Fundamentals of Anesthesia Final Flashcards
- Examples of systolic cardiac murmurs include:
a. mitral stenosis
b. aortic stenosis
c. aortic regurgitation
d. answers b and c
aortic stenosis
- Examples of diastolic cardiac murmurs include:
a. aortic regurgitation
b. mitral stenosis
c. mitral regurgitation
d. answers a and b
aortic regurgitation
- In the triad of symptoms in aortic stenosis, which symptom is evident of the late process of the disease, and indicates a 1-2 year life expectancy?
a. angina pectoris
b. CHF
c. onset of initial murmur
d. syncope
CHF
When caring for a patient with aortic stenosis, what are the hemodynamic goals?
a. NSR, low preload, low afterload, lower coronary perfusion pressures
b. Any rate controlled rhythm is appropriate, high afterload, high preload
c. NSR, maintain preload, high afterload, maintain BP as if treating left main disease (requiring higher perfusion pressures)
d. None of the above are correct
*NSR, maintain preload, high afterload, maintain BP as if treating left main disease (requiring higher perfusion pressures)
- An EF < 40% is one indicator of “poor” left ventricular function.
a. True b. False
True
- In patients with aortic stenosis, anesthetic techniques include:
a. Avoid excessive myocardial depression d/t agents and induction drugs
b. Treat dysrhythmias promptly, as patients with AS rely on their “atrial kick” heavily
c. Avoid tachycardia, as it precipitates ischemia
d. Avoid hypotension
e. All of the above
All of the above
The following patients require higher perfusion pressures:
a. Acute infarct and left main stenosis patients
b. Renal/cerebral insufficiency patients
c. Chronic hypertensive patients
d. All of the above
All of the above
Which induction drug decreases the BP the most?
a. Propofol
b. Etomidate
c. Lidocaine
d. Versed
Propofol
- Which opioid, when administered in appropriate doses, causes little or no change in contractility, little myocardial depression, and has a long half-life (t1/2)?
a. Sufentanil
b. alfentanil
c. fentanyl
d. remifentanil
fentanyl
- In patients with “sick” hearts, induction doses of propofol are likely to cause:
a. Increased BP and HR, vasoconstriction, no depression of contractility, no inotropic
changes
b. Profound negative inotropic effects, pronounced depression of contractility, vasodilation, bradycardia and hypotension, and vascular smooth muscle relaxation
c. Hypertension and tachycardia, positive inotropic effects, vasoconstriction, no change in contractility
d. None of the above
Profound negative inotropic effects, pronounced depression of contractility, vasodilation, bradycardia and hypotension, and vascular smooth muscle relaxation
- Nitrous oxide, isoflurane, sevoflurane and desflurane all produce:
a. Positive inotropic effects, vasoconstriction, decreased afterload
b. Positive chronotropic effects, vasodilation, increased afterload
c. Negative inotropic effects, decreased SNS activity, vasoconstriction
d. Negative inotropic effects, vasodilation, decreased afterload, decreased SNS activity
Negative inotropic effects, vasodilation, decreased afterload, decreased SNS activity
- Ketamine causes:
a. Generalized CV stimulation, increased myocardial work, inhibition of reuptake of
norepinephrine, stimulation of SNS
b. Generalized CV depression, decreased CO, decreased HR, decreased BP
Generalized CV stimulation, increased myocardial work, inhibition of reuptake of
norepinephrine, stimulation of SNS
Which muscle relaxant causes minimal CV effects?
a. Norcuron b. Pancuronium c. Anectine
d. Rocuronium
Norcuron
Aortic stenosis is recognized by its characteristic diastolic murmur best heard in the 3rd left intercostal space with transmission into the neck.
a. True
b. False
False
Calcium channel blockers, such as nifedipine and verapamil, are generally contraindicated in patients with:
a. EF >60%, SBP >90mmHg, sick sinus syndrome, 2nd or 3rd AV block
b. EF >60%, SBP >90mmHg, atrial fibrillation and/or flutter, 2nd or 3rd AV block
c. EF
EF
- Contraindications to beta blockers, such as atenolol and labetolol, generally include:
asthma, COPD, HR
True
- The effects of Nitroglycerin include:
a. Dilates veins > arteries, increases coronary artery flow, relaxes wall tension, is the drug of choice for vasospasm, and may increase HR and worsen ischemia
b. Dilates arteries > veins, decreases coronary artery blood flow, decreases HR, and increases the size of the heart
c. Dilates veins > arteries, increases coronary artery blood flow, increases wall tension, may decrease HR and worsen ischemia
d. Inhibits HPV, decreases SVR and BP, never used in patients with AS
Dilates veins > arteries, increases coronary artery flow, relaxes wall tension, is the drug of choice for vasospasm, and may increase HR and worsen ischemia
The myocardium extracts about 75% of oxygen from the arterial blood.
a. True
b. False
True
The most important factor and primary determinant of myocardial oxygen consumption is HR.
a. True
b. False
True
Which factor is a portion of supply as well as demand?
a. Perfusion pressure
b. CAD
c. HR
d. CO
HR
- Diastole is an extremely important part of the coronary cycle because:
a. Most coronary blood flow occurs during diastole
b. Diastole defines the time available for coronary vascular perfusion
c. The LV is perfused almost entirely during diastole
d. All of the above
All of the above
- Coronary vessel perfusion is:
a. CPP = DBP minus PAWP
b. CPP = SBP plus PAWP
c. CPP = DBP plus PAWP
d. CPP = DBP minus SBP
CPP = DBP minus PAWP
- The most important cellular components of the vessel wall are:
a. Vascular smooth muscle and tunica media
b. Vascular smooth muscle and vasa vasorum
c. Endothelium and vascular smooth muscle
d. Endothelium and basement membrane
Endothelium and vascular smooth muscle
Procedure/s that are considered intermediate risk by the ACC/AHA guidelines include:
a. Open aortic aneurysm repair
b. Lower extremity revasularizations
c. Ruptured aneurysm repair
d. Carotid endarterectomy
Carotid endarterectomy
The 1st most common cause of morbidity/mortality associated with carotid endarterectomy is:
a. Stroke
b. Myocardial ischemia
Myocardial ischemia
Which vessels supply 80-90% of the cerebral blood supply?
a. Carotid arteries
b. vertebral arteries
Carotid arteries
The most common site of atherosclerosis leading to TIA or stroke is the carotid bifurcation.
a. True
b. False
True
- Regional anesthesia for CEA incorporates superficial and deep cervical plexus blocks of the nerves at:
a. C6-C7 b. L1-L5 c. C2-C4 d. none of the above
C2-C4
For anesthesia for CEA, the primary goal is to maintain adequate cerebral perfusion without stressing the heart. That may be accomplished by:
a. Close regulation of BP, maintaining at or slightly above the patient’s normal
b. Avoid tachycardia and monitor leads II and V5
c. No glucose in the IVF
d. Steady PaCO2 at 35-40mmHg
e. All of the above
All of the above
- Increased CO2 generally causes:
a. Cerebral steal
b. decreased cerebral perfusion
c. increased cerebral perfusion
Cerebral steal
- During CEA, many surgeons will monitor stump pressure to evaluate the adequacy of cerebral perfusion. Adequate stump pressure is >60mmHg and reflects:
a. Mean arterial pressure caudad to cross clamp
b. Pressure generated by back pressure from the Circle of Willis
c. Mean arterial pressure cephalad to cross clamp
d. Answers b and c are correct
Answers b and c are correct
- Which drug reverses the effects of heparin?
a. propranolol
b. propofol
c. pradaxa
d. protamine
protamine
During CEA, the anesthesia provider may expect reflex bradycardia d/t surgical manipulation at the carotid baroreceptor. What drug would you have immediately available to treat this issue?
a. anectine b. propofol c. heparin
d. protamine e. atropine
Atropine
During aortic cross clamp, which organ/s is/are at greatest risk for injury?
a. kidneys b. liver c. heart
d. none of the above
kidneys
Which type of aneurysm is confined to the ascending aorta?
a. DeBakey type I
b. DeBakey type II
c. DeBakey type III
d. Stanford type B
DeBakey type II
When cross clamping is required at the aorta distal to the left subclavian or between the subclavian and the left common carotid, where is the BP monitoring most accurate?
a. Right upper extremity and the left femoral artery
b. Right upper extremity and the right femoral artery
c. Left upper extremity only
d. Left femoral artery only
Right upper extremity and the left femoral artery
The Artery of Adamkiewicz supplies the___________ and arises on the ____side.
a. Posterior spinal artery / right side
b. Posterior spinal artery / left side
c. Anterior spinal artery /right side
d. Anterior spinal artery / left side
Anterior spinal artery / left side
Paraplegia is a major complication of cross clamping the aorta.
a. True b. False
true
Methods to protect the spinal cord include:
a. Mild hypothermia, methylprednisolone, increased blood glucose, mannitol
b. Profound hypothermia and increased blood glucose levels
c. Monitoring motors and SSEPS, methylprednisolone, mild hypothermia, and avoiding increases in blood glucose level
d. None of the above
Monitoring motors and SSEPS, methylprednisolone, mild hypothermia, and avoiding increases in blood glucose level
The following drug is a pure D1 agonist and preserves renal blood flow during hypotension under GETA:
a. dopamine
b. mannitol
c. Lasix
d. fenoldopam
fenoldopam
- Which portion of the kidney receives 90% of the blood flow?
a. Inner medulla
b. Outer stripe of inner medulla
c. Outer cortex
d. None of the above
Outer cortex
- Which portion of the kidney is most vulnerable to ischemia?
a. Outer stripe of inner medulla
b. Outer cortex
c. Inner stripe of outer medulla
d. Inner stripe of cortex
Inner stripe of outer medulla
What is the “functional” unit of the kidney?
a. The nephron
b. The outer cortex
c. The inner medulla
d. None of the above
The nephron
- Blood is delivered to the glomerulus via the ______________, and exits the glomerulus via the ________________.
a. Efferent arteriole/Afferent arteriole
b. Afferent arteriole/Efferent arteriole
c. Efferent arteriole/Efferent Arteriole
d. Afferent arteriole/Afferent Arteriole
Afferent arteriole/Efferent arteriole
___Reabsorbs the bulk of the filtered fluid
a. Loop of Henle
b. Proximal Tubule
c. Distal tubule/ Collecting Duct
B
___Make final adjustments on urine pH
a. Loop of Henle
b. Proximal Tubule
c. Distal tubule/ Collecting Duct
C
__Countercurrent Multiplier
a. Loop of Henle
b. Proximal Tubule
c. Distal tubule/ Collecting Duct
A
__Maintains osmotic gradient in medulla
a. Loop of Henle
b. Proximal Tubule
c. Distal tubule/ Collecting Duct
A
The following are/is potentially nephrotoxic agents:
a. NSAIDS
b. Aminoglycosides
c. Radiographic Dye
d. All of the above
All of the above
The most accurate method available to assess overall renal function is:
a. Creatinine clearance
b. BUN
c. Sodium clearance
d. FENa clearance
Creatinine clearance
- Normal GFR =______mL/min
a. <12
b. 50-80
c. 12-50
d. 125
125
- In Extracorporeal Shock-Wave Lithotripsy procedures, the ECG placement should be of good quality, as the _____waves trigger the shock waves.
a. P
b. T
c. ST segment
d. R
R
In TURP procedures, ____________of resecting fluid can be absorbed in each minute of resecting time.
a. 100-300mL
b. 10-30mL
c. 6-8 L
d. None of the above
10-30mL
CNS signs of hyponatremia include:
a. Coma and seizures
b. Blindness and dysrhythmias
c. Restlessness, irritability, confusion
d. All of the above
All of the above
Glycine is often used in TURP procedures. Glycine is metabolized in the liver to:
a. Sodium bicarbonate
b. Potassium
c. Amino acids
d. Ammonia
Ammonia
- Which agent is associated with the BEST maintenance of hepatic blood flow and hepatic oxygenation in the cirrhotic patient?
a. Sevoflurane
b. Desflurane
c. Nitrous Oxide
d. Isoflurane
Isoflurane
What constitutes a portal triad?
a. Bile duct, portal vein, hepatic artery
b. Bile duct, portal artery, hepatic vein
Bile duct, portal vein, hepatic artery
The resident macrophages that line the sinusoids are the:
a. Endothelial cells b. Kupfer cells
Kupfer cells
Blood flow to the liver is 70%________ and 30%___________.
a. Portal artery / Hepatic vein
b. Hepatic artery / Portal vein
c. Portal vein / Hepatic artery
d. Hepatic vein / portal artery
Portal vein / Hepatic artery
Oxygen supply to the liver is provided 50:50 by:
a. Hepatic artery and Portal vein
b. Hepatic vein and Portal artery
c. Hepatic vein and Portal vein
d. Hepatic artery and Portal artery
Hepatic artery and Portal vein
Characteristics of Hepatorenal Syndrome Type I include:
a. Poor outcome
b. Stable/slower course
c. Serum creatinine doubles in less than 2 weeks
d. Answers a and c
e. None of the above
Answers a and c
Which drugs worsen hepatic dysfunction?
a. Acetaminophen
b. Phenytoin
c. Indomethacin
d. All of the above
All of the above
What three laboratory findings are expected in the patient with liver disease?
a. Decreased total bilirubin, decreased albumin, decreased PT
b. Increased total bilirubin, increased albumin, and decreased PT
c. Increased total bilirubin, increased albumin, increased PT
d. Increased total bilirubin, increased PT, decreased albumin
Increased total bilirubin, increased PT, decreased albumin
- All volatile agents reduce portal blood flow in proportion to the decrease in MAP and CO.
a. True
b. False
true
- Effects of positive pressure controlled ventilation include:
a. Increased venous return to heart, decreased CO, compromised hepatic blood flow
b. Compromised hepatic blood flow, decreased CO, reduced venous return to the heart
c. Increased hepatic blood flow, increased CO, and increased venous return to the heart
Compromised hepatic blood flow, decreased CO, reduced venous return to the heart
The most common blood disorder in alcoholics is:
a. Hepatitis A
b. Megaloblastic anemia
c. Hepatitis C
d. Pernicious anemia
Megaloblastic anemia
A chronic alcoholic patient is bleeding and awaiting surgery. What treatments might be implemented to control the bleeding?
a. Platelet transfusion
b. Vitamin K injection
c. FFP and Cryoprecipitate
d. All of the above
All of the above
The NMDA of choice for patients with cirrhosis is:
a. Cisatracurium
b. Vecuronium
c. Pancuronium
Cisatracurium
- In a patient with cirrhosis of the liver, why is it important to maintain blood pressure?
a. Blood flow to liver depends on MAP
b. Oxygenation of the liver is largely dependent on hepatic vessel blood flow, since portal vessel flow is decreased in cirrhosis
c. None of the above
d. A and B are correct
A and B are correct
__Diamox
a. loop diuretic
b. distal tubule and collecting duct
c. carbonic anhydrase inhibitor
C
___Lasix
a. loop diuretic
b. distal tubule and collecting duct
c. carbonic anhydrase inhibitor
A
___Diuril
a. loop diuretic
b. distal tubule and collecting duct
c. carbonic anhydrase inhibitor
B
___Bumex
a. loop diuretic
b. distal tubule and collecting duct
c. carbonic anhydrase inhibitor
A
___Spironolactone
a. loop diuretic
b. distal tubule and collecting duct
c. carbonic anhydrase inhibitor
B
- Which stimulate increases and overproduction of porphyrins?
a. Benzodiazepenes
b. Barbiturates
c. Opioids
d. Sevoflurane
Barbiturates
Which herbal remedies are known to promote bleeding?
a. Ginkgo biloba
b. Ginger
c. Garlic
d. Saw palmetto
e. All of the above
All of the above
The crystalloid of choice in trauma patients is:
a. LR
b. NS
c. Dextrose containing solutions
d. Any cold IV fluid will do
LR
A “safe dose” of anesthesia drug may be a lethal dose for trauma patients.
a. True
b. False
True
Treatment of increasing ICP includes:
a. Diuretics, steroids, barbiturates, deliberate hypercapnia, hyperthermia, reverse trendelenberg position
b. Diuretics, steroids, benzodiazepenes, deliberate hypercapnia, hypothermia
c. Anectine drip
d. Diuretics, steroids, barbiturates, deliberate hypocapnia, mild hypothermia
Diuretics, steroids, barbiturates, deliberate hypocapnia, mild hypothermia
- Deliberate hypocapnia is maintaining a PaCO2 level of:
a. 45-55
b. 12-18
c. 28-32
d. None of the above
28-32
What is Beck’s triad?
Beck’s triad=Neck vein distension, hypotension & muffled
heart tones
Seen in cardiac tamponade
What is pulses paradoxes?
Pulsus paradoxus=10mmHg decrease in BP during spontaneous respiration
Seen in cardiac tamponade
What is the best induction agent for cardiac tamponade?
Best induction agent Ketamine
• maximize inotropy, chronotropy & preload with IVF
What is cardiac tamponade?
Cardiac tamponade a buildup of blood or other fluid in
the pericardial sac puts pressure on the heart, which
may prevent it from pumping effectively
What is the best anesthesia pharmacological agents to use with cirrhosis?
Isoflurane is the only agent that appears to cause significant arterial vasodilation, & may increase hepatic
arterial blood flow
-Propofol induction & Isoflurane is generally acceptable,
avoid Halothane Prolonged 1/2 life of opioids lead to
significant respiratory depression
-Cisatracurium has a unique non hepatic metabolism,
“NMDA of choice”
What drugs worsen cirrhosis?
Worsen underlying hepatic dysfunction: acetaminophen,
isoniazid, methyldopa, phenytoin & indomethacin
What fluids should be avoided in renal patients on dialysis?
o Avoid IVF with K+ in it
o Avoid LR- contains 4 meq/L of K+
What are the effects of positive pressure ventilation on the patient?
o Controlled positive pressure ventilation reduces venous return to the heart, decreases CO & comprises
hepatic blood flow
Name the loop diuretics.
Loop diuretics: Lasix, bumex, ethacrynic acid(edecrin)
& torsemide (demadex)
Thiazides(distal and collecting duct diuretics)
Distal & collecting duct diuretics(to inhibit Na reabsorption):
§ Thiazides: Chlorothiazide (Diuril), hydrochlorothiazide
(esidrix, hydrodiuril), chlorthalidone (hygroton),metolazone
(zaroxolyn)
Potassium sparing diuretics(distal and collecting duct diuretcs)
Distal & collecting duct diuretics(to inhibit Na reabsorption):
§ K-‐sparing diuretics: spironolactone (aldactone), triamterene (dyrenium) & amiloride (midamor)
Carbonic anhydrase inhibitor diuretic?
o Carbonic anhydrase inhibitor:
acetazolamide(Diamox)
Propofol will drop BP worse than anything else, know
about propofol on induction
o Profound negative inotropic effects on sick hearts
o Pronounced depressant of contractility
o Vasodilation (venous/arterial)
o Decreases BP and HR
o Vascular smooth muscle relaxation.
What cardiac effects does N2O have on the patient?
- stimulates the SNS
- decreased contractility
- increases arrhythmias
- ischemia
What cardiac effects does Iso have on the patient?
- minimal cardiac depression
- increased HR
- dilates coronaries
- ?coronary steal?
What cardiac effect does Des have on the patient?
- causes pulmonary HTN
- no increase in coronary blood flow
- increased HR and BP
- not for CAD patients
What cardiac effect does sevo have on the patient?
- mild cardiac depressant
- no increase in HR
- prolongs QTI
- CO poorly maintained
What MR is best to use for its minimal cardiac effects?
vecuronium—>less histamine release
What are the cardiac effects of pancuronium?
- increased HR, BP, CO
- supports BP
- increases ischemia
What are the cardiac effects of anectine?
- variable effects on HR and BP
- decreased HR with BB use
What type of mummer characterizes aortic stenosis?
Aortic stenosis is characterized by systolic murmur best
heard in 2nd R ICS with transmission into the neck
What are the triad of s/s of arctic stenosis?
Triad of s/s: angina pectoris, syncope & CHF
Nitroglycerin and effects it has on the body —> does it dilate veins worse than arteries, etc?
o Give nitro to help with ischemia, but in bigger doses it
can worsen ischemia, etc.
§ Nitro is the active ingredient in dynamite
§ Penetrates endothelium & acts as substrate for formation of NO
§ Dilates veins>arteries(peripheral and coronaries)
§ Increases coronary artery flow
§ Relaxes wall tension
àincreased blood flow through subendocardium
• Nitro softens the wall
àallowing blood to flow to the endocardial vessels
§ Decreases size of heart/ventricular volume
§ Decreases MVO2, BP, SVR, venous return
§ Drug of choice for vasospasm
§ Increases HR
àcan worsen ischemia
What is the most important and the primary determinant of coronary oxygen consumption?
HR
What 6 factors are on the cardiac “supply” side?
- HR
- Perfusion pressure
- o2 content
- LVEDP
- CAD
- O2 extraction
What 5 factors are on the cardiac “demand” side?
- HR
- CO
- PCWP(LAD)
- SBP
- preload/afterload/contractility
Why is diastole so important in the cardiac cycle?
most coronary flow occurs during diastole
(during systole the muscle is contracted so decreased coronary flow)
the LV is perfused almost entirely during diastole
When the aorta is cross-clamped where do you assess BP?
RUE and left femoral
cross-clamp between aorta and left subclavian so left ue is not a good place
What is the coronary perfusion pressure formula?
• Coronary perfusion pressure:how well coronary arteries perfusing the heart muscle
o CPP=DBP–PAWP(orPA diastolic)
§ CPP greatest during diastole with ventricle is relaxed,
the wall is slightly softer & blood flow is generous
L side of heart at such huge risk during an MI. which part
of the ventricle is most vulnerable to ischemia?
subendocardium
When do ETOH withdrawals begin?
24-96 hrs
- earliest is 6-8 hrs after last drink
- most pronounced is 24-36 hrs after last drink
Whats the significance of having the patient of phonate “e”?
assess for recurrent laryngeal nerve damage
If your BMI is _____ you would be classified as overweight?
25-29.9
If your BMI is _____ you would be classified as obese?
30-39.9
If your BMI is _____ you would be classified as morbidly obese?
> 40
Signs and symptoms of a “gas lock”?
gas lock= large air bubble occluding the RB outflow tract
- hypotension
- cyanosis
- hypoxia
- wheezing from plum edema
- “mill wheel” murmur
What will be the MAC value of an intoxicated individual?
decreased MAC
What will be the MAC value of a sober chronic alcoholic?
increased MAC
Where is plasma cholinesterase produced?
the liver
What is tubular secretion?
o Tubular secretion—>transport of substances into the lumen of the renal tubule (movement from the tubular
cells, or from the interstitium, or from the peritubular capillaries).
What is tubular reabsorbtion?
o Tubular reabsorption—>transport of substances out
of lumen of the renal tubule (movement into the tubular
cells or into the interstitium or into peritubular capillaries).
What is GFR?
o GFR—>movement, under pressure, of plasma water
and most of its dissolved constituents from the glomerular
capillary into bowmans capsule. The beat of the heart creates the high glomerular capillary hydrostatic pressure
that is required for the filtration process
What is the best MR to use with renal impaired pts?
Nimbex
What is the difference between strokes, TIAs and RINDS
o Stroke—>neuro deficit lasting > 24 hrs
o RIND’s—>neuro dysfunction > 24 hrs, but < 2 weeks
o TIA—>transient ischemic attacks resolve within 24 hrs;
often precede stroke
What is the earliest sign of aspiration?
hypoxemia
Mallampati airway classification question:
o Class 1—>soft palate, fauces, uvula, pillars
o Class 2—>soft palate, fauces, uvula
o Class 3—>soft palate & base of uvula
o Class 4—>hard palate only
How long a pts glucose will continue to risk postop if you
gave a lot of LR during the case?
o If large amt of LR were administered to DM intraoperatively, glucose will continue to risk 24-‐48 hrs
postop as liver converts lactate to glucose
How fast do you drop blood glucose?
no more than 100/hour
what is the normal Hga1c level?
6(>9 noncompliant)
Normal fasting glucose level?
80-90 mg/dl
