General Flashcards
Tourniquet pressure in upper vs lower extremities?
Upper: should be at least 50 mmHg higher
Lower: should be at least 100 mmHg higher
Remi, etomidate, glyco, lidocaine, and propofol and what they do to seizure duration
Remi: doesnt' affect seizure duration etomidate: Increases seizure duration glyco: no affect lidocaine: decreases seizure duration Propofol: decreases seizure duration
Pt getting heparin subq (prophylaxis BID) for 6 days, needs epidural for hip fracture-how ong do yo have to wait to place it? what do you need to check?
A platelet count should be checked prior to epidural placement or removal in patients receiving heparin for more than five days. recommending a 4-6 hour delay from heparin administration to needle placement (and similar wait before epidural catheter removal)
TNS-what makes your risk more?can you still get TNS from ropi and bupi?
Intrathecal lidocaine has been implicated as the main cause of transient neurologic symptoms (TNS). The lithotomy position in conjunction with lidocaine spinal anesthesia further increases the risk. You still can get it from ropi and bupi-but risk is very low
Fat embolism syndrome FES: what is it? who is at risk? tx? what other conditions give you this same presentation?
FES most commonly affects the pulmonary, neurologic, and integumentary systems. A classic triad of symptoms has been described consisting of petechiae (mostly around the head, neck, and axillae), hypoxemia, and neurologic abnormalities (e.g., altered level of consciousness or seizure). Signs and symptoms usually develop within 12-40 hours after the initial insult. Patients at risk for the development of FES include those with closed long bone fractures or patients undergoing intramedullary instrumentation during orthopedic procedures. In addition, patients with pancreatitis and sickle cell disease can develop the syndrome, albeit rarely.
Diagnosis of fat emboism syndrome?
The diagnosis of FES requires at least one major and four minor criteria from the following table. These criteria are referred to as Gurd’s diagnostic criteria. reatment of FES is supportive therapy. Minimizing the delay to reduction of long bone fractures can help prevent sentinel as well as recurrent fat embolization (C). If significant fat embolization does occur, aggressive respiratory support with high flow oxygen and positive pressure ventilation with PEEP is likely to be necessary to reduce the associated morbidity and mortality (D). Crystalloids and albumin are recommended for fluid resuscitation to replace lost blood volume (B). In addition, albumin can bind fatty acids which may decrease the extent of lung injury.
Are dextrans or corticosteroids helpful with FES?
NO
What do you do if someone gets stuck with a needle that has HBV? Do most acute infections progress to chronic infections/
Hepatitis B virus (HBV) hyperimmune globulin should be administered to someone following blood or bodily fluid exposure to HBV (B). Vaccination against HBV should also be offered.
Most acute infections do NOT progress to chronic
Presence of Antibodies to HBV surface antigen (anti-HBs) means what and provides what?
serologic proof of acute infection resolution
Provides immunitY
What do chronic HBV carriers have?
Chronic HBV carriers have positive HBV surface antigen (HBsAg) and antibodies to the core antigen (anti-HBc)
Active infection with HBC is characterized by what?
Active infection is characterized by the presence of the extracellular version of HBV core antigen (HBeAg)
What is NOT used in the Child Pugh score? child P
Creatinine is NOT used.
mnemonic for Child Pugh
Child please….If (INR) Bit (bilirubin) Act (ascites) As (albumin) Eff ‘em (Encephalopathy)
Do patients have to urinate before being discharged?
Patients who are low risk for urinary retention do not need to void after surgery in order to be discharged. Additionally the ASA recommends that all patients be accompanied by an adult escort, who can help provide care for them following ambulatory surgery. Patients also must have pain and nausea controlled along with stable vitals signs prior to discharge.
What is low risk for urinary retention?
he low risk population for urinary retention includes: young population, general anesthesia without spinal, non-urological procedures, and non-pelvic surgery.
What is is considered the MOST sensitive indicator of obesity’s effects on pulmonary function. In obesity, what is the relationship between FRC and Closing capacity? There’s decreased FRC in obese people why?
Expiratory reserve volume. It decreases a lot with obesity.
Reduced FRC can result in lung volumes below that of closing capacity during normal tidal volume ventilation-resulting in small airway collapse and hypoxemia. Decreased FRC d/t decreased ERV
Chronic hypoxemia seen in obese people can lead to what with blood and pulmonary pressures?
Increased pulmonary HTN, as well as polycythemia and subsequent increased total blood volume due to increased perfusion requirements of the additional body fat.
Why can you NOT use CCBs in patients being treated for malignant hyperthermia?
Because in MH there is prolonged opening of the channel which leads to sustained muscle contraction.dantrolene can decrease the release of calcium from the SR resulting in an additive or synergistic effects with calcium channel blockers.
Are both moderate sedation and monitored anesthesia care (MAC) recognized as physician-delivered services in the current procedural terminology (CPT) coding system?
Yes
MAC vs moderate sedation-what do they do when airway compromise arises? What about afterwards? do they both go to the PACU?
Providers of moderate sedation are not expected to be able to intervene in the event of an impaired airway. By contrast, the provider of MAC must be prepared and trained to convert to general anesthesia (GA) when necessary. ost-procedural transfer of a patient that has undergone MAC to a post-anesthesia recovery area is a requisite not required of patients that have undergone moderate sedation.
Should moderate sedation run risk of airway compromise?
NO
Why is it that people with Gilbert’s get jaundiced after a blood transfusion? What enzyme is messed up in Gilbert’s and what does it do? Inheritance pattern? % of enzyme theyre missing? bilirubin increase per unit transfused?
At least 10% of transfused erythrocytes hemolyze within the initial 24 hours following a blood transfusion. Patients with Gilbert syndrome have a decreased capacity to handle the increased unconjugated bilirubin load. decrease in the activity of the hepatic enzyme, bilirubin glucuronyltransferase. This enzyme is required for hepatocyte uptake of unconjugated bilirubin. Autosomal dominant. they have 1/3 of the enzyme. Bilirubin increases by 250 mg for each unit transfused.
What does midazolam do to IOP?
it decreases IOP. Moreso than: Nitrous oxide, NDMRs, and opioids mildly decrease IOP.
When the distance from a source of ionizing radiation is doubled, how does radiation exposure change? What are the 3 determining factors for total radiation exposure?
It’s reduced by a factor of 4. Total exposure is affected by (1) total radiation exposure time, (2) total radiation exposure intensity, and (3) distance from the radiation source.
One anesthesia time unit is:
15 minutes
What is considered the biggest predictor of difficult intubation in morbidly obese patients? Does a Mallampati score matter? What about OSA?
Having a thick neck circumference. a high Mallampati class airway (III or IV) and a thickened neck circumference most significantly predict the potential for difficult direct laryngoscopy and endotracheal intubation. OSA is predictive of difficult intubation
Other preoperative findings that increase the risk of difficult intubation not related to obesity include:
increased age, male sex, temporomandibular joint (TMJ) pathology, and abnormal (large, protruding) upper teeth.
Are obesity and BMI alone risk factors for difficult intubation?
NO.
Advantages of using a bronchial blocker:
Advantages of using a bronchial blocker instead of a DLT include the ability for selective lobar collapse, such as in cancer patients who have had prior contralateral pulmonary resection and require selective ipsilateral lobar blockade, Additionally, patients that have had prior oral or neck surgery with challenging airways may better tolerate a bronchial blocker since these patients may not anatomically accommodate larger DLTs. Patients with tracheostomies also require bronchial blockers for lung isolation. Similarly, children < 12 years old generally cannot accommodate even a small DLT; Lastly, it has the benefit of not needing to be exchange in prolonged intubation
Why would you want a DLT instead of a bronchial blocker if VATS is converted to an open procedure?
While bronchial blockers can achieve lung separation, they are not considered as reliable as a DLT. Bronchial blockers can migrate into the trachea causing loss of lung isolation and interference with ventilation. Conversion of a VATS to an open procedure may signal surgical difficulty in which lung isolation may become even more critical, and thus, a DLT would be preferred.
What is the maximum recommended dose of lidocaine that may be injected during tumescent liposuction?
55 mg/kg. Max dose of lido: 5 mg/kg, max dose of lido WITH epi is 7 mg/kg.he maximum recommended dose of lidocaine for tumescent liposuction is 35-55 mg/kg and 0.055 mg/kg for epinephrine. 1:100,000
btw, concentration should be no greater than 0.1%
Is the DNR suspended in the OR?
NO!
What does this mean: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”.
Sentinel event
What does Maleficence mean?
Maleficence refers to an act of committing intentional harm to a patient.
Pathophys of MS:
Multiple sclerosis (MS) is an autoimmune disorder in which T-cell autoantibodies attack myelin causing subsequent inflammation within the central nervous system leading to nerve conduction dysfunction or failure.In addition, axonal damage can occur. These combine to result in a variety of symptoms depending on where in the central nervous system the destruction occurs. Patients may experience paresthesias, muscle weakness, ascending spastic paresis, visual changes, gait, and sensory disturbances.
Treatment for MS:
No treatment is curative thus symptom management is the primary goal. Typically, corticosteroids are used for acute relapses. Interferon treatment may be used for some patients with relapsing-remitting disease. Alternative therapies are glatiramer and azathioprine.
T/F: There are types of anesthesia that will not cause MS exacerbation:
FALSE: The conduct of anesthesia in patients with MS is important and it is possible that, regardless of the anesthetic technique used, an exacerbation may occur postoperatively therefore patients should be counseled appropriately.
SHOULD MS PATIENTS KEEP TAKING their meds in the periop period? what else needs to be watched during Anesthesia?
Yes. Multiple sclerosis can lead to alterations in physiology that must be considered in the perioperative period. Specifically, it is important to minimize changes in body temperature, maintain fluid homeostasis, and maintain hemodynamics. Patients with multiple sclerosis may have autonomic instability that can lead to marked hypotension in response to anesthetic agents.
Is resting systolic function altered in aging? (provided they have no coronary artery dz)
No
Catecholamines and aging-Do older people mount the same stress response as younger people?
Plasma levels of catecholamines are significantly elevated (B) in geriatric patients compared to younger subjects. These elevated catecholamine levels are present at rest and during a stress response. For this reason, the stress response that is mounted is less significant than in younger patients.
Old people and beta receptors:
There is decreased sensitivity seen with β-receptor agonism (A) in the elderly population due to chronic desensitization by elevated circulating catecholamines.
Old people and stroke volume and old people and excercise CO? (if sedentary)
Although ejection fraction is normal in geriatric patients without CAD, there may be a reduction in stroke volume with sedentary older populations. Exercise cardiac output and cardiovascular reserve capacity may be reduced due to this decrease in β receptor sensitivity. This reduction may be attenuated with improved physical conditioning.
Vasculat fibrosis and aging:____. what does this lead to? which type of dysfunction?
There is increased vascular fibrosis seen in the aging population. This can lead to numerous complications including systemic hypertension, sinoatrial node dysfunction, and DIASTOLIC dysfunction.
Explain how diastolic filling works? how is this affected in old people? How does the atrial kick work for them-meaning-is it more or less necessary?
Diastolic filling of the ventricles typically has an early, rapid, passive filling phase based on the pressure gradient between the atrium and the ventricle. This is followed by a slow active phase where the atrium contracts, termed the “atrial kick”. A reduction and delay in left ventricular relaxation and reduced passive filling occurs with age. Cardiac output therefore becomes more reliant on the “atrial kick” (E). Atrial fibrillation/flutter may reduce cardiac output by as much as 25% due to loss of the atrial kick.
Do PDIII inhibitors improve lusitropy?
yes
Transient changes after tourniquet release:
Transient consequences of tourniquet release include a 10-15% increase in heart rate, 5-10% increase in serum potassium, a 1-8 mm Hg rise in CO2 tension in blood, and a decrease in core temperature usually no more than 1 °C. These effects do not typically contribute to perioperative morbidity in the healthy patients
A severe, acute drop in EtCO2 and oxygen saturation after an extremity tourniquet release should rouse suspicion for
Pulmonary embolism
Pathyophys of MH:
Normally, skeletal muscle depolarization leads to brief activation (opening) of the ryanodine-sensitive calcium channel receptor (RYR1) located on the sarcoplasmic reticulum. This causes a brief efflux of calcium that produces muscle contraction. Malignant hyperthermia-susceptible patients have RYR1 defects that, in the presence of a triggering agent (succinylcholine or any volatile anesthetic), cause prolonged opening of the channel which leads to sustained muscle contraction. This produces a generalized hypermetabolic state characterized by increased CO2, lactic acidosis, and heat production which can progress to muscle cell breakdown leading to hyperkalemia and rhabdomyolysis and their sequelae (arrhythmias; liver, kidney, and other end-organ damage; and death).
How does dantrolene work?
Dantrolene blocks calcium release from skeletal muscle sarcoplasmic reticulum by interfering with the ability of calcium and calmodulin to activate the voltage-gated ion channels (RYR1 and the L-type calcium channel).
Dose of dantrolene, and how it should be given:
Max initial dose?
After the acute phase has resolved?
Dantrolene should be administered as a rapid 2.5 mg/kg IV bolus as soon as a diagnosis of MH is suspected. The bolus dose can be repeated every 5-10 minutes until signs of acute MH have abated
According to MHAUS, dantrolene should be administered as a rapid 2.5 mg/kg IV bolus which can be repeated every 5-10 minutes as necessary up to 10 mg/kg. After the acute phase has resolved, dantrolene should be continued for 24-48 hours either as a 1 mg/kg bolus every 4-6 hours, or as an infusion of 0.25 mg/kg/hr to prevent recrudescence.
elderly patients have which decreased lung proteins? Old people and FRC? What happens to PaO2 each year? How does PaCO2 change with age?
Elderly patients have deterioration of elastin and an increase in functional residual capacity. PaO2 decreases by 0.5 per year after 20 years of life. There are no age related PaCO2 changes
Do old people have an increased work of breathing?
yes
Aging and Total respiratory system compliance
decreased
Aging and chest wall complinance
decreased
Aging and lung compliance
increased
aging and lung elasticity
decreased
Aging and muscle mass:
decreased
Aging and diaphragm:
flattened
Aging and work of breathing
increased
Aging and PaO2
decreased
Aging and PaCO2:
No change
Aging and diffusing capacity
decreased
Aging and alveolar surface area
decreased
Aging and V/Q mismatch
Increased
Aging and dead space
Increased
Aging and tidal volume
No change
Aging and closing capacity
Increased
