than inhaled agents)
  • prophylactic combination
  • aggressive hydration
  • minimal opioids
  • aggressive pain control
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33
Q

Lap. sx has more (visceral/parietal) pain than open abdominal procedures

A

more visceral pain

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34
Q

Causes for postop lap. sx pain

A
  • shoulder pain 2* diaphragmatic irritation
  • duration of surgery
  • stretching of intra-abdominal cavity d/t higher insuff pressures
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35
Q

Method to reduce stomach injuries with lap. sx

A
  • decompress stomach with NGT
  • decompress urinary bladder via foley
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36
Q

Causes for acute CV collapse during lap sx

A
  • profound vasovagal rxn
  • arrhythmia
  • acute blood loss
  • myocardial dysfxn
  • tension pneumothorax
  • excessive IAP
  • VAE
  • severe resp acidosis
  • cardiac tamponade
  • anesthetic drugs
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37
Q

Hypercarbia during lap. sx is commonly due to

A

pulmonary complications
(less frequently from resorption of CO2)

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38
Q

Effect of hypercarbia on mocardium

A

decreased contractility

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39
Q

Tx for SQ emyphysema

A
  • usually resolves on its own after deflation
  • may be necessary to deflate early to allow for elimination of CO2
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40
Q

Radiographic study required if your patient develops cervical emphysema

A

chest XR

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41
Q

Causes of pneumothorax in lap. sx

A
  • tear in visceral peritoneum
  • break of parietal pleura during dissection around esophagus
  • congenital defect in diaphragm
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42
Q

Presentation of pneumothorax

A
  • increased peak airway pressures
  • reduced SaO2
  • significant HoTN
  • cardiac arrest (rare)
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43
Q

Hypothermia is (more/less/equally) likely during laparoscopy sx compared to open abd

A

equally

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44
Q

Effect of lithotomy position on body systems

A
  • increased VR, CO, ICP
  • exaggerates CHF
  • decreased Vt
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45
Q

Proper way to lift legs into/out of lithotomy

A

lift both legs together, slowly

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46
Q

Nerves affected by lithotomy position

A
  • femoral
  • obturator
  • common peroneal
  • saphenous
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47
Q

Nerve at risk if lateral thigh is resting on a leg support

A

common peroneal

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48
Q

Nerves affected with excessive thigh flexion

A

femoral & obturator

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49
Q

Nerve affected during difficult forceps delivery

A

obturator

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50
Q

Signs of femoral nerve damage/injury

A
  • decreased hip flexion
  • decreased knee extension
  • loss of sensation over superior & medial thigh
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51
Q

Signs of obturator nerve damage/injury

A
  • inability to adduct leg
  • decreased sensation over medial thigh
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52
Q

Signs of saphenous nerve damage/injury

A
  • numbness along anteromedial and postmedial surface of lower leg
  • dull achy pain, burning sensation, muscle tightness, shooting pain, tingling, numbness
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53
Q

Signs of common peroneal nerve damage/injury

A
  • foot drop
    (typically when pinched between head of fibula & leg support)
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54
Q

Potential complications of gyn sx

A
  • perf of uterine wall or bowel
  • injury to cervix
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55
Q

Potential surgical complications with vag hys

A
  • bleeding
  • ureter/bladder/bowel damage
  • infxn/thrombosis
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56
Q

Potential surgical complications with pubovaginal sling

A
  • voiding difficulties
  • bladder or uretheral injury
  • rejection of sling material
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57
Q

Advantages of lap. sx

A
  • reduced bleeding
  • smaller incision, less pain
  • shorter hospital stay
  • lower cost
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58
Q

2 conditions that favor an air embolism

A

1) direct communication between source of air & vasculature
2) pressure gradient favoring passage of air

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59
Q

Amount of air that can make an air embolus fatal

A

20mL

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60
Q

S/s of air embolism

A
  • rapid decrease in EtCO2
  • mill-wheel murmur
  • HoTN
  • tachy/brady/arrhythmias/asystole
  • hypoxemia
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61
Q

Most sensitive means to detect air embolus

A

TEE

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62
Q

Treatment for VAE

A
  • stop CO2
  • Durant’s maneuver (left lateral decubitus, steep T)
  • 100% FiO2
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63
Q

Implications if your patient is on Bleomycin

A
  • subacute pulm damage –> pulm fibrosis
  • keep FiO2 40%x
  • given for sarcoma
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64
Q

Implications if your patient is on Adriamycin

A
  • cardiotoxic effects may last years
  • recent EKG
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65
Q

Treatment for bradycardia with insufflation

A
  • STOP insufflation
  • Atropine
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66
Q

When should Toradol be given during the case?

A
  • after checking with surgical team
  • toward the end with closure
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67
Q

A patient with mets may have what lab derangements?

A
  • tumor markers
  • low albumin
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68
Q

Methods to manage infxn preoperatively

A
  • treat active infxns prior to sx
  • postpone sx if active infxn is present
  • smoking & EtOH cessation
  • optimize DM
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69
Q

3 intraoperative factors that increase infxn rate

A
  • hypoxia
  • hypothermia
  • hypocapnia
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70
Q

Intraoperative management of infxn

A
  • prophylactic abx
  • manage hypoxia / hypothermia / hypocapnia
  • pain control
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71
Q

Culprit for 1/3 of SSIs

A

staphylococci

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72
Q

Definition of SIRS

A
  • nonspecific inflammatory response to an insult that results in activation of the immune system
  • body’s way of attempting to maintain homeostasis
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73
Q

Mechanism of SIRS

A
  • abnormal secretion of cytokines
  • causes attraction of neutrophils, vasodilation, coagulation cascade
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74
Q

Definition of septic shock

A
  • severe sepsis + refractory HoTN OR lactate >=4mmol/L
  • distributive shock with signs of end organ damage
  • DECREASED SVR
  • INCREASED CO
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75
Q

Mechanism of septic shock

A
  • inconsistent blood flow to the microvasculature
  • endothelial cells less responsive to vasoconstrictors
  • loss of glycocalyx –> leaky & release NO
  • disrupted coag cascade
  • DIC
  • RBCs change shape
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76
Q

Describe HYPERdynamic septic shock

A
  • normal or elevated CO with profound vasodilation
  • decreased myocardial contractility
  • high mixed venous O2 (defect in O2 utilization)
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77
Q

Describe HYPOdynamic septic shock

A
  • decreased CO with low/normal SVR
  • myocardial depression
  • low mixed venous O2
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78
Q

Clinical presentation of septic shock

A
  • hypoxemia
  • oliguria –> ARF
  • leukocytosis
  • elevated bilirubin
  • insulin resistance
  • DIC, thrombocytopenia
  • resp failure
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79
Q

Tx of septic shock

A
  • abx
  • correct HoTN
  • evaluate organ fxn
  • intravascular volume expansion
  • colloids > crystalloids
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80
Q

First drug of choice in septic shock mgmt

A

Norepi
- increases BP
- variable effects on CO & HR
- improves organ perfusion by increasing SVR

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81
Q

Potential negative SE of NE for septic shock

A

patient must be fluid resuscitated or it will decrease renal perfusion

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82
Q

Definition of cardiogenic shock

A
  • primary pump failure
  • reduced contractility
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83
Q

Drug of choice for cardiogenic shock

A

Dobutamine
(unless HoTN is present)

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84
Q

Definition of MODS

A

multi organ dysfxn syndrome
- sepsis-related organ failure
- literally every organ system

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85
Q

Lipopolysaccharides are the most common initiators of surgical site infxns. What sets them apart?

A

O polysaccharides found on outer membrane of G- bacteria
- Lipid A is the compound’s toxicity (NOT lipid C)

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86
Q

Amount of time you want a septic patient on abx before sx

A

24 hours

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87
Q

Effects of Epi

A
  • increases CI, HR, SVR
  • strong inotropic
  • increase lactate levels
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88
Q

Effects of Vasopression

A
  • increased SBP
  • little effect on CO, HR, PVR
  • potent arteriole vasoconstrictor in low doses
  • useful in distributive shock
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89
Q

Effects of Dopamine

A
  • raises MAP by increasing CI & SVR
  • improves UO
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90
Q

Effects of Dobutamine

A
  • B1 & B2 receptor agonist
  • potent ino/chronotropic
  • mild peripheral vasodilator
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91
Q

Absolute indications for OLV

A
  • lung isolation to prevent contamination
  • control of distributive ventilation (fistula, cyst, trauma)
  • surgical indications
  • unilateral lung lavage
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92
Q

High priority surgeries that are relative indications for OLV

A
  • aortic aneurysm
  • pneumonectomy
  • lung vol reduction
  • minimally invasive cardiac sx
  • upper lobectomy
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93
Q

Low priority surgeries that are relative indications for OLV

A
  • esophageal
  • middle & lower lobectomy
  • mediastinal mass resection
  • bilat sympathetctomy
  • rib stabilization
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94
Q

If you have the choice, which lung is preferable for OLV

A

R (slightly bigger)

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95
Q

R lung characteristics

A
  • 3 lobes
  • easier to R mainstem
  • shorter 1* segment
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96
Q

L lung characteristics

A
  • 2 lobes
  • slightly smaller d/t heart
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97
Q

The (apex/base) of the lung has better ventilation

A

base
- more compliant/able to stretch

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98
Q

The (apex/base) of the lung has better perfusion

A

base
- dependent

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99
Q

1 reason for hypoxemia

A

V/Q mismatch

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100
Q

Factors that inhibit hypoxic pulmonary vasoconstriction

A
  • hypocapnia
  • very high/low mixed venous O2
  • vasodilators
  • infxn
  • halogenated agents
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101
Q

Factors that promote hypoxic pulmonary vasoconstriction

A
  • PAO2 <50mmHg
  • reuptake of NO
  • endothelin
  • IV anesthetics (maintain)
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102
Q

V without Q =

A

dead space
- anatomical = 2mL/kg

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103
Q

Examples of physiological dead space

A
  • disease
  • PEEP
  • positioning
  • HoTN
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104
Q

Q without V =

A

shunt
- ASD/VSD
- R mainstem
- atelectasis

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105
Q

Concerns with lateral decubitus positioning on dependent arm, nondependent arm, head

A
  • dependent arm (compression injuries)
  • nondependent arm (stretch injuries)
  • dependent eye & ear (pressure/decreased perfusion)
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106
Q

The (up/down) lung has better V & Q in the lateral decubitus position

A

down

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107
Q

Ventilator changes for OLV

A
  • 100% O2
  • decrease Vt (4-6mL/kg)
  • increase RR
  • increased PIP
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108
Q

Size selection for double lumen ETT

A

use the largest tube that fits
- too big = ischemia
- too small = not immediately evident, high cuff volumes, r/f displacement

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109
Q

Bronchial cuff of double lumen ETT holds what volume

A

2-3mL (high volume, low pressure cuffs)

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110
Q

Advantages to double lumen ETT

A
  • CPAP
  • collapse and re-expand lungs
  • secure during position changes
  • split lung ventilation
  • suction either lung

L DLT appropriate for 99% of thoracic surgeries

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111
Q

Complications with double lumen ETT

A
  • proper positioning
  • hypoxia if occluded or malpositioned
  • trauma - large stiff tube
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112
Q

Management of desaturation with OLV

A
  • check position
  • suction
  • recruit ventilated lung
  • PEEP to ventilated lung
  • CPAP to non-dependent lung
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113
Q

Fluid management with OLV

A

<3L in first 24 hours
<1L intraop

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114
Q

Drugs to use in OLV
Drugs to AVOID in OLV

A

USE:
- inhaled anesthetics (bronchodilate and reduce bronchospasm)
- ketamine (bronchodilate BUT increased secretions)

AVOID:
- histaminergic drugs

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115
Q

Gold standard for surgeries requiring OLV

A

epidural with local + opioid

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116
Q

Effect of pain on lung expansion

A
  • decreased breathing and coughing
  • decreased FRC
  • increased atelectasis
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117
Q

Effect of narcotics on lungs

A
  • decreased RR
  • increased sedation
  • PCA is preferred
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118
Q

Describe Type 1 DM

A
  • 5-10% of diabetics
  • autiommune B cell destruction
  • insulin deficiency
  • exogenous insulin ALWAYS required
  • DKA
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119
Q

Describe Type 2 DM

A
  • 90-95% of diabetics
  • genetic & environmental factors
  • insulin resistance or abnormal B cell fxn
  • tx diet, exercise, oral meds, +/- insulin
  • HHNS
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120
Q

3 factors that can cause hyperglycemia

A
  • surgical stress
  • GA
  • relative insulin deficiency
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121
Q

3 factors that can cause hypoglycemia

A
  • NPO
  • hyperinsulinemia
  • exogenous insulin administration
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122
Q

Goal of glycemic control in the OR

A

minimize HYPERglycemia and avoid HYPOglycemia

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123
Q

Goal glucose level in the OR

A

80-200 mg/dL AND treat hypoglycemia ASAP

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124
Q

Effect of autonomic neuropathy in the diabetic patient undergoing sx

A

limited ability to compensate (with tachycardia & increased PVR) for rapid intravascular volume changes
- higher r/f post-induction HoTN
- delayed gastric emptying

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125
Q

Airway issues in the diabetic

A
  • glycosylation of joints
  • decreased AO joint mobility
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126
Q

What % of type 1 diabetics have a difficult airway?

A

30%

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127
Q

DM med with a r/f lactic acidosis

A

biguanides (Metformin)

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128
Q

3 DM drug classes to be d/c’ed before sx

A
  • biguanides (Metformin) x>48hrs
  • sulfonylureas (-zide, -amide) 24-48hrs
  • SGLT2 inhibitors (-agliflozin) 72hrs
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129
Q

2 DM drug classes w/ r/f aspiration

A
  • glucagon-like peptide-1 receptor antagonists (Exenatide)
  • dipeptidyl-peptidase-4 inhibitors (-gliptin)
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130
Q

4 DM drug classes with r/f hypoglycemia

A

1) sulfonylureas
2) meglitinides
3) glucagon-like peptide-1 inhibitors
4) dipeptidyl-peptidase-4 inhibitors

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131
Q

3 DM drug classes that do NOT cause hypoglycemia

A

1) biguanides
2) thiazolidinediones
3) a-glucosidase inhibitors

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132
Q

DM drug class with r/f dehydration, hypovolemia, HoTN, ketoacidosis

A

SGLT2 inhibitors

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133
Q

DM drug class that results in ECF expansion & edema

A

thiazolidinediones

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134
Q

General oral antidiabetic medication guidelines:

A
  • continue usual routine until morning of sx
  • hold oral meds on AM of sx
  • EXCEPT: metformin & sulfonylureas (24-48hrs) & SGLT-2s (72hrs)
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135
Q

Peak action of short, intermediate, & long acting insulin

A

short: 1hr (regular 2-4hr)
intermediate: 6-8hr
long: no peak

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136
Q

Insulin guidelines on day of sx

A

omit short/rapid-acting insulin on AM of sx

if they take 2 types of insulin in the AM: 1/2 to 2/3 of total intermediate/long-acting
if they take 2 types of insulin 2+ times/day: 1/3 to 1/2 total intermediate/long-acting AM dose

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137
Q

Preop insulin mgmt in diabetics depends on 3 things:

A

1) type of DM
2) insulin regimen
3) predisposition to hypoglycemia

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138
Q

Recommendation for insulin administration in type 2 DM the evening before sx

A
  • 75-80% long-acting
  • 75-80% intermediate
  • normal regular/rapid
  • normal pump
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139
Q

Recommendation for insulin administration in type 2 DM the AM of sx

A
  • 50% long-acting
  • 50% intermediate (unless AM glucose <120)
  • HOLD regular/rapid
  • 60-80% pump, HOLD short-acting
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140
Q

When does the mild correction scale begin for DM type 1

A

> =180mg/dL

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141
Q

When does the moderate correction scale begin for DM type 2

A

> =140mg/dL

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142
Q

Typical basal insulin dose via continuous pump

A

0.5-1.0 units/hour of rapid acting insulin
increased/decreased at various times of day d/t activity levels

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143
Q

Perioperative insulin pump guidelines

A
  • <2hr px - continue basal rate
  • > 2hr px - IV insulin in fusion AM of sx
  • glucose check Q1h
  • follow institutional algorithm
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144
Q

Typical intraop IV insulin infusion goal range

A

140-180mg/dL

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145
Q

Nerve that runs along the lateral border of each thyroid lobe

A

recurrent laryngeal nerve

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146
Q

3 hormones secreted by the thyroid

A
  • T3
  • T4
  • calcitonin
147
Q

Thyroid hormone synthesis depends on…

A

hypothalamic-pituitary-thyroid axis

148
Q

Ratio of T3:T4

A

1:10

149
Q

T3 / T4
More directly released from thyroid:
More protein bound:
More potent:
Longer half-life:
More active:

A
  • directly released = T4
  • protein bound = T4
  • potent = T3
  • half-life: T4
  • active: T3
150
Q

Effect of thyroid hormones on the body

A
  • increased BMR
  • increased O2 consumption
  • increased CO2 production
151
Q

Most common form of HYPERthyroidism & presentation

A

Grave’s disease (autoimmune); presents as hypermetabolism

152
Q

Most common form of HYPOthyroidism & presentation

A

Hashimoto’s thyroiditis (autoimmune); presents as decreased BMR

153
Q

Hyperthyroidism presentation

A
  • heat intolerance
  • weight loss
  • diarrhea
  • muscle weakness/fatigue
  • tremors
  • tachydysrhythmias (AFIB!)
154
Q

Hypothyroidism presentation

A
  • cold intolerance
  • weight gain
  • constipation
  • fatigue
  • mood swings
  • pericardial effusion
155
Q

Meds to treat hyperthyroidism & MOA

A
  • thionamides (inhibit thyroid synthesis)
  • BB (reduce SNS stimulation, prevent T4-T3 conversion)
  • K+ or Na+ iodide (inhibits synthesis & release)
  • radioactive iodine (destroys thyroid tissue
156
Q

Anesthetic considerations for hyperthyroid patient

A
  • euthyroid state is ideal
  • tracheal deviation?
  • r/f corneal abraisons
  • avoid ketamine, pancuronium, paralysis
  • no change in MAC
157
Q

4 major complications of thyroid surgery

A
  • RLN injury (hoarseness, stridor, obstruction)
  • hemorrhage
  • hypoCa2+ (inadvertent removal of PT glands)
  • thyroid storm
158
Q

When does post-thyroidectomy hypoCa2+ develop? How is it treated?

A
  • 24-48 hours postop
  • airway management & Ca2+ administration
159
Q

Thyroid storm is most likely to trigger…

A
  • during times of stress
  • 18 hours after sx
160
Q

4 Bs of treating thyroid storm

A
  • block thyroid hormone production
  • block thyroid hormone release
  • block conversion of T4 –> T3
  • block adrenergic effects of thyroid hormones
161
Q

Anesthetic implications for patients with HYPOthyroidism

A
  • mild/moderate acceptable for sx
  • large tongue/goiter –> airway obstruction
  • delayed gastric emptying
  • prone to hypodynamic circulation
  • sensitive to anesthetics, benzos, narcs
  • may not respond to catecholamines
  • monitor for myxedema coma
162
Q

Myxedema coma typically occurs..
Symptoms?
Treatment?

A
  • rare, but postoperatively d/t infxn, cold, sedatives
  • AMS, coma, sz, brady, HF
  • MEDICAL EMERGENCY –> urgent administration of Levothyroxine
163
Q

Location of catecholamine secretion

A

adrenal medulla

164
Q

Ratio of Epi:NE secretion

A

4:1
(80% Epi, 20% NE)

165
Q

Location of steroid hormone secretion

A

adrenal cortex
(cortisol, aldosterone, testosterone)

166
Q

Adrenal cortex layers and the hormone they secrete

A

(outermost)
- glomerulosa (mineral corticoids - aldosterone)
- fasciculata (glucocorticoids - cortisol)
- reticularis (sex hormones - androgens)

167
Q

Aldosterone:
- effects
- stimulated by
- location it acts on

A
  • effects: responds to salt and water loss to maintain intravascular volume (Na+ retention, K+ secretion)
  • stimulated by: angiotensin II
  • acts on: distal tubule & collecting duct
168
Q

Hormone required for vasculature to respond to the vasoconstrictive effects of catecholamines

A

cortisol

169
Q

Effects of cortisol

A
  • gluconeogenesis
  • protein catabolism
  • FA mobilization
  • anti-inflammatory
  • improves myocardial performance via increasing # & sensitivity of B receptors on heart
170
Q

Effect of stress on daily cortisol production

A

normal = 8-30mg/day
stress = 150mg/day

171
Q

HPA axis is potently stimulated by…

A

surgery/stress

172
Q

What patients should receive stress dose steroids?

A
  • at r/f HPA suppression
  • > 20mg/day for >3weeks within last year
173
Q

Hydrocortisone dose for:
superficial surgery
minor
moderate
major

A
  • superficial = normal AM dose
  • minor = normal AM dose + 25mg
  • moderate = normal AM dose + 50-75mg + taper
  • major = normal AM dose + 100-150mg + taper
174
Q

Steroid equivalent doses

A

0.75mg Dexamethasone
4mg Methylprednisolone
5mg Prednisone
20mg Hydrocortisone

175
Q

8mg Dexamethasone = ____mg Hydrocortisone

A

200mg

176
Q

Most potent steroid

A

Dexamethasone

177
Q

Least potent steroid

A

Cortisone

178
Q

Steroid with highest mineralcorticoid effect

A

Fludrocortisone

179
Q

Steroids with NO mineralcorticoid effect

A
  • Triamcinolone
  • Dexamethasone
  • Betamethasone
180
Q

DOA of long-acting glucocorticoids

A

36-72 hours

181
Q

Cause & effect of primary adrenal insufficiency

A
  • cause: adrenal gland disorders; lack of (-) feedback by cortisol
  • effect: deficiency in both mineral- and glucocorticoids –> volume depletion & HoTN
182
Q

Cause & effect of secondary adrenal insufficiency

A
  • cause: pituitary gland or hypothalamus disorders (regulatory centers)
  • effect: deficiency in GLUCOcorticoids only –> decreased vascular tone & HoTN
183
Q

Example of 1* adrenal insufficiency

A

Addison’s dz - autoimmune destruction of adrenal glands

184
Q

Cortisol deficiency s/s

A
  • weakness
  • fatigue
  • weight loss
  • N/V
185
Q

Exogenous steroid administration can lead to what disorder?

A

secondary adrenal insufficiency

186
Q

Patients with 2* adrenal insufficiency are at risk for ________

A

adrenal crisis

187
Q

S/S of adrenal crisis under anesthesia

A
  • hemodynamic instability
  • refractory HoTN
188
Q

Tx of acute adrenal crisis

A
  • steroid replacement (hydrocortisone 300mg/day)
  • ECF volume expansion
  • hemodynamic support
189
Q

Final metabolite of NE and Epi

A

vanillylmandelic acid (VMA)

190
Q

Primary sites of catecholamine metabolism

A

kidneys & liver
5% NE excreted unchanged in urine

191
Q

Pheochromocytomas secrete more ___ than ___

A

NE > Epi

192
Q

Triad of symptoms for pheo

A

1) diaphoresis
2) palpitations
3) headache

193
Q

5Ps of pheo

A

pain
pallor
palpitations
perspiration
pressure

194
Q

Preop mgmt of pheo patients should include…

A
  • assess CV system for dysfxn
  • assess effectiveness of HTN tx.
  • a-adrenergic blockade (phenoxybenzamine)
  • B-blockade after a-blockade
  • CCB
  • tyrosine hydroxylase inhibitor
  • correct hypovolemia
195
Q

Which patients require an awake art line?

A

pheochromocytoma

196
Q

Things to avoid in pheo patients

A
  • stimulation of catecholamine release
  • indirect release of catecholamines
  • histamine release
  • vagolytics/sympathomimetics
  • succs
  • DA receptor antagonists
  • glucagon
197
Q

What happens during phase I of pheo surgery? What should we watch for?

A
  • tumor dissection & location of vascular supply
  • HTN/arrhythmias
198
Q

What happens during phase 2 of pheo surgery? What should we watch for?

A
  • effluent vein clamped
  • HoTN
199
Q

3 events likely to cause hemodynamic instability in pheo patients

A
  • insufflation
  • tumor manipulation
  • ligation of tumor blood supply
200
Q

Goal of anesthesia for pheo patient

A

avoid stimulation

201
Q

Gold standard HTN treatment for intraop pheo

A

clevidipine (CCB)
1-2 mg/hr; doubled at 90sec intervals
reduces SBP 2-4mmHg per 1-2mg/hr

202
Q

Alternative HTN options for intraop pheo

A
  • Na+ nitroprusside
  • phentolamine
  • nicardipine
  • labetolol
  • esmolol
  • Mg
203
Q

Besides HTN, what other side effects can occur during pheo surgery

A

arrhythmias (lido, esmolol, amiodarone)
HoTN (fluids, phenyl, vaso, methylene blue)
hypoglycemia

204
Q

Why might pheo patients develop hypoglycemia postop?

A

rebound hyperinsulinemia d/t sudden reduction in circulating catecholamines

205
Q

Highest risk patients to develop intraop renal failure

A
  • > 56 years old
  • male
  • HTN
  • heart or liver failure
  • aortic cross clamp sx
  • emergency
  • intraperitoneal sx
  • renal insuff
  • DM
206
Q

4 major functions of the renal system

A
  • maintain ECF composition
  • maintain ECF volume
  • endocrine fxns
  • arterial BP regulation
207
Q

4 components to regulation of ECF composition by the kidneys

A

1) ions (Na, K, Ca, Mg, Cl, H+, HCO3)
2) osmolality (ADH)
3) plasma (AA, glucose, proteins, vitamins)
4) metabolic products & toxins

208
Q

How is regulation of ECF volume managed by the kidneys?

A

aldosterone

209
Q

What system is responsible for arterial BP maintenance in the kidneys?

A

RAAS

210
Q

3 hormones secreted by the kidneys

A
  • EPO
  • vit D
  • renin
211
Q

EPO production is stimulated by…

A

decreased PO2 stimulates RBC formation in bone marrow

deficiency in BRF = anemia

212
Q

Definition of normal UO, oliguria, and anuria

A
  • normal = >0.5mL/kg/hr
  • oliguria = <20mL/hr
  • anuria = none
213
Q

Kidneys get __% of CO

A

25%
(80% cortex, 20% medulla)

214
Q

Renal O2 consumption = ____ mL/min

A

18 mL/min

215
Q

Best overall measure of renal fxn

A

GFR
(normal = 90)

216
Q

Renal lab value that changes with diet, dehydration, co-existing dz, fever

A

BUN
(normal = 10-20 mL/dL)

217
Q

Renal lab value that is a product of muscle mass, high protein meals, and is affected by Cimetidine

A

serum creatinine
(normal = 0.7-1.5 mg/dL)

218
Q

Most reliable measure of GFR

A

creatinine clearance
(normal = 110-150mL/min)

219
Q

CrCl values and associated impairment

A
  • normal = 95-100 mL/min
  • mild = 50-80
  • moderate = <25
  • ESRD = <10
220
Q

Indirect effects of anesthesia on renal fxn

A
  • CV depression, vasodilation
  • neural = increased renal vascular resistance
  • endocrine d/t stress response
221
Q

Direct effects of anesthesia on renal fxn

A
  • volatiles decrease renal vascular resistance, compound A
  • IV agents inhibit prostaglandin activity
  • surgical stimulation
222
Q

Auto regulation effect of BP on renal perfusion

A
  • low BP = vasodilates afferent arteriole, increase renal BF
  • high BP = vasoconstriction of afferent arteriole, decreased renal BF
  • needs MAP 50-180
223
Q

Hallmark sign of acute renal failure

A

retention of nitrogenous waste products (azotemia)

224
Q

Pre-renal causes of ARF

A
  • decreased renal BF
  • hypovolemia
  • blocked afferent arteriole
225
Q

Intrarenal causes of ARF (acute tubular necrosis)

A
  • renal tubular damage
  • ischemia
  • nephrotoxins
  • myoglobinuria
226
Q

Postrenal causes of ARF

A
  • obstruction of urinary outflow tract
227
Q

Area of kidney most vulnerable to ischemia

A

inner strip of outer medulla
- less blood flow but higher O2 demand

228
Q

Strategies to prevent ARF

A
  • MAINTAIN RENAL PERFUSION
  • maintain adequate intravascular vol
  • maintain O2 transport
  • use diuretics or dopamine
229
Q

How to distinguish between pre-renal and renal failure

A

fractional excretion of Na+ (FENa+) is 90% specific & sensitive
pre-renal = <=1%
renal failure = 1-3%

230
Q

Characteristics of chronic renal failure

A
  • chronic anemia (Hgb 5-8)
  • electrolyte disturbances (hyperK, hyperMg, hyperPhos, hypoCa)
  • HTN (80% of CRF)
  • chronic metabolic acidosis
  • nervous sytem probs
  • infxn
231
Q

1 COD of patients with CRF

A

sepsis

232
Q

Drugs to avoid in CRF

A
  • Diazepam
  • Lorazepam
  • Meperidine
  • Pancuronium
  • Doxacurium
233
Q

Avoid which fluid in patients with hyperK+

A

LR

234
Q

Reversal agents rely on the ___ for elimination

A

renal system

235
Q

Predictors of RA severity

A
  • corticosteroid use
  • hands and feet involvement
  • high BMI
236
Q

Important anesthesia consideration for RA patients

A
  • positioning of extremities
  • reduced neck mobility
  • unstable atlantoaxial joint
237
Q

Considerations for ortho trauma cases

A
  • r/f aspiration
  • closed head injuries
  • C-spine involvement
  • internal bleeding
  • pneumothorax
  • pelvic fx = blood loss, DVT
238
Q

Possible complications with arthroscopc procedures

A
  • pneumothorax
  • pneumomediastinum
  • tourniquet pain
  • fluid volume overload
  • pulm edema
239
Q

Considerations regarding irrigation fluid with arthroscopic cases

A
  • airway edema
  • pulmonary edema
  • fluid overload
240
Q

Indications for interscalene block

A
  • shoulder
  • arm
  • elbow
    (spares branches of the lower FA)
241
Q

Most proximal regional block

A

interscalene

242
Q

Describe Horner syndrome & when it may appear

A
  • RLN paralysis
  • mild ipsilateral ptosis & miosis
  • nasal congestion
    may occur with interscalene block
    self-limiting
243
Q

Major potential complications with interscalene block

A
  • Horner syndrome
  • diaphragmatic paralysis
  • intravascular injection
  • avoid in severe COPD
244
Q

Indication for supraclavicular block

A
  • shoulder
  • arm
  • elbow
  • FA
  • hand
245
Q

Primary risk associated with supraclavicular block

A

pneumothorax

246
Q

Indication for infraclavicular block

A
  • elbow
  • FA
  • hand
  • tourniquet pain
247
Q

Risks associated with infraclavicular block

A
  • intravascular injection (into axillary and subclavian arteries)
  • pneumothorax
248
Q

Indication for axillary block

A

(not popular)
- FA
- hand

249
Q

Limitations to axillary blocks

A
  • positioning
  • tourniquet pain
  • spotty
250
Q

Major downside of a femoral block

A

no weight bearing

251
Q

An adductor/saphenous nerve block will provide ____

A

analgesia to knee and medial leg

252
Q

Major benefits to adductor/saphenous nerve block

A
  • allows for WB
  • spares quadriceps muscle
  • faster ambulation postop
  • lasts 12-16 hours
253
Q

Which block has the highest rate of complications

A

psoas compartment block

254
Q

Ankle blocks are used for…

A
  • foot surgery, amputation
255
Q

5 nerves included in an ankle block

A
  • saphenous
  • deep peroneal
  • superficial peroneal
  • posterior tib
  • sural
256
Q

Indications for spinal anesthesia

A
  • hip & knee sx
  • hernia
  • C-section
257
Q

Symptoms of a sympathetic blockade with spinal anesthesia

A
  • vasodilation
  • unopposed parasympathetic tone
  • intercostal muscle paralysis
258
Q

LAs in order of length of procedure

A

Procaine
Lido/Mepivacaine
Bup/Tetra/Ropivacaine

259
Q

First and last nerves blocked

A

sympathetic = first
motor = last

260
Q

Ortho cases from most to least painful

A

joint scope > TKA > THA

261
Q

LAST has a worse prognosis when which LAs are used

A

Bupivacaine, Levobupivacaine, Ropivacaine

262
Q

Risk factors for LAST

A
  • extreme ages
  • liver disease/low plasma protein
  • metabolic or respiratory acidosis
  • conduction abnormalities
  • renal failure
263
Q

Management of LAST

A
  • stop injection
  • treat hypoxia, hypercapinia, acidosis
  • intralipid 20%
  • Midazolam for sz
  • fluids
  • lower Epi dose
  • Amiodarone for arrhythmias
264
Q

Drugs to avoid in LAST

A
  • CCB
  • BB
  • vasopressin
  • LA
  • propofol
265
Q

Most common position for ortho surgeries

A

dorsal / supine

266
Q

Proper arm position on armboard

A

supine
(palms in if tucked)

267
Q

Things to remember about lateral decubitus positioning

A
  • used for hip, shoulder, extremity sx
  • r/f brachial plexus injury
  • no BP cuff on dependent arm
  • V/Q mismatch
268
Q

Cons to beach chair position re: perfusion

A
  • cerebral hypoperfusion
  • HoTN & brady events
269
Q

HBEs are common with which procedure set-up

A
  • GETA
  • interscalene block
  • beach chair position
270
Q

Cons to beach chair position re: safety

A
  • potential for extubation
  • r/f neck stretching
  • r/f c-spine injury
  • r/f embolism
271
Q

SAFE bed movements while in beach chair position

A
  • Tburg/reverse Tburg
  • table up/down
  • L or R tilt
  • Leg up/down
272
Q

UNSAFE bed movements while in beach chair position

A
  • flex/reflex
  • back up/down
273
Q

Describe tourniquet pain

A
  • localized pain and distal ischemia
  • dull pain (C-fibers)
  • lasts 45-90min
  • r/f sympathetic surge
274
Q

Tourniquet associated nerve damage can occur…

A

TTT > 2 hrs

275
Q

Tourniquets are contraindicated in what paitent population

A

vaso-occlusive crisis (RBC sickling)

276
Q

Tx for tourniquet pain

A
  • intermittent deflation
  • double tourniquets
  • deepen anesthetic
  • beta blockade
277
Q

Expected complications associated with tourniquet deflation

A
  • venous return (acidotic, hypothermic, hyperK)
  • acute dysrhythmias
  • acute HoTN (rapid SVR reduction, direct myocardiac depression)
278
Q

Tx for tourniquet deflation issues

A
  • fluid resuscitation
  • pressors
  • hyperventilation
  • IV Ca2+ or HCO3
  • cardioversion / defib
279
Q

First sign of bone cement implantation syndrome

A

fall in EtCO2
(along with dyspnea)

280
Q

Describe BCIS

A
  • intramedullary HTN
  • BM and air embolization
  • inflammatory response
  • pulm HTN, R heart strain
281
Q

Management of BCIS

A
  • hyperventilation
  • fluid resuscitation
  • treat HoTN
  • bronchodilators
  • turn off N2O
282
Q

3 parts of the brain affected by drug use

A
  • basal ganglia
  • extended amygdala
  • prefrontal cortex
283
Q

Tx for anxiety r/t stimulant use

A
  • benzos
  • barbiturates
  • haldol
284
Q

Tx for tachycardia / HTN r/t stimulant use

A
  • a & B blockers
  • direct vasodilators
285
Q

How to promote secretion of stimulants

A
  • IV hydration
  • gastric lavage
  • ammonium chloride to acidify urine
286
Q

Effect of ACUTE stimulant use on MAC

A

increases MAC

287
Q

Effect of CHRONIC stimulant use on MAC

A

decreases MAC

288
Q

HoTN associated with stimulant use should be treated with…

A

direct acting vasopressors
(poor response to indirect acting)

289
Q

2 drugs to avoid in patients on stimulants

A

ketamine & pancuronium
(increase HR)

290
Q

The analgesic and pulm depressant effects of opioids are (shortened/prolonged) in patients on halluginogens

A

prolonged

291
Q

Effects of barbiturates, ketamine, and opioids are (shortened/prolonged) in patients on weed

A

prolonged

292
Q

Most frequently abused legal drugs according to poison control

A
  1. Hydromorphone
  2. Oxycodone
  3. Methadone
293
Q

Drugs to avoid in patients on chronic opioids

A

opioid antagonists

294
Q

Methadone half-life

A

15-25 hours

295
Q

Effect of acute depressant intoxication on MAC

A

decreases MAC

296
Q

Effect of chronic depressant use on MAC

A

increases MAC

297
Q

Promotion of depressant drug secretion

A
  • IV hydration
  • gastric lavage
  • ammonium chloride to acidify urine
298
Q

Most widely consumed psychoactive substance

A

caffeine

299
Q

Tx for pre-op caffeine-related headache

A

IV narcotics

300
Q

Dose of caffeine to reduce withdrawal symptoms

A

100mg IV
no adverse HR or BP rxn

301
Q

Effect of ACUTE ETOH intoxication on MAC

A

decreases MAC

302
Q

Major thing to remember with acutely ETOH intoxicated patients

A
  • prone to gastric regurg
  • no LMA
  • decompress stomach
  • less IV and volatile required
303
Q

Acute ETOH leads to increased incidence of 2 things

A
  • hypoglycemia
  • hypothermia
304
Q

Effect of chronic ETOH use on MAC

A

increases MAC

305
Q

Effect of chronic ETOH use on coagulation

A
  • increased INR
  • decreased PLT
306
Q

Chronic ETOH and liver fxn r/t anesthesia

A
  • decreased albumin production
  • decreased coagulation factors
  • more free drug
307
Q

Med for esophageal verices

A

octreotide

308
Q

Acute intox with amphetamines & cocaine has what effect on MAC

A

increases MAC

309
Q

Airway plan for lumpectomy

A

GA with LMA

310
Q

Pain plan for lumpectomy

A
  • fentanyl
  • LA
311
Q

Airway plan for mastectomy

A

GETA
TIVA +/- N2O

312
Q

Pain plan for mastectomy

A
  • Tylenol & Celebrex preop
  • Dilaudid
  • 3x antiemetics
313
Q

DIEP flap =

A

deep inferior epigastric perforator
- fat, skin, & BV
- NO MUSCLE
- done s/p mastectomy

314
Q

Airway plan for DIEP flap

A

GETA
+/- art line
2 PIV
NO PRESSORS

315
Q

Pain plan for DIEP flap & gender reassignment

A

long-acting narcotics

316
Q

Airway plan for gender reassignment

A

GETA
+/- art line
2 PIV

317
Q

Contraindications to liposuction

A
  • CV disease (d/t Epi component)
  • severe coagulation disorder
318
Q

Airway plan for liposuction

A

GETA or LMA
*very stimulating

319
Q

Airway plan for face lift

A

GETA - sx suture to teeth/blenderm tape
2 PIV

320
Q

Face lift patients need judicious administration of what

A

IVF to decrease swelling

321
Q

Drug to avoid in face lift surgeries

A

Toradol

322
Q

Airway plan for blepharoplasty

A

GA with LMA or ETT
PONV prophylaxis

323
Q

2 things to remember with blepharoplasty

A
  • oculocardiac reflex can be elicited
  • avoid bucking d/t increased intraorbital pressure
324
Q

Rhinoplasty/septoplasty has high r/f…

A

PONV - consider TIVA/dirty TIVA, always 3x antiemetics
- decompress stomach at end
- NO MASK post-extubation

325
Q

Liver receives ___% of CO

A

25-30%

326
Q

Describe the hepatic blood supply

A
  • portal vein = 75% BF, 50% O2 delivery
  • hepatic artery = 25% BF, 50% O2 delivery
  • venous return to the IVC by the R, L, and middle hepatic veins
327
Q

Impact of portal HTN

A
  • end result of hepatic injury/fibrosis
  • portosystemic shunts develop
  • bypass liver’s detox capabilities
  • buildup of nitrogenous waste
    –> hepatic encephalopathy
328
Q

3 issues that develop from portal HTN

A
  • varices & variceal hemorrhage
  • ascites
  • hepatorenal syndrome
329
Q

Cardiac effects of liver dz

A
  • hyperdynamic circulation
  • decreased SVR & MAP
  • increased CO
  • volume up but severely intravascularly dry
  • prolonged QT
  • decreased response to catecholamines
  • AV shunting
  • looks like sepsis
330
Q

What fraction of the liver can be removed and the organ still be able to regenerate

A

2/3

331
Q

T/F: the liver is the largest internal organ in the body

A

True

332
Q

Avg hepatic venous pressures
- what venous pressure constitutes portal HTN?

A
  • average = 4-5mmHg
  • portal HTN = pressure gradient >5mmHg
333
Q

What causes portal HTN?

A

injured hepatocytes are replaced by fibrous tissue which impedes BF

334
Q

Equation for hepatic BF

A

mean arterial (portal venous pressure) - hepatic vein pressure

335
Q

Impact of stress on hepatic BF
Impact of increased CVP on hepatic BF

A

BOTH decrease flow

336
Q

Liver functions:

A
  • protein metab
  • cholesterol/lipid metab
  • drug metab & detox
  • glucose maintenance/buffer
  • bilirubin excretion
  • blood reservoir (1L)
  • pro & anti-coag production
  • vitamin storage
337
Q

Describe the stages of liver damage

A

healthy liver –> fatty liver –> liver fibrosis –> cirrhosis

338
Q

T/F: AST and ALT assess liver fxn

A

False
- ALT does NOT assess liver fxn - it assesses hepatocellular injury & necrosis
- ALT is localized primarily to the Liver
- AST present in many tissues

339
Q

Clotting factors synthesized by the liver:

A
  • all of them EXCEPT: III, IV, VIII
340
Q

2 coag labs indicative of severe hepatic dysfxn

A
  • PT & INR
    *prolonged PT is non-specific for liver dz
341
Q

Hepatic dz causes thrombocytopenia. What are some effects of that?

A
  • liver is 1* site of thrombopoietin
  • direct BM suppression
  • DIC
  • splenic sequestration of up to 90% of PLT
342
Q

Main players in hepatic drug metab

A

smooth ER of hepatocytes

343
Q

Bilirubin is a byproduct of what? What are the 2 fractions?

A
  • byproduct of Hgb from RBCs
  • lipid soluble / indirect / unconjugated
  • water soluble / direct / conjugated
344
Q

1 cause of acute liver failure

A

drug related (50% acetaminophen)

345
Q

4 characteristics of acute liver failure

A
  1. encephalopathy
  2. coagulopathy (INR >1.5)
  3. no hx of liver dz
  4. illness <26 wks
346
Q

2 vascular abnormalities unique to setting of portal HTN

A
  1. hepatopulmonary syndrome
  2. portopulmonary syndrome
347
Q

% of patients with hepatic dz with SOB

A

50-70%

348
Q

Hepatopulmonary syndrome (HPS) triad:

A
  1. liver dysfxn
  2. unexplained hypoxemia
  3. intrapulm vascular dilation
349
Q

Define orthodexia

A

positional oxygen change; IPVDs predominate in the base of the lungs
- standing worse, supine better

350
Q

Tx for type 1 HPS

A

increase FiO2

351
Q

Mechanism of reduced metab of drugs by liver

A
  • reduced protein binding
  • decreased fxnl mass of hepatocytes
  • portocaval shunts
352
Q

Compare drugs with high/low hepatic extraction ratios

A
  • high: significantly affected by changes in hepatic BF
  • low: not significantly affected by BF, but are affected by protein binding, induction/inhibition of enzymes, age, liver dz
353
Q

Cause of hepatic encephalopathy

A

hyperammonemia
- body can’t get rid of ammonia so it synthesizes glutamine
- glutamine is osmotically active –> edema
- systemic inflammatory response

354
Q

Increased mortality from hepatic sx associated with:

A
  • albumin <4
  • pre-existing lung dz
  • intraop transfusion / high blood loss
  • concurrent intra-abd op
  • prolonged OR time
355
Q

Describe the pringle maneuver

A
  • portal vein & hepatic artery temporarily occluded via clamping of the portal triad
356
Q

Liver sx complications

A
  • BLEEDING
  • air embolism
  • post-op (coagulopathy, liver dysfxn, neurologic, cardiac, resp)
357
Q

Periop risk assessment for liver dz sx

A

Child-Turcotte-Pugh
Albumin, Ascites
Bilirubin
Encephalopathy
PT/INR

358
Q

Labs included in the MELD score

A
  • INR
  • Creatinine
  • Bilirubin
359
Q

Score that allocates organs for liver tx
- what score has an acceptable risk?

A

MELD
- score <11 = low postop mortality and acceptable risk

360
Q

How to optimize a liver pt for sx

A
  • treat active infxns
  • minimize vasoactive infusions
  • optimize central blood bolume
  • minimize ascites
  • improve encephalopathy & coagulopathy
361
Q

Effect of liver dz on NMBAs

A

prolonged succs, vec, roc, pan

362
Q

Reasons to give albumin to cirrhotics

A
  • after large volume paracentesis
  • presence of SBP to prevent renal impairment
  • presence of hepatorenal syndrome
363
Q

Indication for TIPS procedure

A

decompress portal HTN in setting of esophageal varices/intractable ascites

Patho (2 decks)

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