General Flashcards
1
Q
Tourniquet pressure in upper vs lower extremities?
A
Upper: should be at least 50 mmHg higher
Lower: should be at least 100 mmHg higher
2
Q
Remi, etomidate, glyco, lidocaine, and propofol and what they do to seizure duration
A
Remi: doesnt' affect seizure duration etomidate: Increases seizure duration glyco: no affect lidocaine: decreases seizure duration Propofol: decreases seizure duration
3
Q
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
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)
4
Q
TNS-what makes your risk more?can you still get TNS from ropi and bupi?
A
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
5
Q
Fat embolism syndrome FES: what is it? who is at risk? tx? what other conditions give you this same presentation?
A
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.
6
Q
Diagnosis of fat emboism syndrome?
A
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.
7
Q
Are dextrans or corticosteroids helpful with FES?
A
NO
8
Q
What do you do if someone gets stuck with a needle that has HBV? Do most acute infections progress to chronic infections/
A
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
9
Q
Presence of Antibodies to HBV surface antigen (anti-HBs) means what and provides what?
A
serologic proof of acute infection resolution
Provides immunitY
10
Q
What do chronic HBV carriers have?
A
Chronic HBV carriers have positive HBV surface antigen (HBsAg) and antibodies to the core antigen (anti-HBc)
11
Q
Active infection with HBC is characterized by what?
A
Active infection is characterized by the presence of the extracellular version of HBV core antigen (HBeAg)
12
Q
What is NOT used in the Child Pugh score? child P
A
Creatinine is NOT used.
13
Q
mnemonic for Child Pugh
A
Child please….If (INR) Bit (bilirubin) Act (ascites) As (albumin) Eff ‘em (Encephalopathy)
14
Q
Do patients have to urinate before being discharged?
A
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.
15
Q
What is low risk for urinary retention?
A
he low risk population for urinary retention includes: young population, general anesthesia without spinal, non-urological procedures, and non-pelvic surgery.
16
Q
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?
A
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
17
Q
Chronic hypoxemia seen in obese people can lead to what with blood and pulmonary pressures?
A
Increased pulmonary HTN, as well as polycythemia and subsequent increased total blood volume due to increased perfusion requirements of the additional body fat.
18
Q
Why can you NOT use CCBs in patients being treated for malignant hyperthermia?
A
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.
19
Q
Are both moderate sedation and monitored anesthesia care (MAC) recognized as physician-delivered services in the current procedural terminology (CPT) coding system?
A
Yes
20
Q
MAC vs moderate sedation-what do they do when airway compromise arises? What about afterwards? do they both go to the PACU?
A
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.
21
Q
Should moderate sedation run risk of airway compromise?
A
NO
22
Q
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?
A
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.
23
Q
What does midazolam do to IOP?
A
it decreases IOP. Moreso than: Nitrous oxide, NDMRs, and opioids mildly decrease IOP.
24
Q
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?
A
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.
25
One anesthesia time unit is:
15 minutes
26
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
27
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.
28
Are obesity and BMI alone risk factors for difficult intubation?
NO.
29
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
30
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.
31
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%
32
Is the DNR suspended in the OR?
NO!
33
What does this mean: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”.
Sentinel event
34
What does Maleficence mean?
Maleficence refers to an act of committing intentional harm to a patient.
35
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.
36
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.
37
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.
38
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.
39
Is resting systolic function altered in aging? (provided they have no coronary artery dz)
No
40
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.
41
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.
42
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.
43
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.
44
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.
45
Do PDIII inhibitors improve lusitropy?
yes
46
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
47
A severe, acute drop in EtCO2 and oxygen saturation after an extremity tourniquet release should rouse suspicion for
Pulmonary embolism
48
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).
49
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).
50
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.
51
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
52
Do old people have an increased work of breathing?
yes
53
Aging and Total respiratory system compliance
decreased
54
Aging and chest wall complinance
decreased
55
Aging and lung compliance
increased
56
aging and lung elasticity
decreased
57
Aging and muscle mass:
decreased
58
Aging and diaphragm:
flattened
59
Aging and work of breathing
increased
60
Aging and PaO2
decreased
61
Aging and PaCO2:
No change
62
Aging and diffusing capacity
decreased
63
Aging and alveolar surface area
decreased
64
Aging and V/Q mismatch
Increased
65
Aging and dead space
Increased
66
Aging and tidal volume
No change
67
Aging and closing capacity
Increased
68
Aging and residual volume:
increased
69
Aging and FRC
Increased
70
Aging and vital capacity:
decreased
71
Agign and FEV1
decreased
72
Aging and foced vital capacity (FVC)
decreased
73
Aging and TLC
unchanged
74
Post op visual loss is more common after which type of procedures:
Spine, cardiac, head and neck
75
ION: how many types? painful or painless visual loss: ___. How does it present?
2 types: Anterior or posterior, and it can be arteritic and non arteritic. Painless visual loss. ON following surgery generally presents with painless visual loss, visual field deficits, and sluggish pupils.
76
Risk factors for ION:
Vascular risk factors that may increase the risk of ION include: hypertension, diabetes, atherosclerosis, hyperlipidemia, smoking history, prone positioning, and lengthy spinal fusions.
77
When does AION vs PION typically occur:
AION most commonly occurs with surgery on the anterior part of the body (cardiac) and PION most commonly occurs with surgery on the posterior part of the body (spine).
78
Concept of HBO therapy. Also, look at photo
The concept of HBO derives from the arterial content (CaO2) equation. Recall that: CaO2 = (1.39 x SaO2 x Hgb) + (0.003 x PaO2). The dissolved oxygen component (0.003 x PaO2) becomes the main source of arterial oxygen content when oxygen saturation (SaO2) or hemoglobin (Hgb) concentration are no longer adequate to support cellular metabolism. The use of HBO, therefore, increases the PaO2 sometimes to as high as 2000 mm Hg (~3 atmospheres of pressure; 1 atm = 760 mm Hg).
79
Which type of hypoxia is an indication for HBO?
Acute-NOT chronic
80
Toxicity from anticholinesterases is treated with: What kind of symptoms do you see with anticholinesterases? Seen with what?
ATROPINE.Signs and symptoms of acute toxicity are generally those associated with cholinergic crisis. These most commonly include bradycardia, miosis, lacrimation, salivation, bronchorrhea, bronchospasm, urination, emesis, and diarrhea. In addition, nicotinic activity can cause fasciculations initially, followed by weakness and paralysis. Cholinergic activity in the CNS results in confusion and somnolence. Diagnosis is generally made by history and physical exam. Seen with pesticides (organophosphate)
81
Which muscle relaxant would you avoid with organophosphate poisoning?
Avoid Sux.Succinylcholine should be avoided, however, because it is degraded by pseudocholinesterase, which is also inhibited by organophosphates.
82
Tx of organophosphate poisoning:
| Pharmacologic and how they both work and what they will both help?
Treatment of organophosphate poisoning first consists of supportive measures. If patients have markedly depressed mental status or muscle weakness, 100% oxygen and tracheal intubation should be performed.If topical exposure is suspected, the patient’s clothes should be removed and the affected areas should be aggressively irrigated.Pharmacologic treatment consists of pralidoxime and atropine, although there is debate on the effectiveness of pralidoxime. Pralidoxime works by binding to the organophosphate molecules and reactivating acetylcholinesterase. By reactivating acetylcholinesterase, it is effective in treating both muscarinic and nicotinic symptoms. It generally only works if given within the first 48 hours of exposure. Atropine is a cholinergic antagonist at the muscarinic receptors, therefore preventing cholinergic parasympathetic activity. It is therefore most useful for drying pulmonary secretions and treating bradycardia.
83
Benefits of Microlaryngeal tube? Don't use in which type of surgeries?
A MLT tube is designed with a smaller internal diameter (sizes 4.0-6.0) to allow room for the surgeon. Relative to standard ETTs of a given diameter, MLT tubes are longer in order to accommodate the adult airway, have larger-volume cuffs with low-pressures, and are designed to be less flexible.
The MLT tube is not safe for use with lasers.
84
Things you see in opioid withdrawal syndrome:
Hypertension, tachycardia, diaphoresis, abdominal cramping, and diarrhea characterize opioid withdrawal syndrome. Patients who experience withdrawal after stopping opioids may have developed a physical dependence for opioids.
85
```
Put these in order from LEAST sensitive to GREATEST sensitivity in detecting VAE:
Doppler
ETCO2
TEE
PAC
EKG
```
EKG->ETCO2->PAC->precordial Doppler->TEE
86
Why should Intravenous and inhaled anesthesia should be used with caution during tumescent liposuction?
any of the warning signs of local anesthetic toxicity are masked while patients are sedated or under general anesthesia.
87
Max dose of liocaine during tumescent liposuction?
The maximum acceptable dose of lidocaine during tumescent anesthesia is 35 to 55 mg/kg.
88
Risks of tumescent liposuction:
The risks to the patient during liposuction go beyond local anesthetic toxicity. Vigilance must be maintained as patients are at risk for fluid overload and pulmonary edema when large volumes are infused. In addition, lidocaine is metabolized by the hepatic enzyme CYP 3A4. Patients taking CYP3A4 inhibitors may be at increased risk for toxicity. A few examples include: grapefruit juice, verapamil, diltiazem, amiodarone, and omeprazole. There have been several case series of cardiac arrest involving tumescent anesthesia. Risk factors for cardiac arrest include high concentrations of lidocaine and concomitant use of sedative
89
Where does the radial nerve run compared to the brachial artery?
Radial nerve injury is unlikely as it runs lateral and deep to the mid and distal brachial artery.
90
Where does the ulnar nerve run compared to the brachial artery?
The ulnar nerve runs sufficiently medial to the brachial artery to make damage unlikely.
91
Potential complications of brachial artery cannulation include
median nerve damage, distal ischemia due to lack of collateral circulation, and CRBSIs.
92
When is activated charcoal helpful? When is it not?
Even in the setting of recent ingestion (< 4 hrs), activated charcoal is ineffective for methanol poisoning since it does not absorb alcohols. For substances that are absorbed by activated charcoal, 12 hours may be too long after ingestion to help, with some exceptions (e.g. slow release medications).
93
When can methanol poisoning occur?
Methanol poisoning can occur following ingestion of substances including paint thinners, antifreeze, windshield washer fluid, and improperly distilled alcohol.
94
Why is mehtanol bad for you? Signs and symptoms of methanol toxicity?
Methanol itself is not toxic, but when metabolized by alcohol dehydrogenase in the liver, it is converted to formaldehyde and formic acid. Both of these substances are highly toxic, particularly to the central nervous system, resulting in a variety of symptoms including altered consciousness, respiratory depression, bradycardia, and vision changes including potentially irreversible blindness. These symptoms usually develop over 12-24 hours after ingestion of methanol. In addition, methanol ingestion can cause severe abdominal pain, often from acute pancreatitis. Formic acid accumulation will lead to an anion-gap metabolic acidosis both directly and indirectly due to its interference with oxidative phosphorylation.
95
The most effective way to eliminate methanol, formaldehyde, and formic acid is through
hemodialysis, though this is typically reserved for large ingestions and patients with severe symptoms, particularly severe acidosis and/or vision changes. For less severe cases, folinic acid may be administered which increases formic acid elimination.
96
How does ethanol work to help with methanol toxicity? What about fomepizole?
Ethanol acts as a competitive inhibitor of alcohol dehydrogenase and slows the conversion of methanol to its toxic metabolites.lternately, administration of fomepizole can be considered since it is a direct alcohol dehydrogenase inhibitor. Either of these therapies will decrease peak plasma concentrations of formaldehyde and formic acid as well as allow for renal and pulmonary elimination of unmetabolized methanol. At high plasma levels, methanol’s half-life is 25-30 hours but increases to 30-50 hours with alcohol dehydrogenase inhibition.
97
Correction of metabolic acidosis in methanol poisoning?
Correction of the metabolic acidosis should be considered with sodium bicarbonate and/or transient hyperventilation.
98
Why is there LV hypertrophy in aging?
The left ventricle (LV) must pump against higher pressures associated with the increased afterload that is observed with aging. This stimulates hypertrophy of the left ventricle as well as decreased compliance of the LV itself. This reduced ventricular relaxation results in diastolic LV dysfunction (negative lusitropy) and reduced stroke volume and cardiac output.
99
How does dexamethasone help with mountain sickeness?
Dexamethasone can be used to treat AMS symptoms and/or HACE by decreasing edema.
100
RBCs and altitude:
In response to hypoxia from altitude, the kidneys increase erythropoietin secretion leading to increased hemoglobin concentration. This effect is seen after 1-3 weeks of altitude exposure.
101
Kids in need of liver transplants vs adults:
An adult (living) liver donor may undergo the less technically challenging left hepatectomy when donating to a child. An adult liver recipient requires a larger donor liver volume, which generally requires the donor to undergo a right hepatectomy.
102
Least appropriate for use with airway surgery using a CO2 laser? Most resistant? Most flammable?
When using CO2 lasers, metal-wrapped or flexible metal tubes are considered the most resistant to ignition and airway fire while PVC-based ETTs are the most flammable. When using Nd:YAG lasers, silicone-based ETTs and those with rubber shafts with silver foil and sponge coatings are most resistant to ignition.
103
The most important initial steps of an airway fire are to
simultaneously extubate the patient (if an airway device is present) and turn off airway gas flow. Any sponges or other flammable materials should be removed from the airway and saline should be poured into the airway to extinguish any residual fire. Once the fire is out, ventilation should be reestablished with as low FiO2 as possible. If an airway device was present and removed it should be examined to determine if any fragments may have been left in the airway. Finally, consider bronchoscopy for airway assessment
104
Is nitrous flammable?
yes
105
In mac cases, ppl were most often sued for:
Monitored anesthesia care claims in the closed claims database had a high severity of patient injury. Many of the claims may have been prevented with improved monitoring, since respiratory depression resulting in brain damage or death was the most common issue.
106
What is inspiratory capacity, and what happens to it in aging?
The inspiratory capacity (IC) consists of the inspiratory reserve volume (IRV) plus the TV. It can also be derived by subtracting the FRC from total lung capacity (TLC). The IC decreases with aging due to a decrease in TLC and an increase in FRC.
107
Nitrous oxide s/p eye surgery
Nitrous oxide administration should be avoided for five days after intraocular air injection, 10 days after sulfur hexafluoride injection, or 30-90 days or longer after other perfluoropropane injection. This is because of blood:gas partition coefficient differences, which allows for nitrous oxide to readily diffuse into and expand the intraocular gas bubble
108
increased IOP and sux-is it a total no go?
Succinylcholine is relatively contraindicated in the setting of preexisting elevated intraocular pressure. A rapid sequence dose of rocuronium (1.2mg/kg) may be used to provide adequate airway relaxation if the patient is not NPO.
109
Burns and opioids, burns and benzos. What do they bind to?
Severe burns lead to hypoalbuminemia which increases the free fraction of many anesthetic drugs including benzodiazepines and opioids. Lower doses of benzodiazepines should be considered, while higher doses of opioids are usually required due to the rapid development of tolerance. Insulin resistance is seen due to increased catecholamine and corticosteroid levels. Proliferation of extrajunctional acetylcholine receptors leads to exaggerated hyperkalemia with succinylcholine use and resistance to nondepolarizing neuromuscular blockers.
110
Grade of laryngeal view
Grade I: visualization of the entire laryngeal aperture.
Grade II: posterior third of glottis visible.
Grade IIa: arytenoids and posterior cords visible.
Grade IIb: only epiglottic edge and arytenoids visible.
Grade III: no cords visible, only epiglottis visible.
Grade IIIa: only epiglottic edge visible (epiglottis raised).
Grade IIIb: downfolded or floppy epiglottis is visible.
111
Photo of laryngeal view
okay
112
Can you use lidocaine in ECT?
NO
113
Do old people have a larger volume of distribution?
Yes.
114
Roc and aging-change in onset of action? what about prolongation of duration?
Aging is not associated with a clinically significant change in the onset of action, however, there is a prolongation of duration due to a decrease in elimination and larger volume of distribution. Rocuronium is primarily eliminated by hepatic clearance.
115
Pancuronium and cisatricurium and aging:
Cisatracurium: No major age-related changes occur since it is undergoes Hofmann degradation for elimination. A slightly decreased onset of action may be seen in the elderly due to a slower biophase equilibration.
Pancuronium: Age-related changes are controversial. One would expect if a patient has decreased renal clearance that there would be a prolongation since pancuronium is renally excreted, however, this is not always the case.
116
Vecuronium and aging-what about clearance?
Vecuronium: Clearance is slower when renal or hepatic metabolism is decreased because vecuronium relies on hepatic clearance and renal excretion (although 40% of vecuronium is excreted unchanged in the bile)
117
Neonates have an increased sensitivity to non-depolarizing neuromuscular blockers because of their immature neuromuscular junctions, but this is offset by:
This attribute is offset, however, by their increased volume of distribution as they have an increased extracellular space.
118
BBB and PAC
In patients with preexisting LBBB there is potential for complete heart block during PAC placement and use is cautioned. This is not to say that LBBB can not occur secondary to PAC placement as it can with significant compromise, however incidence of severe heart block from insertion and use of PAC is low
119
complications of PAC? What makes one of those risks almost two fold more?
Complications of PAC are many including arrhythmia, valve damage, infection, PA rupture or infarction, thromboembolism, endocardial damage and misinterpretation of data and therefore placement should be weighed carefully in each patient. Interestingly the risk of endocarditis increase two-fold with use of non-heparin coated PACs.
120
One of the most feared complications of PA placement? Tell me about it:
Complications of PAC are many including arrhythmia, valve damage, infection, PA rupture or infarction, thromboembolism, endocardial damage and misinterpretation of data and therefore placement should be weighed carefully in each patient. Interestingly the risk of endocarditis increase two-fold with use of non-heparin coated PACs.
121
Schedule drug photo:
Ok
122
Root cause focuses on what? What does it NOT focus on/
Root cause analysis focuses on correctly defining the event, determining the situational awareness, and the reasoning behind why a decision was made. It does NOT consider determination of “who” caused an event to be a fundamental endpoint.
123
The RLN supplies what? What happens when it is damaged unilatrerally? Bilaterally?
The RLN supplies sensation to the larynx below the vocal cords, and it gives motor branches to the cricoarytenoid muscles, which abduct the vocal cords.RLN trauma causes hoarseness due to a paralyzed vocal cord when unilateral and airway obstruction when bilateral. Damage of the RLN is the most common cause of legal action against the care team during surgeries that put it at risk (thyroid, parathyroid, mediastinoscopy).
124
Can motors be used for RLN?
Motor evoked potentials are not useful for monitoring the recurrent laryngeal nerve during thyroid surgery. Motor evoked potentials stimulate the cortex, and a response is measured in the nerve.
125
Can you neural map during RLN sugery?
Yeah
126
So, how can you monitor the RLN during surgery?
everal methods are available that identify the recurrent laryngeal nerve through either direct visualization or neural mapping. None have been proven to be superior and randomized controlled trials are still lacking. A decision on which type to use should be based on surgeon preference and experience.
127
Succinylcholine is dosed by:
Total body weight
128
Thiopental and weight:
LBW (Induction)
| TBW (Maintenance)
129
Propofol and weight:
LBW (Induction)
| TBW (Maintenance)
130
Fentanyl and weight:
LBW
131
Remifentanil and weight:
LBW
132
Vec, Roc, and cisatricurium and weight:
LBW
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Difficult intubation settings in: Trisomy 21 (NOT 18), hypothyroidism, thyroid goiters, and type 1 dm
Trisomy 21 may predispose to subglottic stenosis. Ankylosing spondylitis may cause fusion of the cervical spine. Hypothyroidism can lead to myxedema, anasarca, and angioedema. Thyroid goiters and tracheal stenosis may cause fixed intrathoracic and extrathoracic obstruction on flow-volume loop. Type 1 diabetes mellitus may cause diabetic stiff joint syndrome and difficult laryngoscopy due to AO joint glycosylation.
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How do Anesthesiologists bill?
The total billable charge for an anesthetic is generally represented by: (BU + TU + Modifying Factors) x Anesthesia Conversion Factor. Modifying factors include QCU, physical status modifier, and specialized monitoring.
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Other random things you can bill for:
1) Extremes of age (patients < 1 year or >70 years)
2) Use of (deliberate) total body hypothermia
3) Use of controlled hypotension
4) Anesthesia complicated by emergency conditions
Sometimes ASA status and invasive lines.
Can NOT bill for drugs used, fluids,or blood products
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How do you diagnose fat embolism syndrome?
1 Major criteria and 4 minor,in addition to evidence of fat macroglobulinemia
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What are the Major criteria for FES?
Pul edema/respiratory insufficiency, Hypoxemia (PaO2 <60, FiO2 <0.4), Central nervous system depression, petechial rash
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What are the minor criteria for FES?
tachycardia, fever, unexplained drop in hematocrit or platelets, elevated erythrocyte sedimentation rate, retinal fat emboli, fat in urine, and fat in sputum)
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Is the American Medical Association involved in operating room safety?
Apparently not (eye roll emoji)
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Take a look at all the people with their hand in the OR
1) The Joint Commission
2) Accreditation Association for Ambulatory Healthcare
3) Drug Enforcement Agency
4) Food and Drug Administration
5) Centers for Disease Control and Prevention
6) Department of Health and Human Services
7) Centers for Medicare and Medicaid Services
8) Occupational Safety and Health Administration
9) American National Standards Institute
10) National Fire Protection Association
11) National Committee for Quality Assurance
12) National Academy of Sciences/Institute of Medicine
13) Safe Medical Devices Act
14) Health Insurance Portability and Accountability Act
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Safe anesthetics for people with malignant hyperthermia:
Safe anesthesia agents for malignant hyperthermia include benzodiazepines, nitrous oxide, and non-depolarizing muscle relaxants.
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Preparing the anesthesia machine:
Preparing the anesthesia machine will include removing the vaporizers from the machine or taping them in the “OFF” position. It’s recommended the CO2 absorbent be changed and 10 L/min of oxygen should be flushed through the circuit for a period of time; Please note that some anesthesia machines require up to 60 minutes of a flush – refer to the manufacturer's information.
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Waste gas exposure in the operating room is regulated by, and what do the parts per million have to be?
The National Institute for Occupational Safety and Health (NIOSH) and the standard acceptable level for halothane is 2 parts per million (ppm) which is equivalent to 0.0002%. If volatiles are used with nitrous oxide, they must be kept below 0.5 ppm.
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Absolute contraindications to ECT:
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Pheochromocytoma
Recent MI <4-6 weeks
Recent CVA <3 weeks
Recent intracranial surgery <3 mos
Unstable cervical spine
Intracranial mass lesion
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What do you need to know about MOCA? What's no longer required?
Parts of the MOCA include:
- Maintain an unrestricted license to practice in the United States or Canada
- Obtain 250 category 1 CME credits, with no more than 60 credits/year
- Participate in MOCA minute, 30 questions/quarter (120/year), questions are emailed to participants. Designed to evaluate and fill knowledge gaps.
- Participate in two Part 4 activities of evaluation and improvement of practice. Simulation is encouraged but no longer required. Online activities, including online simulation training, are available.The MOCA requires that 250 CME credits are achieved over the 10-year cycle. These CME credits are only acknowledged if they are ACCME/AMA PRA-approved Category 1. There are several different types of CME category credits but only category 1 are recognized for MOCA.
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When should adenosine NOT be used?
denosine should not be used in the presence of irregular wide-complex tachycardias (e.g., polymorphic ventricular tachycardia, ventricular fibrillation, and atrial fibrillation with aberrancy or Wolff-Parkinson-White syndrome) since it can result in hemodynamic instability and an increase in the ventricular rate.
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Tell me about atrial flutter and why won't adenosine work for it? Will adenosine work for atrial tachycardia?
Atrial flutter is the second most common pathologic SVT (first is atrial fibrillation) and is caused by the presence of a reentrant pathway in the right atrium around the tricuspid valve. It is generally regular with an atrial rate of approximately 300 bpm with a 2:1 conduction resulting in a ventricular rate of approximately 150 bpm. Adenosine will slow the ventricular rate in the setting of atrial flutter, but since the AV node is not part of the reentrant pathway, adenosine will not terminate the arrhythmia.
Atrial tachycardia is a regular SVT with a ventricular rate between 150-250. It can be caused by a micro-reentrant circuit or an automatic atrial focus. Despite the general lack of AV node involvement, 60-80% of atrial tachycardias terminate with adenosine.
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So, what will adenosine work for as far as (aVNRT) and AVRT( Atrioventricular reciprocating tachycardia)
Adenosine will terminate SVTs caused by a reentrant circuit involving the AV node (i.e., AVNRT, AVRT). Frequently, atrial tachycardia will also terminate. Adenosine will slow the ventricular rate in atrial fibrillation and atrial flutter, but it is very unlikely the tachyarrhythmia will terminate.
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What are unreliable signs/symptoms of acute compartment syndrome?
Pulse oximetry and pain
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What are reliable signs of compartment syndrome?
1. Compartment pressure >30 mm Hg
2. Creatine phosphokinase level >5000 U/ml (possibly as little as >1000 U/ml)
3. Loss of normal phasic patterns of tibial venous blood flow
4. Loss of distal pulses in the setting of closed extremity injury
5. Compartment perfusion pressure < 21 mm Hg
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How does aspirin work? What increased risks do people taking this medication have?
Aspirin is a potent cyclooxygenase (Cox) inhibitor used to reduce the risk of thromboembolic events (e.g., myocardial infarction and stroke), particularly in high risk patients such as those with a history of myocardial infarction or stroke, atrial fibrillation, intravascular stents, diabetes, etc. The Cox enzyme is required for production of prostaglandins such as thromboxane A2 which is critical for platelet activation and thrombus formation. Since platelets do not have the intracellular machinery required to produce Cox (specifically, Cox-1), aspirin causes an irreversible inhibition of the enzyme. Return of normal platelet function only occurs as new platelets are created (2-5 days).
Due to irreversible inhibition of Cox-1 in platelets, there is an increased risk for surgical bleeding in patients taking aspirin (or other Cox inhibitors). Previously, aspirin was routinely held for 5-10 days before surgical procedures to reduce this risk. However, acute withdrawal of aspirin has its own set of side effects including increased risk for thrombotic and thromboembolic events given the proinflammatory and procoagulant physiology created by surgery
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In which procedures should aspirin be held?
Aspirin should be held for a few specific types of surgery: intracranial neurosurgical procedures, middle ear surgery, posterior eye surgery, intramedullary spine surgery, and possibly prostate surgery. Bleeding in these types of surgeries may cause disastrous neurologic and neurovascular complications (esp. neurosurgical and spine procedures) and/or may be very difficult or impossible to control (esp. middle ear and posterior eye procedures).
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Should patients undergoing major vascular surgery still continue asprin?
Yes
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BMS and Drug eluding stents and continuation time:
Bare metal cardiac stents require 1 month of dual antiplatelet therapy (aspirin and ADP-receptor antagonist) before stopping the ADP-receptor antagonist prior to a scheduled surgery. Aspirin should be continued perioperatively. Dual antiplatelet therapy should continue for 6 months in the case of drug-eluting stent placement with continuation of aspirin perioperatively.
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Old people are more sensitive to which type of opioids? What should their dose be? Why?
synthetic ones: fentanyl, alifentanil, and sufentanil. The dose should be cut in half.This increased BRAIN sensitivity is the primary reason for dose adjustments compared to pharmacokinetic changes.
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Remifentanil and the aging patient-should the doses be changed? If so, how?
Remifentanil has interesting pharmacokinetic and pharmacodynamic changes in the aging patient. Remifentanil is also more potent in the elderly patient owing to an increased brain sensitivity and therefore bolus doses should be halved. Because the central volume of distribution and central clearance is decreased, infusion rates of remifentanil should be decreased by one-third.
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Renal clearance in older people, and how does that affect morphine dose?
Morphine requirements are decreased in an elderly patient because of increased brain sensitivity and decreased renal clearance. Because both morphine and its metabolite morphine-6-glucuronide are renally cleared, morphine has an increased duration of effect and doses should be reduced.
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If creatinine number is the same in an older person as it is in a 40 year old, what does that say about creatinine clearance in the elderly?
Recall that creatinine clearance is decreased in the elderly even if the serum creatinine number is the same as the 40-year-old.
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Goal temp for hypothermia for cardiac arrest?
Goal temperature is typically 32 °C and 36 °C, or at the very least to prevent hyperthermia.
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What is the quickest method of cooling to induce hypothermia?
endovascular cooling, it cools at 4 degrees per hour
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Most deaths associated with the use of induced hypothermia occur during?
during the rewarming phase due to too rapid rewarming.
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How long should it take to re-warm the patient after endovascular cooling? Why?
It should take 24 hours.Rapid rewarming is potentially dangerous and can cause significant rises in intracranial pressure and electrolyte shifts that can cause cardiac arrhythmias.
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Meperidine and its use during endovascular cooling?
Drugs such as meperidine are frequently used to blunt the shivering response to hypothermia and prevent the associated significant increase in oxygen demand. Shivering in response to hypothermia can increase tissue oxygen demands by as much as 400-500%. It also increases oxygen consumption
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Diagnosis of Abdominal compartment syndrome?
t can be diagnosed clinically by a tense, distended abdomen and an intravesical pressure >20-25 mm Hg (often measured via a Foley catheter). Patients can experience organ hypoperfusion due to compromised capillary blood flow and venous drainage. This can lead to multiorgan failure and death if there is a delay in surgical abdominal decompression.
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Pathophys of Abdominal compartment syndrome? How does it affect CVP, IVC, ICP, Renal function, CO?
Elevation of IAP causes compression of the inferior vena cava (IVC), which leads to reduced venous return to the heart and decreased cardiac output (A). Cardiac output is further decreased by displacement of the heart secondary to diaphragmatic elevation, increased systemic vascular resistance, and hypovolemia.
Central venous pressure is increased (B) due to the increased intrathoracic pressure secondary to elevation of the diaphragm. This is despite decreased venous return to the heart and often coexisting hypovolemia. Increased intrathoracic pressure also contributes to the increased pulmonary artery occlusion pressure that is associated with ACS.
Compression of renal vasculature, decreased cardiac output, and direct pressure on renal parenchyma caused by increased IAP all contribute to decreased urinary output (D). Glomerular filtration rate may continue to be low even after correction of hypovolemia with fluid resuscitation.
Increased peak inspiratory pressures (E) are caused by diaphragmatic elevation and corresponding reduction in pulmonary compliance. Mechanical ventilation is often required for these patients as well as the addition of positive end-expiratory pressure (PEEP) to maintain oxygenation.
There's increased ICP alsoppears to be mediated mechanically by diaphragmatic elevation, reduced chest wall compliance, and increased central venous pressure (CVP).
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Look at photo of ACS and its effects on different organ systems:
Okay
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When it comes to DLT, ventilating one lumen means:
| Look at #23 on test for general on 6/29/2019 for further clarity on DLT and ventilation
ventilating one lumen implies the other lumen is clamped, as would be typical for this placement procedure.
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What is closing capacity?
Closing capacity is the volume remaining in the lungs during expiration when small airways begin to close
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Tourniquet pain is probably due to what?
Tourniquet pain with associated hypertension can occur after 30-60 minutes of tourniquet inflation. This pain likely arises from unmyelinated c-fibers.There is a greater incidence of tourniquet pain with intravenous regional anesthesia than with epidural or spinal. General anesthesia is associated with the least amount of tourniquet pain. Since tourniquet pain resolves spontaneously with the release of the tourniquet, use of long-acting opioids or antihypertensive agents to treat the pain or associated hypertension should be avoided.
