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A1 > Foundations Final > Flashcards

Foundations Final Flashcards

1
Q

Risk of MI in the GP

A

0.3%

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2
Q

Risk of MI in previous MI patients (<1, <3, 3-6, 6<)

A

<1- 33%
<3- 30%
3-6- 15%
>6- 6%

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3
Q

How long to wait after MI for elective surgery?

A

4-6 weeks

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4
Q

What SYMPTOM increases the risk of MI during surgery/ anesthesia?

A

Unstable angina

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5
Q

What heart valve condition is the greatest risk for intraoperative MI?

A

Aortic stenosis (14x higher risk)

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6
Q

Goal METS score

A

0- pain at rest
4- can you walk up 2 flights of stairs without losing your breathe? (Goal)
10- can endure athletics

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7
Q

Anesthetic considerations for OSA pateints

A

Awake extubation
Minimize opioids and versed

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8
Q

What are asthmatics at risk for?

A

Bronchospasm

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9
Q

Which pt are at high risk for aspiration?

A

SBO
GERD
DM
Hiatal hernia
Ascites
Previous gastric bypass
Obesity/ pregnancy

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10
Q

What is mendelson syndrome?

A

Chemical pneumonitis
>25 ml
<2.5 PH
Particulate aspirate > clear aspirate

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11
Q

DM rules

A

Hold oral DM meds the morning of surgery (metformin 2 days)
Take 1/4-1/2 insulin
Check BG upon arrival and intra-op

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12
Q

Signs and symptoms of pheochromocytoma

A

HTN
Diaphoresis
Tachycardia
Headache
Tremulousness (tremors)
Weight loss
HCT >45
Orthostatic HOTN

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13
Q

Cessation of smoking for how long will reduce the effects of nicotine

A

12-48 hours

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14
Q

Cessation of smoking for how long will improve PPC to normal rates

A

8 weeks

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15
Q

Drug of choice for cocaine induced HTN

A

CCBs

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16
Q

ASA classes

A

1- healthy
2- BMI 30-40
3- BMI >40, at least 1 organ failure causing distress to life
4- Surgery is constant threat to life; CVA, TIA, MI <3 months,
5- NEED surgery to survive; AAA, trauma, MODS
6- brain dead, organ donor

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17
Q

6 questions to ask in pre op

A

Name
DOB
Allergies
Surgery
Anesthesia history (and family)
Last meal

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18
Q

Most common intraop allergic reaction cause

A

Roc

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19
Q

Which herbs decrease anesthesia needs?

A

Kava kava, valerian root

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20
Q

Which meds increase bleeding?

A

Ginkgo, garlic, ginseng, fish oil

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21
Q

How long to stop ASA before surgery?

A

7 days

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22
Q

How long to stop NSAIDS before surgery?

A

1-2 days

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23
Q

How long to stop plavix before surgery?

A

7 days

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24
Q

NPO guidelines

A

2h- clear liquids
4- breast milk
6- cow milk, light meal
8- greasy, fatty meal

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25
Q

What is STOP BANG

A

Assessment for OSA
Snoring
Tiredness
Observed apnea
Pressure (high blood pressure)
-
BMI >35
Age >50
Neck >40
Gender of male
0-3- low risk
4+- high risk

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26
Q

Mallampati is used to assess ___

A

Oropharyngeal space
1- pillars
2- uvula
3- soft
4-hard

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27
Q

Thyromental distance assesses ___

A

Submandibular space
6-9cm

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27
Q

Inter incisor gap assesses ___

A

Mouth opening and ability to align the oral, pharyngeal, and laryngeal axis
4-6 cm

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28
Q

Why would the TMD be out of range ?

A

<6- Mandibular hypoplasia
>9- Larynx is caudal, tongue is caudal

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29
Q

Mandibular protrusion test assesses ___

A

TMJ funciton
1- good overbite
2- even bite
3- underbite- high risk

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30
Q

Normal AO flexion and extension

A

Flexion and extension- 90-165
Extension- 35, 23 is difficult

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31
Q

Conditions that impair AO mobility

A

DM
Downs syndrome
DJD
Ankylosing spondylitis
Klippel feil
RA
Surgical fixation
Trauma

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32
Q

BONES

A

Mask
Beard
Obesity
No teeth
Elderly >55
Sleep apnea

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33
Q

LEMON

A

Look at airway (shape of face, physiology)
Evaluate 332
Mallampati
Obstruction
Neck mobility

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34
Q

SHORT

A

Surgical airway
Surgical hx
Hematoma
Obesity
Radiation
Tumor

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35
Q

RODS

A

Restricted mouth opening
Obstruction of airway
Distorted airway
Stiff lungs

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36
Q

How to chronic HTN patients react to induction?

A

A drop in BP more than normal
Maintain 20% baseline

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37
Q

What is Sellick maneuver

A

Cricoid pressure

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38
Q

Hyperthyroid rules

A

Need to be normal for 6-8 weeks, then iodine for 2 weeks
Use Beta blockers intraop to reduce T4 to T3

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39
Q

Considerations for hypothyroid

A

None!

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40
Q

What to do if patient is high off of marijuana in pre op?

A

Delay
MJ will cause tolerance to sevo

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41
Q

What to do if patient didnt take their pre op beta blocker?

A

Give BB intraoperatively

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42
Q

Why would you give reglan in pre op?

A

Reduces gastric volume

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43
Q

Why would you give robinol in pre op?

A

Reduce secretions

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44
Q

Half life of cefazolin?

A

2 hours

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45
Q

How long does it take for vitamin K to improve PT?

A

6-8 hours

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46
Q

How would you treat central anticholinergic syndrome after a dose of scopalamine?

A

Physostigmine 1-2mg IV

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47
Q

How long to wait after a CVA for surgery?

A

9 months

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48
Q

Which ASA; sever sytemic disease of at least 1 organ system that causes functional limitation

A

3

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49
Q

How do illegal drugs affect the pupils?

A

PCP- nystagmus
Cocaine- midriasis (dilation)
Fent- Miosis (constriciton)

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50
Q

How long to delay surgery after a viral respiratory infection?

A

6 weeks

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51
Q

Risk of PONV

A

Female
History of PONV
Non smoker
<50
GA (instead of RA)

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52
Q

Which sites bring the greatest risk of PPC?

A

Thoracic
Aortic
Upper abdomen

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53
Q

When do anesthesia related deaths from airway occur?

A

During emergence, not induction

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54
Q

Intraoperative awareness risk factors

A

Female
Young
Obesity
Previous awareness
Trauma/ OB/ Open heart
NDNMB

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55
Q

What is the biggest factor in anesthesia related deaths?

A

1- Human error
2- Communications

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56
Q

What percent of soda lime is water content?

A

15%

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57
Q

Sevo + baralyme =

A

Fire

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58
Q

Which tank pressure reads the same unless its empty?

A

N2O
CO2

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59
Q

The HIGH pressure leak test requires a pressure of ___

A

30 cm H2O

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60
Q

Circuit compliance equation

A

VT on ventilator - (Compliance of circuit x peak pressure)

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61
Q

Which bellows is safer?

A

Ascending

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62
Q

Which modes of ventilation are best for the LMA?

A

SIMV, PSV

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63
Q

A jet ventilator functions based on the ____ effect

A

Venturi

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64
Q

Critical temp of N2O

A

36.5

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65
Q

The unidirectional valves must be placed between the ___ and ___

A

patient
Reservoir bag

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66
Q

How much pressure for low pressure test?

A

-65cmh2o for 10 seconds

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67
Q

Failsafe tasks

A

30cmh2o- alarm
20cmh2o- stops n2o output

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68
Q

What two steps if you suspect a pipeline crossover

A

1- open oxygen tank
2- close wall supply

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69
Q

Other names for flowmeters

A

Thorpe tubes
Rotameter

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70
Q

Where to read flowmeter indicators

A

Ball-middle
All others- top

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71
Q

Vapor pressure of iso, sevo, des

A

Iso- 240
Sevo- 160
Des- 660

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72
Q

Most common cause of a vaporizer leak? How is it caught?

A

Loose filler cap which is caught by a low pressure leak test

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73
Q

Estimate liquid anesthetic usage formula

A

% of anesthetic x FGF x 3

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74
Q

What causes the pumping effect?

A

PPV
O2 flush

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75
Q

What is the boiling point of Des?

A

23 C

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76
Q

Tec 6

A

Des
39 c, 2atm
Electronic
injects
non elevation compensated
Turn up at elevation

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77
Q

Why is the ascending bellow safer?

A

It will not rise if there is a leak/ crack, so it will be easily detected

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78
Q

How much peep does the gas driven bellow vs the piston ventilator have?

A

Gas driven- 3
Piston- none

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79
Q

What is the primary base of soda lima?

A

Sodium hydroxide NAOH
Neutralizes CO2

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80
Q

What PH will change the soda lime to purple?

A

10.3

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81
Q

Sevo + dessicated soda lime =

A

Compound A

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82
Q

Order of carbon monoxide production from volatile agents and dessicated soda lime

A

Des
Iso
Sevo

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83
Q

open vs closed relief valves

A

open- active only, no need for any pressure relief valve
closed active- (needs positive and negative negative pressure relief)
closed passive- (needs positive pressure relief only)

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84
Q

High and low pressure system parts

A

H- cyclinder x 3, yoke x 2
L- vaporizer, CGO, check valve, flowmeter tubes

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85
Q

What does the high pressure leak test assess?

A

Low pressure system and breathing circuit

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86
Q

When will the failsafe not alarm?

A

Pipeline crossover
Flowmeter leak

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87
Q

When will hypoxia prevention device not alarm?

A

Pipeline crossover
Flowmeter leak
3rd gas administration
Defective mechanic / pneumatic components

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88
Q

Types of oxygen analyzers

A

Galvanic- Needs daily calibration
Pragmatic- faster, self calibrating

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89
Q

What are the risks of a leak in the bellow?

A

Barotrauma
Alteration in concentration

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90
Q

How to prevent rebreathing in the Bain system

A

FGF needs to be 2.5x minute ventilations

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91
Q

Best breathing system for spontaneous vs mechanical ventilations

A

ADB- spont
DBA- mech vent

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92
Q

Intrinsic muslces of the larynx and their function

A

Chubby tired leprochauns piss terrible venom
Cricothyroid- cords tense/ elongate
Thyroaryetnoids- shorten/ relax
Lateral cricoaryetnoids-adduction
Posterior cricoaryetnoids- abduction
Traverse aryetnoids
Vocalis- shorten/ relax

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93
Q

Risk factors for either RLN to be damaged

A

Overinflation of ETT
Tumor
Excessive neck stretching
Neck surgery- thyroidectomy

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94
Q

Risk factors for injury to the L RLN

A

LA enlargement
PDA ligation
AAA
Thoracic tumor

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95
Q

Pharmacologic tx for laryngospasm

A

Adult/kids - succ 1mg/kg IV or 4mg/kg IM
Neonates- 2mg/kg iv or 5mg/kg IM
0.02mg/kg atropine in kids under 5

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96
Q

Valsalva vs muller

A

opposites

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97
Q

How much pressure for sellick maneuver

A

20N before induction
40N after induction

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98
Q

Anesthetic considerations for ludwigs angina?

A

Bacterial infection in mouth
Awake nasal intubation or trach

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99
Q

HELP aligns what two axis?

A

external auditory
Sternum

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100
Q

Contraindications for NPA

A

Cribiform plate injury (lefort 2 or 3)
Coagulopathy
Nasal fracture
Previous caldwell luc
Previous transphenoidal hypophysectomy

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101
Q

Max cuff pressure in LMA

A

60cm h2o

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102
Q

Max PPV pressure in LMA

A

20cm h2o

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103
Q

Biggest ETT that can fit inside an LMA

A

3.5
4
4.5
5
6
6
7

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103
Q

Which meds to give for extubation of a difficult airway

A

BB, CCB, vasodilators
Lidocaine
Opioids

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104
Q

Strongest contraindication to an LMA

A

Tracheomalacia

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105
Q

What angle is the glidescope

A

60

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106
Q

Which local anesthetic has the fastest onset for the oral mucosa?

A

Benzocaine

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107
Q

What position for intubation with the LMA Fastrach?

A

Neutral with a pillow

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108
Q

Steps in airway fire

A

Remove ETT
Turn off gas
Pour saline
Reestablish airway

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109
Q

Most important factor from BONES

A

Beard

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110
Q

When is cricoid pressure contraindicated?

A

Active vomiting
C spine fracture

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111
Q

The order of laryngospasm treatment

A

Fio2 1.0
Remove offending stimulus
Deepend anesthetic
CPAP
SUCC 1mg/kg iv or 4mg/kg im

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112
Q

What is the largest ETT an LMA Fastrach can intubate?

A

8.5

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113
Q

What do the roots of the brachial plexus pass thru?

A

Between the anterior and middle scalene muscles

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114
Q

What do the brachial plexus trunks pass thru?

A

Lateral border of scalenes

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115
Q

What do the brachial plexus divisions pass thru?

A

Between the clavicle and first rib

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116
Q

Where do the cords of the brachial plexus pass thru?

A

Under the pec minor

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117
Q

Where do the branches of the brachial plexus diverge?

A

Axilla

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118
Q

Supraclavicular branches of the brachial plexus

A

Long thoracic c5 c6 c7
Suprascapular c5 c6
Dorsal scapular c5

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119
Q

Infraclavicular branches of the brachial plexus

A

Lateral pectoral
Medial pectoral

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120
Q

Supraclavicular indications

A

Clavicular
Carotid endarectomy

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121
Q

Intercostobrachial indications

A

Arm pain from bier block

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122
Q

Dermatome of upper arm

A

c4- superior delt
c6- lateral delt, thumb
c7- 2 and 3 finger
c8- 4 and 5 finger
t1- medial arm
t2- axilla

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123
Q

Brachial plexus combined sensory and motor peripheral nerves

A

MARMU

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124
Q

Brachial plexus sensory peripheral nerves

A

Medial brachial cutaneous
Medial antebrachial cutaneous

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125
Q

Clinical assessment of brachial plexus blockade

A

Push er- radial- elbow extension
Pull em- musculocutaneous- bicep contraction
Pinch u- ulnar- pinch pinky
Pinch me- median- pinch 2nd digit

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126
Q

Interscalene indications, side effects, and volume

A

Shoulder, upper arm, clavicle (although it may need a superficial cervical plexus block as well)
phrenic nerve paralysis, horners, hypo-brady episode (prevent with BB), total spinal, RLN injury from large volume
7-15 ml

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127
Q

When is a pneumo from a block a higher risk?

A

Tall patients

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128
Q

SS of pneumo

A

Dyspnea
Chest pain
Coughing

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129
Q

Supraclavicular indications, side effects, and volume

A

Upper arm, elbow, wrist, hand (no shoulder)
Pneumo (highest risk), subclavian artery puncture, LAT,
20-25 ml

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129
Q

Infraclavicular indications, side effects, and volume

A

Upper arm, elbow, wrist, hand- good alt for supra (respiratory) and axilla (mobility)
LAST, pneumo, PAIN bc all pec muscles
20-30 ml

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130
Q

Axillary block indications, side effects, and volume

A

Forearm and hand, full stomach,
Musculocutaneous injury,
LAST
15-20 ml

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131
Q

Distal blocks indication, SE, volume

A

Used in forearm or hand surgery if nerves were missed in brachial plexus block
Radial- 5ml/ 10ml low
Ulnar- 5ml high or low
Median- 5ml high or low (NOT IN CARPAL TUNNEL PT, no epi)

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132
Q

Volume for digital nerve block

A

3 ml no epi

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133
Q

Volume for bier block, what drug not to use

A

50ml NO BUPIVICAINE NO EPI

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134
Q

Max inflation time of bier block tourniquet

A

2hr

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135
Q

Biggest risk of IVRA

A

LAST- wait 20 minutes at least

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136
Q

IVRA pressure

A

250 upper
350 lower

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137
Q

Contraindications to IVRA

A

Crush injury/ compound
No peripheral access
Cellulitis
Sickle cell
PVD

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138
Q

Which artery will be at risk for LAST during a supraclavicular block?

A

Subclavian

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139
Q

Landmarks for a low median nerve block

A

Flexor palmaris longus tendon
Flexor carpi radialis tendon

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140
Q

What angle of insertion for different parts of the spine durine neuraxial anesthesia

A

Lumbar- 90 degrees
Thoracic- 45 degrees

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141
Q

Spine landmarks

A

C7- cervical prominens
T3/ T7- top/ bottom of scapula
L1- 10th rib
L4- superior iliac crest
S2- superior iliac spine

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142
Q

What is the hardest and thickest layer in the spine?

A

Dura- collagen and elastic fibers

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143
Q

Epidural space borders

A

Cranial- Foramen magnum
Caudal- Sacrococcygeal ligament
Anterior- posterior
Posterior- ligamentum flavium
Lateral- pedicles

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144
Q

Batsons plexus

A

Epidural veins
Can become engorged in pregnancies and obese, will increase risk of needle injury

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145
Q

3 meninge layers

A

DAP

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146
Q

Epidural needles

A

Crawford- 0
Hustead- 15
Tuohy- 30

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147
Q

Spinal needles

A

Cutting- Quincke, pitkin
Pencil- Sprotte Whitaker Pencan
Rounded- Greene

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148
Q

How far to inject for epidural

A

4-6cm

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149
Q

Onset and duration of spinals

A

Rapid
<2 hours

150
Q

Sequence of blocks and reversal

A

Sympathetic
slow pain, temperature, touch
fast pain, temperature, touch
Touch/ pressure
motor/ proprioception

151
Q

What determines the spread of a spinal

A

Baricity, dose, site, position

152
Q

What determines the spread of an epidural?

A

Volume, dose, level, pregnancy

153
Q

What determines the duration of a spinal?

A

LA used, dose

154
Q

What determines the duration of an epidural?

A

LA used

155
Q

Benefits of hyperbaric vs isobaric

A

Hyper- denser, consistent block
Iso- longer blocks for non pregnants

156
Q

How does age affect spinals?

A

Older age causes a slower onset and longer duration

157
Q

What patient variables dont effect spinal spread?

A

Height
Weight
BMI
Spine length

158
Q

How does gender affect spinal?

A

Females and pregnant- increased motor block with bupivicaine

159
Q

How does pregnancy affect a spinal?

A

Pregnant patients develop a higher level of sensory block

160
Q

What medications need to be stopped before neuraxial anesthesia? Which dont need to be stopped?

A

Need to be stopped- plavix, enoxparin, IV heparin, warfarin
Dont need to be stopped- NSAIDS (ASA, advil), subq heparin (bc its a small dose), herbs (although prodigy says herbs WILL need to be stopped 1-7 days in advance)

161
Q

Does increasing the dose of a local anesthetic change the level of the block?

A

No

162
Q

Does increasing the dose of spinal local anesthetics alter block density and duration?

A

Yes- larger dose increases density and duration

163
Q

How will the addition of a vasopressor (epi or neo) affect a spinal?

A

Prolong block by inhibiting absorption

164
Q

How does the addition of alpha 2 agonists affect a spinal block? What are the side effects?

A

Clonidine and dexmedetomidine prolong duration
They can cause bradycardia (treat with atropine)
Large doses of clonidine can cause sedation and HOTN

165
Q

How does the addition of opioids affect a spinal?

A

Enhances intraop anesthesia
Post op pain releif
Morphine can provide post op pain relief for 12-24 hours

166
Q

Morpine S/E in a spinal

A

Itching
Nausea/ vomitting
Delayed respiratory depression

167
Q

With epidurals, pregnant patients will develop a ______ block when compared to non pregnant patients

A

More extensive

168
Q

What are older patients at risk for with epidurals?

A

HOTN

169
Q

What is the onset for the full effect of an epidural?

A

20-30 minutes

170
Q

How do alpha 2 agonists affect epidurals?

A

Speed onset
Improve quality
Post op analgesia
Sedation is common

171
Q

How do opioids affect epidurals?

A

Speeds onset
Improves quality of block
Post op analgesia

172
Q

What is the dosage and drug for a test dose in the epidural space?

A

45mg lido- sensory and motor block w/ in 3 minutes, rapid analgesia
15mcg epi- hr increase by 10, SBP increase by 15

173
Q

What is the most significant complication for epidurals in the pregnant patient?

A

Inadvertant spinal injection
To prevent this- observe and aspirate to prevent intravascular injection

174
Q

Site of action for epidurals

A

Must diffuse thru the dural cuff to get to the nerve roots

175
Q

Site of action for spinals

A

Myelinated preganglionic fibers of the spinal nerve roots

176
Q

Differential block in spinals

A

SNS is 2-6 levels above sensory
Sensory is 2 levels above motor

177
Q

Differential block of epidurals

A

Sensory and SNS are 2-4 above motor

178
Q

When monitoring a sensory block, what is the first, second, and third sensory modality blocked?

A

1- temperature (alcohol pad wont feel cold)
2- pain (pen poke)
3- light touch

179
Q

What is the modified bromage scale?

A

A way to assess a motor block level
0- no motor block (can lift leg, move feet and knees)
1- patient can only move feet and knees
2- patient can only move feet
3- complete motor block- patient cannot move legs, knees, or feet

180
Q

What dermatome is the knee

A

L4

181
Q

What dermatome is the nipple line and xyphoid process?

A

t4
t6

182
Q

What dermatomes innervate the digits

A

c6- thumb
c7- 2nd and 3rd digit
c8- 4th and 5th digit

183
Q

For an upper abdomen surgery, c section, or cysectomy, what sensory level of block is required?

A

t3
Apex then contradicts and says T6-t8 in the post section quiz

184
Q

For a lower abdomen or appendectomy surgery, which level of sensory blockade is required?

A

t6
Apex then contradicts and says t8-t11

185
Q

For a total hip, vaginal delivery, or TURP, what level of sensory blockade is required?

A

t10

186
Q

For lower extremity surgery, what level of sensory blockade is required?

A

L1-L3/L4

187
Q

For foot surgery, what level of sensory block is required?

A

L2/L3

188
Q

For a hemorrhoidectomy, what level of blockade is required?

A

S2-S5

189
Q

For thorax surgery, what level of blockade is required?

A

t2-t6
Apex then contradicts and says t4-t8

190
Q

For abdominal surgery (gastrectomy, esophagectomy, pancreatectomy, hepatic resection), what level of blockade is required?

A

T6- L1

191
Q

For lower extremity surgery, what level block is required?

A

L2-L5

192
Q

Spinal doses

A

2-chlorprocaine- 30-60mg
levobupivicaine- 10-20mg

193
Q

How much (%) will epi increase duration of a spinal?

A

20-50%

194
Q

Epidural concentrations

A

2-chlorprocaine- 3%
Levobupivacaine- 0.5%

195
Q

Contraindications to neuraxial anesthesia

A

Refusal
Coagulopathy
Increased ICP
Sepsis
Infection at puncture site
Hypovolemia
Difficult airway
Full stomach
Valve lesions with fixed stroke volume (Severe stenosis)

196
Q

Complications of neuraxial anestheisa

A

PDPH
Meningitis
SIH
Cauda equina
Failed spinal
Unilateral block

197
Q

Where does the spinal cord end in adults and infants?

A

L2
L3

198
Q

Where is the dural sac in the adult and infant?

A

S2
S3

199
Q

In the spinal space, which opioids have the greatest amount of spread?

A

Morphine
dilaudid

200
Q

In spinals, which opioids have the least amount of spread?

A

Fent
Sufent

201
Q

Which are the largest spinal nerves? Why is this important?

A

L5
S1
They are most resistant to the effects of LAs

202
Q

What order are the spinal nerves anesthetized in ?

A

1- pre ganglionic sympathetic
2- temperature
3- pain (pin prick)
4- touch
5- motor

203
Q

A patient with severe COPD is showing signs of respiratory compromise after a spinal, which muscles are compromised?

A

intercostals
Abdominal
NOT the diaphragm or SCM

204
Q

S&S of PDPH

A

Tinnitus
Headache
Diplopia

205
Q

Treatment for PDPH

A

Lay flat
Caffiene
NSAIDS
IV fluids
Theophylline
Definitive treatment: blood patch 10-20ml, complete when patient feels pressure in legs/ butt/ back, can be repeated in 24h if not effective ? Side effects: backache and radicular pain
Alternative: sphenopalatine block with 2% lido for 10 minutes into the turbinates

206
Q

Most common side effects with a spinal vs an epidural

A

Spinal- meningitis, cauda equina
Epidurla- epidural abscess, spinal hematoma, spinal cord injuiry

207
Q

What is the most effetive skin preparation method for neuraxial anesthesia?

A

CHG + Iso alcohol

208
Q

Epidural hematoma signs and treatment

A

Back pain
Lower extemity weakness
Bowel/ bladder dysfunction
Decompression within 8 hours of symptom onset

209
Q

Presentation of subdural injection

A

Hallmark sign- patchy block 15-30 minutes later with possible loss of consciousness

209
Q

Which (coagulation) meds do and dont need to be stopped before neuraxial anesthesia?

A

Need to be stopped- plavix, iv heparin, enoxparin, warfarin
Dont need to be stopped- ASA, NSAIDS, subq heparin, herbs

210
Q

Most important factors in the development of nausea in neuraxial anesthesia

A

Opioid premedication
HOTN

211
Q

Greatest points of lordosis and kyphosis in the spine

A

Lordosis- C5, L3
Kyphsosis- T6, S2

212
Q

What region is the paramedian/ taylor appraoch used in?

A

L5/S1- the largest space

213
Q

LA with the highest allergic potential

A

Esters

214
Q

Order of ligaments and tissues when performing neuraxial

A

Skin
Subq
Supraspinous ligament
Interspinous
Ligamentum flavium
Epidural space
Dural
Subdural potential space
Arachnoid
Subarachnoid
Pia??
Posterior
Anterior

215
Q

What is the conus medularis and where is it?

A

End of the spinal cord
L2 (L3 in infant)

216
Q

What is the dural sac and where is it?

A

The end of the subarachnoid space
S2 (S3 in infant)

217
Q

What are the two “pops” felt when conducting a spinal?

A

1st pop- ligamentum flavium
2nd pop- dura mater

218
Q

Cardiovascular side effects from spinals

A

Drop in preload
Drop in HR
Asystole (7 in 100,000)

219
Q

What level of block is needed for a knee procedure?

A

T12

220
Q

What is the pressure of CSF?

A

10-20 mmHg

221
Q

MOA of tramadol in a spinal for analgesia

A

Mu agonism
Serotonin and norepi uptake antagonism

222
Q

How would you treat hotn/ bradycardia after a spinal?

A

IV fluids
Ephedrine
Phenyl

223
Q

Where is CSF produced?

A

Choroid plexus

224
Q

What drug is associated with cauda equina?

A

Hyperbaric lidocaine

225
Q

Which opioid in a spinal will cause nausea?

A

Morphine

226
Q

Which nerve fibers do opioids work on in spinals?

A

C

227
Q

Which LA has a high risk for TNS?

A

Lidocaine

228
Q

Tell me everything you know about transient neurological symptoms

A

Causes: excessive stretching of neck
Risks: Lidocaine, lithotomy
S&S: severe back pain, severe butt pain that radiates to the legs that deveops within 36 hours and stays for 7 days
Tx: NSAIDS, opioids, trigger point injection

229
Q

Tell me everything you know about cauda equina syndrome

A

Causes: neurotoxicity from 5% lido, microcatheters
S&S: bowel/ bladder dysfunction, paralysis
Tx: Supportive

230
Q

Epidural droperidol is used for ____

A

Pruritis
Nausea

231
Q

Pharmacology for preventing vs treating SIH

A

Zofran blocks bezold jarish reflex
Phenyl
Co-loading 15ml/kg (NOT before)
——
Treating;
Pressors
Anticholinergics
Crystyalloids

232
Q

Which LA decreases the effectiveness of epidural opioids?

A

Chlorprocaine

233
Q

What is the hanging drop method? What is the pressure inside the epdirual space?

A

During an epidural; if you place a drop of liquid by the catheter, it should suck the fluid in
The pressure is negative

234
Q

What effect does epidural bicarb have?

A

Speeds onset

235
Q

Which virus can be reactivated by epidural morphine?

A

HSV-1

236
Q

Alternative treatment for PDPH?

A

Sphenopalatine block
2% lido 5-10 minutes
Into turbinates

237
Q

How to remove an epidural for a patient on enoxparin

A

Hold enoxparin for 24 hours
Pull catheter
Restart enoxparin 4 hours later (prodigy says 2 hours which is out dated)

238
Q

Where does the lumbar plexus arise from and what does it innervate?

A

L1-L4 (T12 contribution in 50% of people)
Front of leg

239
Q

Where does the sacral plexus arise from?

A

L4-S4
Back of leg

240
Q

6 nerves of the lumbar plexus

A

I inevitably get lazy on fridays
Illiohypogastric
Illioinguinal
Genitofemoral
Lateral femoral cutaneous
Obturator
Femoral

241
Q

5 nerves of the sacral plexus

A

SIPPS
Superior gluteal
Inferior gluteal
Posterior cutaneous
Pudendal
Sciatic

242
Q

What is the largest nerve in the body?

A

Sciatic

243
Q

All about pericapsular nerve group block

A

Indications: HIPs, or alternative to the femoral and fascia iliaca when used with lateral femoral cutaneous
30-40ml
Ureter injury, last, quad weakness

244
Q

All about fascia iliaca

A

Indications: Femoral, quad, knee, acute pain management for hips
40ml
LAST, failed block, quad weakness

245
Q

All about fascia iliaca

A

Indications: Femoral, quad, knee (it targets the femoral, obturator, and lateral femoral cutaneous nerves)
Faster than femoral and lateral femoral blocks
20-30ml
LAST, nerve injury, quad weakness, failed block

246
Q

All about femoral nerve block

A

Femoral triangle: SAIL (sartorius muscle, adductor longues muscle, and inguinal ligament)
Femoral anatomical structures inside the triangle: VAN (vein, nerve, artery)
Indications: Quad, knee, femoral
Most common lower extremity block
When combines with sciatic, it provides a complete lower extremity block

247
Q

All about adductor canal block

A

Indications: ACL, MCL, patella, vein harvesting, supplement to sciatic for foot/ankle surgery
15-20ml
LAST, nerve injury, quad weakness, MYOTOXICITY

248
Q

All about popliteal block

A

Indications: lower leg, ankle, foot, may require saphenous supplementation
25ml
Foot drop, LAST, hematoma

249
Q

All about ankle block

A

Nerves:
Sensory- saphenous, sural, superficial peroneal
Combined- deep peroneal, posterior tibial
Indications: foot surgery
5ml
Nerve compression, ischemia, hematoma, last

250
Q

Which nerve does NOT need to be blocked for surgery of the toes?

A

Saphenous

251
Q

Why would you choose adductor canal block over a femoral block in a multimodal pain management plan?

A

Limits quad weakness

252
Q

Stimulation of the tibia nerve in the popliteal fossa causes:

A

Plantar flexion and foot inversion

253
Q

Review all nerves and pictures of innervation

A
254
Q

The lateral and medial cords supply the __ branches

A

Ulnar
Median
Musculocutaneous

255
Q

Which nerve block has the highest incidence of chylothorax?

A

Infraclavicular especially left side

256
Q

Where do the roots, trunks, divisions, and cords branch off at?

A

Lateral scalene muscle
Under the clavicle
Under the pec minor muscle
In the axilla

257
Q

Where do different brachial plexus blocks target?

A

R- interscalene
T- supraclavicular
D- supraclavicular
C- infraclavicular
B- axilla

258
Q

Which lung is at higher risk for pneumo during a supraclavicular block

A

R

259
Q

What is the 3 in 1 block

A

Anesthetizes the femoral, lateral femoral, and obturator

260
Q

Which nerve block has the highest risk of chylothorax?

A

Infraclavicular

261
Q

Which regions of the body are the targets of upper body blocks?

A

Interscalene- roots
Supraclavicular- trunks/ divisions
Infraclavicular- cords
Axilla- branches

262
Q

Where do the brachial plexus RTDCB branch off?

A

Roots- lateral scalenes
Trunks- between clavicle and 1st rib
Divisions- under pec
Cords- axilla (and beyond the lateral pec)

263
Q

Which autonomic reflex is likely to be activated during an interscale block in the seated position?

A

Bezold jarich
HOTN, bradycardia, vasodilation

264
Q

Most common cause of injury to median nerve

A

IV in the AC
Axillary block
APEX says almost always unknown causes, NOT improper position

265
Q

The sacral plexus gives rise to the ___ and ___ nerves. Those give rise to the ___

A

Back of leg
Common peroneal
Tibial
—
CP- peroneals, sural
Tibial- posterior tibial, sural

266
Q

The lumbar plexus gives rise to the ___ and __ nerves. They give rise to ____.

A

Front of leg
Obturator
Femoral
—
Femoral- saphenous

267
Q

Large tongue

A

Big Tongue
Beckswitch
Trisomy 21

268
Q

Please Get That Chin

A

Pierre
Goldenhar
Treacher colllins
Cri du chat

269
Q

Kids Try Gold

A

Klippel fiel
Trisomy 21
Goldenhar

270
Q

How can LAST risk be decreased?

A

Test dose
Incremental dosing with periodic aspiration

271
Q

LAST treatment (5 steps)

A

1- manage airway- fio2 100%
2- Benzos or Succ (avoid prop bc myocardial depressant.
3- ACLS (if epi is used, keep dose below 1mcg/kg.) avoid vaso. Use amio for arythmias
4- Lipid emulsion (Patient over 70kg- 100 ml bolus in 2 minutes, then 250 ml over 20 minutes. Patient under 70kg- 1.5ml/kg of LEAN body wieght over 2 minutes, then 0.25ml/kg/min) Both boluses can be repeated if patient remains unstable. Continue for 15 minutes after patient regains stability. MAX DOSE 12ml/kg. Safe in pregnancy. Pancreatitis is a complication.
5- Other (avoid BB and CCB, consider CPB)

272
Q

LAST lipid emulsion dosing

A

Patient over 70kg- 100 ml bolus in 2 minutes, then 250 ml over 20 minutes.
Patient under 70kg- 1.5ml/kg of LEAN body wieght over 2 minutes, then 0.25ml/kg/min.
Both boluses can be repeated if patient remains unstable.
Continue for 15 minutes after patient regains stability.
MAX DOSE 12ml/kg. Safe in pregnancy. Pancreatitis is a complications

273
Q

Blood type vs screen vs cross match

A

Type- 5 minutes to assess antigen
Screen- 45 minutes to assess all relevant antibodies
Crossmatch- 45 minutes to mix donor and recipient blood

274
Q

Which blood product contains the highest amount of fibrinogen?

A

Cryo

275
Q

Maximum allowable blood loss formula

A

[Pt weight x 70 x (starting hgb - ending hgb)] / starting hgb

276
Q

Acute transfusion reaction treatment

A

Stop infusion
Fluid bolus to save kidneys
Sodium bicarb to alkalize urine

276
Q

Acute transfusion reactive S&S

A

Within 5 minutes;
hemoglobinuria, hotn, increased bleeding

277
Q

Donors that increase risk of TRALI

A

Multiparous female
History of blood transfusion
History of organ transplant

278
Q

Patients at greatest risk for TRALI

A

Critical illness
Sepsis
Burns
Post CPB

279
Q

Which electrolyte abnormalities will occur after a massive transfusion?

A

Hypocalcemia (bound by citrate)
Hyperkalemia
Hyperglycemia from dextrose

280
Q

Who is blood salvage most appropriate for?

A

Living donor kidney transplant
Hip surgery
When blood is expected to exceed 1L or 20% EBV
Jehovas witness
Anemia

281
Q

EBV formulas

A

Premie neonate- 100 ml/kg
Neonate- 90ml/kg
Infant- 80ml/kg
Adult- 70ml/kg

282
Q

Importance of Leukoreduction

A

HLA alloimmunization- when the body develops antibodies
Removes WBC from RBC and platelets to remove the risk ^^

283
Q

How much benadryl to give a patient experiencing an allergic transfusion reaction?

A

50mg IV
If patient experiences any airway symptoms, stop transfusion and treat as anaphylaxis

284
Q

Success with type screen crossmatch

A

T 99.8
S 99.94
C 99.95

285
Q

Irradation

A

Prevents graft vs host (pancytopenia, fever, hepatitis, diarrhea)
Exposes unit to gamma radiation to disrupt WBC in donor cells

286
Q

Recommended order of administering uncrossmatched blood

A

1- type specific partially crossmatched
2- type specific non crossmatched
3- tope o neg non crossmatched

287
Q

What is in cryo?

A

8,13
Fibrinogen
vWF

288
Q

FFP doses

A

Warfarin reversal 5-8 ml/kg
Coagulopathy- 10-20 ml/kg

289
Q

RBC storage time

A

35 days or 42 with never preservatives

290
Q

How to prevent anaphylaxis in IgA patients?

A

Washing

291
Q

Which populations benefit from irraditation

A

DiGeorge syndrom
Leukemia
Lymphoma
Stem cell transplants

292
Q

S&S/ Tx acute hemolytic reaction

A

Hemoglobinuria, HOTN, bleeding
STOP infusion
Maintain urine output 100ml/hr w iv fluids, mannitol 25g, and lasix 40mg
Alkalinze urine with NaHCO2

293
Q

TRALI diagnostic criteria and Tx

A

<6h
Bilat infiltrates
Pf <300 or spo2 90% on RA
Normal PCWP (no LA htn/ FVO)
—
PEEP
Low Vt
Cautious with fluids

294
Q

TACO S&S and Tx

A

Pulmonary edema
FVO
LV dysfunction
Mitral regurg
Increased PCWP
Increased BNP
–
Supportive

295
Q

Contraindications to blood salvage

A

Sickle cell
Drugs in sterile field
Infected surgical site
OB is controversial

296
Q

How soon to administer thawed FFP? how about cryo?

A

24h
6h

297
Q

How long can platelets be at room temp?

A

5 days

298
Q

Cryo indications

A

Fibrinogen deficiency (80-100)
vWF disease
Hemophilia

299
Q

Stage of shock by blood loss

A

1- <750
2- 750-1500
3- 1500-2000
4- >2000

300
Q

Plasma osmolarity formula

A

Nax2 + glu/18 + BUN/2.8

301
Q

Presentation of demylenation

A

AMS
Seizures
Spastic quadraplegia
Pseudobulbar palsy
Coma/ death

302
Q

Tonicity of d5w, ns, lr, plasmalyte, albumin, 3%

A

253
308
273
294
30
1026

303
Q

MUDPILES

A

Methanol
Uremia
Pareldehyde
Isoniziad
Lactic (sepsis, cyanide poison)
ETOH
Salicylates

304
Q

Increased co2 production

A

Sepsis
Overfeeding
MH
Shivering
Thyroid
Burns
Seizure

305
Q

Decreased CO2 dlearance

A

Airway obstruction
Vd
ARDS
COPD
Hypoventilation

306
Q

AGAP formula

A

Na- (cl +hco3)

307
Q

Historical fluid maintenance

A

fasting hours x hourly maintenance

4:2:1
4ml for the first 10kg
2ml for the next 10kh
1ml for the rest/
hours fasted x deficit /
third space loss (1-8ml/kg depending on surgery type)

308
Q

ERAS preop, intraop, postop

A

Pre op- proper fasting, abx, avoid premedication
Intra op- ponv prophylaxis, goal directed fluid therapy, short acting drugs
Post op- opioid free analgesia, ponv, judicious fluids, early ambulation

309
Q

5% albumin contains ___ mgs

A

50
(25% contains 250mgs)

310
Q

How long can FFP be stored at 1-6 C?

A

5 days

311
Q

Rate and time length for cryo

A

200ml/hr at least
within 6h

312
Q

Factor 8 is most appropriate for the treatment of ___

A

Hemophilia A

313
Q

Presentation of febrile transfusion reaction

A

Fever
Chills
Headache
Malaise

314
Q

Risks for ulnar injury

A

Male (especially 50<)
Prolonged hospitalization
Extremes of weight
Cardiac surgery

315
Q

Ulnar nerve is spared best by what action?

A

Forearm supination

316
Q

Dorsal winging

A

Long thoracic nerve

317
Q

Most common cause and presentation of obturator, femoral, and peroneal injury

A

O- traction during abdomen surgery, forceps delivery, flexion of thigh/ inability to adduct
F- traction during ab surgery/ inability to extend knee, flex hip
P- external compression against stirrup/ foot drop, inability to evert foot

318
Q

Most common cause of postoperative vision loss

A

Ischemic optic neuropathy

319
Q

Most common cause of perioperative eye injury

A

Corneal abrasion from drying or direct trauma

320
Q

Risk factors for ischemic optic neuropathy

A

Its a result of hypoperfusion and IICP
Male, obese, DM, HTN, PVC
Prone, long surgery <6h, large blood loss, hotn SBP <100
Anemia

321
Q

When can airway edema present?

A

Steep trend and sitting
Robotic assisted prostatectomy

322
Q

Where do the peroneals rise from?

A

Superficial and deep - common
Common- sciatic

323
Q

When to assess for thoracic outlet syndrome

A

Before going prone
Ask patient to clasp hands behind her head- if they cant, TUCK the arms instead of extending

324
Q

How to monitor dependent arm in lateral decub?

A

SPO2 on dependent arm

325
Q

MOA ulnar injury

A

Elbow flexion
External strap compression

326
Q

Median nerve injury presentation

A

Acute- hand of benediction
Chronic- ape hand

327
Q

Etiology of radial injury

A

IV pole compression
Excessive nibp
Tourniquet
Sheets too tight

328
Q

Suprascapular vs LT injury

A

LT- winging
Suprascapular- dull shoulder pain

329
Q

Factors that contribute to rhabdo

A

hotn
Prolonged surgery time
Pressure of OR table against gluteal and flank muscles

330
Q

Which positions produce the smallest and largest change in CO?

A

Smallest- supine, lateral
Largest- prone, lateral jack knife, kidney

331
Q

Which position is rhabdo associated with?

A

Lateral decub
Lithotomy is associate with compartment syndrome which can progress to rhadbo

332
Q

Which position is associated with VAE

A

Sitting

333
Q

Extreme flexion of the thigh can result in injury to the ___ nerves

A

Sciatic
Obturator
Femoral

334
Q

Suprascapular injury is most caused by ___

A

Ventral circumduction of dependent shoulder in lateral decubitus

335
Q

Etiology of LT injury

A

Lateral position
Trauma
Preexisting neuropathy

336
Q

When going from standing to supine, how will hemodynamics be affected

A

Increase- CO, SV
Decrease- HR, MAP, PVR

337
Q

Surgical site above the level of the head =

A

VAE

338
Q

When in the trend position, the heart will

A

Vasodilate, decrease HR

339
Q

What does peak pressure represent? What are 3 causes of increased peak pressure with a normal plateau pressure?

A

Reduction in dynamic compliance- increased airway resistance
Bronchospasm, kinked ETT, aspiration of a foreign body, secretions

340
Q

What does plateau pressure represent?What would cause an elevated plateau pressure

A

Small airways/ alveoli/ recoil of lungs
Barotrauma, pneumo, subQ emphysema (especially above 35cm H2O Plat pres)

341
Q

4 phases of capnography

A

1- exhalation of dead space
2- exhalation of dead space mixed with alveolar gas
3- exhalation of alveolar gas
4- inhalation

342
Q

A and B angle of capnography

A

A- 100 degrees, increased in copd, bronchospasm
B- 90 degrees, if its bigger that means incompetent inspiratory valve

343
Q

Mainstream or in line faster response?

A

Mainstream increases dead space

344
Q

Cause of biphasic capnography

A

single lung transplant
Severe kyphoscoliosis

345
Q

Most to least responsive Spo2 site

A

Ear, nose, tongue, forehead, esophagus
Finger
Toe

345
Q

What alters reliability of pulse ox

A

Blue/ green/ black
External light
Hypoperfusion/ ischemia/ hypothermia
LVAD/ CPB
Dark skin

346
Q

What decreases paco2/ etco2 gradient?

A

Dysfunctional inspiratory valve

347
Q

Most likely cause of an acutely decreased etco2

A

Hypovolemia/ hemorrhage

348
Q

Dynamic vs static compliance

A

Dynamic is measured by PIP (think kink, mucus plug, bronchospasm)
Static is measured by Pplat (think endobronchial intubation, tension pneumo, pna)

349
Q

Methemoglobinemia tx

A

Meth blue 1-2mg/kg over 5 minutes

350
Q

What is channeling on etco2

A

Elevated baseline

351
Q

For every inch change in height, the bp changes by ___

A

2mmHg

352
Q

Under damped cause

A

Stuff tubing
Catheter whip

353
Q

Overdamp cause

A

Air bubbles
Clots
Low pressure in bag
Kinks
Loose connection

354
Q

Distance from vena cava to pulmonary artery and pcwp position

A

15-30cm
25-35cm

355
Q

Distance from central line insertion to vena cava

A

Rij 15
Lij 20
Subcalvian-10
Basiolic, femoral- 40

356
Q

Highest chance of chylothorax when placing CVC

A

LIJ

357
Q

ACxVy

A

A- atrial contraction
c- ventricular contraction/ tricuspid closure
x- atrial relaxation
v- atrial passive refill
y- atrial empty

358
Q

Large a vs V wave on CVP

A

A- diastolic dysfunction or tricuspid stenosis
V- tricuspid regurg

359
Q

How can u tell the pcwp is NOT in zone 3?

A

inability to draw blood
nonphaseic pcwp tracing
PCWP > PADiastolic

360
Q

When will PCWP overestimate vs underestimate LDEV

A

Over- peep/copd/ph/ppv, diastolic dysfunction, mv disease, shunt (alot)
Under- aortic regurg

361
Q

What under vs over estimates CO via thermodilution

A

Under- cold and high volume
over- hot, low volume

362
Q

Svo2 formula

A

Sao2- (vo2/hgb x 10 x co x 1.34)

363
Q

What will increase svo2

A

Cyanide toxicity
Increased pao2
Increased hgb
Increased Co
Hypothermia
sepsis
shunt

364
Q

What will decrease svo2

A

thryotoxicosis
anemia
pain
shivering
fever
low pao2
Low hgb
Low co

365
Q

Limitations to pulse contour anaylsis

A

Spontaneous ventilation
PEEP
Small Vt
Open chest
RV dysfunction
Dysrhuthmias

366
Q

When will u see a delta wave

A

WPW

367
Q

Normal vs l vs r vs extreme r devation

A

normal- 2- 6 (-30 - 90)
R- 6-9 (>90)
RR- 9-12
L- 12-3 (<-30)

368
Q

What leads do u measure axis

A

1 avf
should both be positive

369
Q

Causes of r axis deviation

A

copd
bronchospasm
cor pulmonale
ph
pulmonary embolus

370
Q

Causes of l axis deviation

A

HTN
lbbb
AS
AR
MR

371
Q

Volatile agents __ amplitude and __ latency of SSEPs

A

decrease
increase

372
Q

How to preserve evoked potentials

A

TIVA no n2o
If using a volatile agent, use <0.5 MAC with prop not N2o
No muscle relaxants during monitoring, but during induction is ok
Ketamine enhances signal, good?

373
Q

What does it mean if u lose an evoked potential during surgery

A

Ischemia- treat with fluids, transfusions
other factors that influence amplitude/ latency- hypoxia, hypercarbia, hypothermia

A1 (122 decks)

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